Work Related Health Risks Among Women Embroidery Artisans in India’s Informal Economy

Work Related Health Risks Among Women Embroidery Artisans in India’s Informal Economy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Work Related Health Risks Among Women Embroidery Artisans in India’s Informal Economy Ankit Sheth, Rakesh Balachandar, Nikhil Kulkarni, Ankit Viramgami, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8486548/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Hand embroidery is a culturally significant craft and key source of livelihood for women in rural India, particularly in regions like Kutch-Bhuj, Gujarat. Despite its socioeconomic value, the sector is dominated by informal, home-based work arrangements lacking occupational safety measures and consistent health surveillance. Artisans, predominantly women, are exposed to multiple occupational hazards, yet systematic data on these exposures and associated health outcomes are limited. Materials and methods A cross-sectional observational study was conducted among 101 female embroidery workers from artisan clusters in Kutch-Bhuj. Eligible participants were women aged 18 years or older with at least two years of embroidery experience. Data were collected using structured interviews and validated tools, including adapted ATS and Nordic Musculoskeletal Questionnaires. Anthropometric measurements, vision screening, blood pressure, haemoglobin, and random blood sugar were assessed using standardized protocols. Workplace illumination was measured against Indian standards. Results The workforce was predominantly older (mean age 45.9 years), socially disadvantaged, and largely illiterate. Nearly two-thirds had over ten years of work experience. High burdens of health problems were identified: anaemia (61.4%), overweight/obesity (34.6%), and hypertension (15.9%). Musculoskeletal complaints affected 58.4%, chiefly the lower back and neck. Eye-related symptoms were widespread (60.4%), with 54.9% exhibiting far vision impairment and 36.6% near vision impairment; depth perception and peripheral vision deficits were also common. Suboptimal workplace lighting and ergonomics were noted. Conclusion Women embroidery workers in Kutch-Bhuj face a substantial burden of occupational exposures and related health morbidities, shaped by informal work arrangements and limited access to health interventions. Findings underscore the urgency of integrating occupational health services with primary care, improving ergonomic and environmental conditions, and developing gender-responsive health education and social security programs to protect this vulnerable population. Occupational Health Services Vision Screening Ergonomics Lighting Female Musculoskeletal Pain Primary Health Care INTRODUCTION Hand embroidery is a highly valued artisanal craft that forms an integral part of India’s cultural heritage and sustains rural economies by providing livelihoods for thousands of women, especially in regions like Kutch-Bhuj, Gujarat.[ 1 ] In these areas, women artisans not only uphold centuries-old traditions through their skilled craftsmanship but also play a critical role in supporting household and community incomes.[ 2 ] Despite its cultural and economic importance, embroidery remains part of the informal sector, with home-based and small-scale operations that lack regulatory oversight, access to occupational safety provisions, and consistent healthcare coverage.[ 3 ] Despite the social and economic importance of embroidery, the sector is fraught with health risks. The All-India Artisans and Craft Workers Welfare Association (AIACA) baseline study found high rates of respiratory ailments, musculoskeletal disorders, heat stress, hand tremors, and widespread visual impairment across craft clusters, underlining the occupational hazards pervasive in this sector.[ 4 ] These health risks are often compounded by hazardous working conditions: most artisans work in confined, poorly ventilated spaces and are chronically exposed to inadequate lighting, poor ergonomics, and repetitive motion. The use of personal protective equipment is rare, often due to lack of awareness or the constraints of informal work. Within this context, women bear the greatest burden. The embroidery workforce in India is overwhelmingly female. While embroidery empowers women by enabling economic contribution from within the home and offering some social autonomy, the informal and household-based nature of the work often renders their labour invisible and unprotected. Gendered barriers, including low literacy, constrained mobility, minimal decision-making power, and weak social security coverage, further restrict women artisans’ ability to seek preventive care or advocate for healthier work environments.[ 5 ] These intersecting vulnerabilities leave women artisans exposed to increased occupational risks, even as their skills remain the backbone of this traditional industry.[ 6 ] Despite recognition of occupational health risks in the informal economy, there is limited evidence from the embroidery sector in India on the systematic assessment of occupational exposures alongside health outcomes. Few studies have evaluated health indicators like musculoskeletal morbidity or symptoms of visual problems among embroidery workers. However, the lack of integrated exposure and health data has impeded the design of targeted interventions and practical workplace improvements in settings where regulation and formal health surveillance are absent. This study seeks to address these gaps by undertaking a comprehensive assessment of occupational exposures and associated health outcomes among female embroidery workers in the Kutch-Bhuj region. By combining field-based workplace exposure measurements with structured health assessments—including musculoskeletal, nutritional, and vision screening—this research generates essential new evidence to inform practical interventions and policy recommendations. Ultimately, this work aims to improve the health, visibility, and well-being of women artisans whose labour is central to both cultural preservation and rural economic resilience. METHODS Study Design and Setting This study employed a cross-sectional observational design to evaluate occupational exposures and health outcomes among hand embroidery workers in the Kutch-Bhuj district of Gujarat, India. The research was conducted in rural and semi-urban artisan clusters, specifically targeting the villages of Sumrasar, Hodka, and Bhadroi, which are recognized centers for traditional embroidery work. The study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional reporting.[ 7 ] The embroidery of Kutch-Bhuj is renowned for its diverse techniques and styles, such as Rabari mirror work, Ahir floral motifs, Mutwa’s fine geometric patterns, and the intricate Suf stitch. The embroidery process involves intricate handwork, where artisans use needles and threads to create elaborate patterns on fabric, often drawing upon designs passed down through generations. Each piece is crafted with precision, requiring sustained concentration and fine motor control as the worker manipulates the needle and thread to achieve the desired motifs. While these traditional techniques showcase remarkable skill and creativity, the process also exposes workers to risks such as eye strain from detailed work and musculoskeletal discomfort from prolonged, static postures. Study Population and Sample Size The study population comprised female embroidery workers engaged in hand embroidery, reflecting the demographic reality of this sector in the region. Eligible participants were female embroidery workers aged 18 years or older, residing in the selected Kutch-Bhuj clusters, with at least two years of continuous hand embroidery experience and willing to provide informed consent. Exclusion criteria included acute illness in the past two weeks, physical or mental conditions preventing participation, contraindications to vision screening, or inability to provide reliable information. Based on an anticipated prevalence of 50% for vision problems, a sample size of 97 was calculated to achieve 10% absolute precision at a 95% confidence level. Ultimately, 101 embroidery workers were enrolled, ensuring adequate representation for statistical analysis. Eligible participants were approached directly at worksites and recruited based on their eligibility, considering the dispersed and informal nature of the workforce. Data Collection Tools Structured Interviews and Standardized Questionnaires Data were collected using a structured, pretested, semi-closed questionnaire administered in the local language by trained personnel. The tool captured sociodemographic characteristics (age, education, income, marital status), occupational history (duration of work, working hours, type of embroidery, use of artificial lighting), medical and family history, and personal habits (tobacco use and dietary patterns). Health history, healthcare access, and perceived health needs were also recorded. Respiratory symptoms were assessed using a modified version of the ATS-DLD-78-A questionnaire, which was adapted to the local language and pre-tested for clarity and comprehensiveness.[ 8 ] The adapted questionnaire was found to be reliable with Cronbach’s α = 0.82. The Modified Nordic Musculoskeletal Questionnaire (NMQ) was used to identify pain sites and assess severity.[ 9 ] Irrelevant items were excluded to suit study objectives. The revised tool showed high reliability (Cronbach’s alpha = 0.885) and strong content validity (CVI = 0.95). Clinical and Laboratory Examinations Anthropometric measurements included height, measured using a stadiometer, and weight, recorded with a calibrated digital scale. Blood pressure was measured using a standard mercury sphygmomanometer, following the recommended protocol of taking two readings at rest and recording the average. Haemoglobin levels were estimated on-site using the HemoCue system, a portable photometric device that provides reliable point-of-care assessment of anaemia status.[ 10 ] Random blood sugar was measured with a glucometer (AccuChek), and in cases of elevated readings, further testing such as HbA1c (Afinion, Abbott) was recommended to assess glycaemic control. Vision Screening Vision assessment was a central component of the health evaluation, given the visual demands of embroidery work. The Titmus Vision Tester 2A/2S, a standardized instrument, was used to assess both distant and near visual acuity, as well as muscle balance, depth perception, colour perception, and binocular vision. Supplementary testing employed Snellen charts for distant vision and Jaeger charts for near vision, ensuring a comprehensive appraisal of visual function. Peripheral field vision was also tested to identify any deficits that might affect work performance or safety. All vision tests were conducted in a standardized manner under appropriate lighting conditions. Environmental Measurements Illumination levels at embroidery workshops were assessed to evaluate workplace lighting adequacy. Measurements were conducted at 19 locations in the villages of Sumrasar (n = 12) and Hodko (n = 7) during typical work hours. A digital Illuminance Meter (Equinox Model 802) was used to record lux values in both horizontal and vertical planes at the workers’ eye and positioned at level of work surface. Observations were made under varying lighting conditions, including natural daylight and artificial sources (tube light, bulb, or absence of artificial light). Definitions and Classification Standards BMI was calculated as weight in kilograms divided by height in meters squared (kg/m²) and categorised according to WHO Asia-Pacific guidelines: underweight (< 18.5), normal (18.5–22.9), overweight (23.0–24.9), and obese (≥ 25).[ 11 ] Anaemia was defined as haemoglobin concentration < 12 g/dL in women, in accordance with World Health Organization (WHO) criteria.[ 12 ] Blood pressure classification followed ISH/ESC guidelines, with hypertension defined as systolic ≥ 140 mmHg and/or diastolic ≥ 90 mmHg, and graded as Grade I (140–159/90–99 mmHg) or Grade II (≥ 160/100 mmHg).[ 13 ] Diabetes was defined according to American Diabetes Association (ADA) thresholds, as random blood sugar ≥ 200 mg/dL or HbA1c ≥ 6.5% when available.[ 14 ] Vision impairment was classified following WHO ICD-10 definitions. Far vision impairment was categorised as mild (worse than 6/12 but equal or better than 6/18 in the better eye), moderate (worse than 6/18 but equal or better than 6/60), and severe (worse than 6/60 but equal or better than 3/60). Near vision impairment was defined as worse than N/6 at 40 cm.[ 15 ] Depth perception was assessed using the Titmus Vision Tester stereopsis evaluation, with scores < 70% considered impaired. Peripheral vision deficits were recorded when participants failed to detect stimuli at the standard nasal or temporal field angles. Musculoskeletal problems were defined using the Modified Nordic Musculoskeletal Questionnaire as self-reported pain, ache, or discomfort in any anatomical site during the last twelve months.[ 9 ] Illumination adequacy was assessed against the Indian Standard IS 3646 (Item 12.1.7, IS 3646 Part 1: 1992, reaffirmed 2003) for hand tailoring, which prescribes a recommended service illumination level of 1000–2000 lux with provision for local task lighting.[ 16 ] Quality Assurance All data collection tools and techniques were standardized, and staff were trained in their administration to ensure consistency and reliability. Instruments were calibrated regularly, and pilot testing was conducted prior to the main study to refine procedures and ensure cultural appropriateness. Data were reviewed daily for completeness and accuracy, and any discrepancies were resolved through follow-up with participants where necessary. Data Management and Statistical Analysis Data were entered into a secure digital database with double-entry verification and cleaning before analysis. Descriptive statistics were calculated for all variables, with frequencies and percentages for categorical variables and means, standard deviations, or medians with ranges for continuous variables. Associations between exposures such as work duration with vision impairment was assessed using chi-square tests. Statistical significance was set at p < 0.05. All analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY). Health outcome measures and environmental exposure data were interpreted with reference to established occupational health standards and national/international guidelines. RESULTS A total of 101 female embroidery workers participated in the study. As shown in Table 1 , the workforce was predominantly older, with over one-third (35.6%) aged above 50 years and a mean age of 45.93 ± 17.18 years. Most participants were currently married (84.2%) and belonged to the Scheduled Caste community (97.0%). Educational attainment was low, with 72.3% being illiterate and only 5.9% having completed higher secondary school or above. More than half (51.5%) resided in pucca houses, although a significant proportion (33.7%) lived in kutcha structures. Most households accessed piped tap water (78.2%), yet more than half (52.5%) did not treat their drinking water. The median household size was five members, and the median monthly family income was INR 10,000, reflecting modest socio-economic conditions. Occupational and lifestyle characteristics are summarised in Table 2 . All participants were engaged in hand embroidery, working an average of 4.55 ± 1.96 hours daily. Nearly two-thirds (64.4%) had more than ten years of work experience, with an overall mean work duration of 21.57 ± 15.16 years. Approximately half (49.5%) possessed an artisan card, indicating formal recognition of their skills. Vegetarianism predominated (87.1%), tobacco chewing was reported by 8.9% of workers, and none reported smoking or alcohol consumption. Nutritional status, non-communicable disease profile, and anaemia prevalence are presented in Table 3 . Malnutrition was evident at both ends of the spectrum, with 19.8% underweight and 34.6% classified as obese (Obese I or II), in line with the Asian BMI classification. Hypertension was observed in 15.9% of workers, with an additional 12.9% categorised as having high-normal blood pressure. Diabetes prevalence was low at 4.0% based on random blood sugar levels. Anaemia was highly prevalent, affecting 61.4% of participants. Self-reported symptoms and musculoskeletal complaints are detailed in Table 4 . Respiratory symptoms were relatively rare, reported by 3–4% of workers. Conversely, ocular symptoms were common, affecting 60.4% overall, most frequently watering of the eyes (39.6%), itching (31.7%), and burning sensation (23.8%). Musculoskeletal problems were also prominent, with 58.4% reporting at least one site of pain, most commonly in the lower back (39.6%), followed by the neck (27.7%) and knees (22.8%). Vision assessment findings are summarised in Table 5 . Among workers tested, 54.9% exhibited some degree of far vision impairment, predominantly mild (40.9%), while 36.6% had near vision deficits. Only 5.4% of those assessed passed the depth perception test, indicating significant stereopsis impairment. Peripheral vision loss was observed in 38.6% of participants. These visual deficits, coupled with high rates of musculoskeletal complaints, underscore the occupational health risks associated with prolonged, detailed embroidery work. Workplace exposure assessment Illumination levels varied widely across the embroidery workplaces (n = 19). In Sumrasar, three of the twelve assessed locations achieved adequate lighting as per IS 3646 standards, while two locations exceeded recommended levels due to direct sunlight glare. The remaining seven locations demonstrated inadequate lighting, requiring installation or improvement of local light sources. In Hodko, all seven locations recorded lux values below the prescribed range, indicating consistently poor illumination conditions. Overall, the findings highlight substantial deficits in workplace lighting, with only 16% (3/19) of locations meeting adequacy standards, while 74% (14/19) were inadequate, and 10% (2/19) excessive. Such inadequate illumination is likely to contribute to visual strain, musculoskeletal discomfort, and reduced occupational efficiency among embroidery workers. Table 1 Socio-demographic and household characteristics of embroidery workers (n = 101) Variable n (%) Sex Female 101 (100) Age group (years) 50 36 (35.6) Mean ± SD (Min, Max) 45.93 ± 17.18 Social group Scheduled Caste 98 (97.0) Other Backward Class 3 (3.0) Education Not literate 73 (72.3) Primary or below 15 (14.9) Higher secondary & above 6 (5.9) Type of housing Pucca 52 (51.5) Kutcha 34 (33.7) Semi-pucca 15 (14.9) Median household size 5 (range 1–30) Median family income (INR) 10,000 (range 4,000–40,000) Table 2 Occupational profile and personal habits of embroidery workers (n = 101) Variable n (%) Work hours per day ( Mean ± SD) 4.55 ± 1.96 Work experience in years 10 65 (64.4) Mean ± SD (Min, Max) 21.57 ± 15.16 Has artisan card 50 (49.5) Diet Vegetarian 88 (87.1) Mixed 13 (12.9) Tobacco use (current) 9 (8.9) Alcohol use 0 (0.0) Table 3 Nutritional status, non-communicable disease profile, and anaemia prevalence (n = 101) Variable n (%) BMI (Asian classification) Underweight (< 18.5) 20 (19.8) Normal (18.5–22.9) 33 (32.7) Overweight (23.0–24.9) 13 (12.9) Obese I (25.0–29.9) 28 (27.7) Obese II (≥ 30) 7 (6.9) Blood pressure Normal 72 (71.2) High normal 13 (12.9) Grade I hypertension 10 (9.9) Grade II hypertension 6 (6.0) Diabetes (RBS ≥ 200 mg/dL) 4 (4.0) Anaemia (Hb < 12 g/dL) 62 (61.4) Table 4 Self-reported symptoms and musculoskeletal problems (n = 101) Symptom n (%) Any respiratory symptom 3 (3.0) Chronic cough 1 (1.0) Dyspnoea (all grades) 4 (4.0) Any eye symptom 61 (60.4) Watering 40 (39.6) Itching 32 (31.7) Burning 24 (23.8) Redness 10 (9.9) Any musculoskeletal problem 59 (58.4) Lower back pain 40 (39.6) Neck pain 28 (27.7) Knee pain 23 (22.8) Table 5 Vision assessment outcomes among embroidery workers Vision parameter n (%) Far vision (n = 93) No impairment 42 (45.1) Mild impairment (worse than 6/12, equal or better than 6/18) 38 (40.9) Moderate impairment (worse than 6/18, equal or better than 6/60 13 (14.0) Near vision (n = 93) No impairment 59 (63.4) Impaired (worse than N/6 at 40cm) 34 (36.6) Depth perception (n = 37) Pass [Shepard–Fry percentage more than 70% (Angle of Stereopsis in seconds of arc 50)] 2 (5.4) Fail [Shepard–Fry percentage less than 70% (Angle of Stereopsis in seconds of arc 50)] 35 (94.6) Peripheral vision (n = 57) Pass [Left & Right Peripheral (85°,70°,55°), Nasal 45° - response yes] 35 (61.4) Fail [Left & Right Peripheral (85°,70°,55°), Nasal 45° - response no] 22 (38.6) DISCUSSION This cross-sectional study provides a comprehensive assessment of occupational exposures and health outcomes among female embroidery workers in Kutch-Bhuj, Gujarat, a population typically overlooked in occupational health research. The findings reveal significant health challenges affecting this artisanal workforce, most notably a high burden of malnutrition, anaemia, musculoskeletal pain, and vision impairment. These results highlight the vulnerability of women engaged in traditional craft sectors and underscore the urgent need for targeted preventive strategies and policy interventions. The demographic profile of the embroidery workers indicates a predominantly older, socially marginalized, and socioeconomically disadvantaged workforce, reflecting national trends seen among Indian craftswomen.[ 17 – 20 ] With more than one-third above 50 years of age and the majority being illiterate, these women face intersecting vulnerabilities related to age, caste, and education—factors consistently linked to adverse health outcomes and reduced healthcare access in India and other low- and middle-income countries (LMICs).[ 21 – 23 ] The high prevalence of illiteracy and limited monthly income further restrict these women’s ability to access preventive and healthcare services, mirroring findings from studies on informal sector workers in South Asia.[ 24 , 25 ] Occupationally, the workforce was highly experienced, with two-thirds having more than a decade of engagement in embroidery. The mean daily work duration of 4.6 hours, though seemingly modest, involved persistent, repetitive fine-motor activity under suboptimal ergonomic conditions. The high prevalence of musculoskeletal pain, particularly in the lower back, neck, and knees, aligns with previous research on home-based handcraft workers, which documents increased risk of musculoskeletal disorders due to prolonged static postures, repetitive motion, and inadequate workstations.[ 26 – 30 ] These patterns have been consistently demonstrated in studies of female artisanal and garment sector workers in India, Bangladesh, and Southeast Asia.[ 31 – 33 ] Visual morbidity represents another critical occupational hazard. Over half of the sample demonstrated either mild or moderate far vision impairment, more than one-third had near vision deficits, and nearly all those assessed had impaired depth perception. These findings corroborate earlier reports of high rates of visual fatigue and deterioration among needlecraft workers, where sustained close-up work, poor lighting, and lack of corrective eyewear drive cumulative ocular strain and function loss.[ 34 – 37 ] The high prevalence of eye-related symptoms such as watering, burning, and itching further reflects this cumulative burden. Nutritional status was also concerning, with a dual burden of underweight (19.8%) and overweight/obesity (34.6%)—an increasingly recognized phenomenon among women in poverty-affected households with shifting dietary patterns. Anaemia was widely prevalent (61.4%) in line with national data on rural and disadvantaged Indian women, and likely undermines work capacity, productivity, and quality of life. The presence of hypertension (15.9%) and diabetes (4%) underscores the non-communicable disease (NCD) risk now well-documented among women in the informal sector, exacerbated by age, nutrition transitions, and limited healthcare access. The home-based, informal nature of embroidery work exacerbates risk exposure, as workers lack protection under formal occupational safety regulations, have limited bargaining power, and minimal access to health surveillance or benefits. This finding is consistent with global reports highlighting the occupational invisibility of women in artisanal value chains and the gendered impacts of informal labour structures. Study strengths and limitations Strengths of this study include its robust sample size, use of validated tools, and careful measurement of occupational and health parameters. Limitations include the cross-sectional design, reliance on self-reported morbidity for some outcomes, and the restriction to selected artisan clusters, which may limit generalizability. Future research should explore longitudinal associations and the impact of targeted workplace interventions, ergonomic improvements, and vision care programs. Policy implications This study was conducted in response to a priority request from the Development Commissioner (Handicrafts), Ministry of Textiles, and was supported by the National Health Mission (NHM) of Gujarat. Drawing from field data and stakeholder consultations, the study developed occupational Standard Operating Procedures (SOPs) tailored to the unique risks encountered by female embroidery workers in informal, home-based settings. These SOPs encompass practical recommendations to improve workplace lighting, ergonomic redesigns of workstations, scheduled rest breaks, access to periodic occupational health screening (vision tests, nutritional and anaemia assessment, blood pressure monitoring) integrated into the primary healthcare system, and culturally sensitive health education modules. The initial adoption of these SOPs by DC Handicrafts and NHM Gujarat establishes a replicable model for embedding occupational health services within other informal and traditional craft sectors. Policies focused on women-centred outreach, social security enrolment, and occupational health literacy are particularly critical for safeguarding the health and livelihoods of this highly vulnerable female workforce. CONCLUSION The findings from this study highlight the significant vulnerability of women in the hand embroidery sector, resulting from intersecting challenges related to gender, caste, socioeconomic marginalization, and informal work conditions. These artisans face both elevated occupational health risks and a lack of workplace protections. Integrating occupational health screening and preventive care into primary healthcare—particularly via community health workers—offers a practical and equitable means to support this high-risk group. Policy priorities should include accessible health education, social security enrolment, ergonomic improvements, and regular vision and nutrition assessments targeted to women in the informal artisan workforce. Advancing these measures is essential for promoting women’s health equity and preserving the economic independence and cultural heritage upheld by these artisans. Declarations Ethics approval: The study was approved by the Institutional Human Ethics Committee of ICMR-National Institute of Occupational Health (ICMR-NIOH/EC/2023/2) and conducted in accordance with the Helsinki Declaration. Consent to participate: Written informed consent was obtained from all participants, who were assured of confidentiality, anonymity, and their right to withdraw at any time. Participants identified with health problems during clinical assessments were referred to nearby government hospitals for further evaluation and management. Consent to publish: Written informed consent for publication of anonymized data was obtained from all participants. Availability of data and materials: The datasets generated are not publicly available due to privacy concerns but are available from the corresponding author upon reasonable request. Competing interests: The authors declare no competing interests. Funding: This study was funded by the State Health Systems Resource Centre (SHSRC), Gujarat, under the National Health Mission. The funder had no role in the study design, data collection, analysis, interpretation, or in the writing of the manuscript. The funding supported field implementation and the development of craft-specific occupational health SOPs for submission to relevant authorities. The authors being full time research faculties of the non-profit occupational health research institutes, conducted and reported this study within their independent capacity. Authors' contributions: AS, NK, RB and AV conceived and designed the study and contributed to data collection. All authors contributed to data interpretation and manuscript revision. AS, NK and AV performed the data analysis. AS drafted the manuscript. All authors approved the final version of manuscript. Acknowledgements: The authors gratefully acknowledge the support of Dr. A. M. Kadri, Dr. Harsh Bakshi, and Dr. Aastha Vala from SHSRC Gujarat for their facilitation, guidance, and coordination throughout the study. We extend our sincere thanks to Mr. Raviveer Choudhary and Mr. Shekhar Sharma from the office of DC Handicrafts, Bhuj, for their support during fieldwork and stakeholder engagement. We are deeply thankful to all participating copper bell makers for their time and cooperation. Clinical Trial Registration: Not applicable References Planning Commission. A Report of the Steering Committee On Handlooms and Handicrafts Constituted for the Twelfth Five Year Plan (2012–2017). VSE Division, Government of India; 2012. Pathak S, Mukherjee S. Entrepreneurial ecosystem and social entrepreneurship: case studies of community-based craft from Kutch, India. Journal of Enterprising Communities: People and Places in the Global Economy. 2021;15(3):350-74. OECD. Tackling vulnerability in the informal economy: OECD publishing; 2019. AIACA. 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Prevalence of work related musculoskeletal disorders (WMSDs) and ergonomic risk assessment among readymade garment workers of Bangladesh: A cross sectional study. PLoS One. 2018;13(7):e0200122. Garg P, Raj P, Chellaiyan VG, Singh A. A Cross-Sectional Study on Visual Problems among Zari Artisans of North India. Journal of Surgical Specialties and Rural Practice. 2023;4(1):23-7. Khan MA. Assessment Of Refractive Error Among Zari Artisans Of Uttar Pradesh. African Journal of Biomedical Research. 2024:963-70. Marmamula S, Narsaiah S, Shekhar K, Khanna RC. Visual impairment among weaving communities in Prakasam district in South India. PLoS One. 2013;8(2):e55924. Madraswala ME, Moodley VR, Mashige KP. Visual Status, Ocular Profiles and Associated Quality of Life of Workers in the Weaving Community of Salem District, Tamil Nadu, South India. Indian J Occup Environ Med. 2025;29(1):65-9. Additional Declarations No competing interests reported. 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National Institute of Occupational Health","correspondingAuthor":false,"prefix":"","firstName":"Nikhil","middleName":"","lastName":"Kulkarni","suffix":""},{"id":574887956,"identity":"76c48716-d2e5-4f10-b776-c3742f0d5a26","order_by":3,"name":"Ankit Viramgami","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYDACZijNxsDA+CABLmxAnBZmA+K0IAE2CaKUGRznffjpxi+7aD4G5mcVD2q25TPwLz4mwVBwB7eWw+zG0rl9ybltDGxmNxKO3bZskHiWJsFg8AynFslmNgbp3B5moBYGsxuJDbcNGCTOGBsAjcKnhfl3bk89UAv7twKitPAzs7FJ5/w4DNTCY8YA1sLfY/iAkBbr3IbjuW3MPMUSQL8YsEmwJT5IwKOFjf8Y8+2cP9W589vbN378UXPbgJ//8IEDH/7g1gIGjEC/I+JUIoGBIQG/BiD4g+LWAwTVj4JRMApGwcgCAHzlTKc/cy2sAAAAAElFTkSuQmCC","orcid":"","institution":"ICMR - National Institute of Occupational Health","correspondingAuthor":true,"prefix":"","firstName":"Ankit","middleName":"","lastName":"Viramgami","suffix":""},{"id":574887957,"identity":"de838aae-3c4b-41a5-88a8-539592b6af40","order_by":4,"name":"Shilpa Ingole","email":"","orcid":"","institution":"ICMR - 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The All-India Artisans and Craft Workers Welfare Association (AIACA) baseline study found high rates of respiratory ailments, musculoskeletal disorders, heat stress, hand tremors, and widespread visual impairment across craft clusters, underlining the occupational hazards pervasive in this sector.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] These health risks are often compounded by hazardous working conditions: most artisans work in confined, poorly ventilated spaces and are chronically exposed to inadequate lighting, poor ergonomics, and repetitive motion. The use of personal protective equipment is rare, often due to lack of awareness or the constraints of informal work.\u003c/p\u003e \u003cp\u003eWithin this context, women bear the greatest burden. The embroidery workforce in India is overwhelmingly female. While embroidery empowers women by enabling economic contribution from within the home and offering some social autonomy, the informal and household-based nature of the work often renders their labour invisible and unprotected. Gendered barriers, including low literacy, constrained mobility, minimal decision-making power, and weak social security coverage, further restrict women artisans\u0026rsquo; ability to seek preventive care or advocate for healthier work environments.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] These intersecting vulnerabilities leave women artisans exposed to increased occupational risks, even as their skills remain the backbone of this traditional industry.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite recognition of occupational health risks in the informal economy, there is limited evidence from the embroidery sector in India on the systematic assessment of occupational exposures alongside health outcomes. Few studies have evaluated health indicators like musculoskeletal morbidity or symptoms of visual problems among embroidery workers. However, the lack of integrated exposure and health data has impeded the design of targeted interventions and practical workplace improvements in settings where regulation and formal health surveillance are absent.\u003c/p\u003e \u003cp\u003eThis study seeks to address these gaps by undertaking a comprehensive assessment of occupational exposures and associated health outcomes among female embroidery workers in the Kutch-Bhuj region. By combining field-based workplace exposure measurements with structured health assessments\u0026mdash;including musculoskeletal, nutritional, and vision screening\u0026mdash;this research generates essential new evidence to inform practical interventions and policy recommendations. Ultimately, this work aims to improve the health, visibility, and well-being of women artisans whose labour is central to both cultural preservation and rural economic resilience.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study employed a cross-sectional observational design to evaluate occupational exposures and health outcomes among hand embroidery workers in the Kutch-Bhuj district of Gujarat, India. The research was conducted in rural and semi-urban artisan clusters, specifically targeting the villages of Sumrasar, Hodka, and Bhadroi, which are recognized centers for traditional embroidery work. The study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional reporting.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe embroidery of Kutch-Bhuj is renowned for its diverse techniques and styles, such as Rabari mirror work, Ahir floral motifs, Mutwa\u0026rsquo;s fine geometric patterns, and the intricate Suf stitch. The embroidery process involves intricate handwork, where artisans use needles and threads to create elaborate patterns on fabric, often drawing upon designs passed down through generations. Each piece is crafted with precision, requiring sustained concentration and fine motor control as the worker manipulates the needle and thread to achieve the desired motifs. While these traditional techniques showcase remarkable skill and creativity, the process also exposes workers to risks such as eye strain from detailed work and musculoskeletal discomfort from prolonged, static postures.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population and Sample Size\u003c/h3\u003e\n\u003cp\u003eThe study population comprised female embroidery workers engaged in hand embroidery, reflecting the demographic reality of this sector in the region. Eligible participants were female embroidery workers aged 18 years or older, residing in the selected Kutch-Bhuj clusters, with at least two years of continuous hand embroidery experience and willing to provide informed consent. Exclusion criteria included acute illness in the past two weeks, physical or mental conditions preventing participation, contraindications to vision screening, or inability to provide reliable information. Based on an anticipated prevalence of 50% for vision problems, a sample size of 97 was calculated to achieve 10% absolute precision at a 95% confidence level. Ultimately, 101 embroidery workers were enrolled, ensuring adequate representation for statistical analysis.\u003c/p\u003e \u003cp\u003eEligible participants were approached directly at worksites and recruited based on their eligibility, considering the dispersed and informal nature of the workforce.\u003c/p\u003e\n\u003ch3\u003eData Collection Tools\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStructured Interviews and Standardized Questionnaires\u003c/h2\u003e \u003cp\u003eData were collected using a structured, pretested, semi-closed questionnaire administered in the local language by trained personnel. The tool captured sociodemographic characteristics (age, education, income, marital status), occupational history (duration of work, working hours, type of embroidery, use of artificial lighting), medical and family history, and personal habits (tobacco use and dietary patterns). Health history, healthcare access, and perceived health needs were also recorded.\u003c/p\u003e \u003cp\u003eRespiratory symptoms were assessed using a modified version of the ATS-DLD-78-A questionnaire, which was adapted to the local language and pre-tested for clarity and comprehensiveness.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] The adapted questionnaire was found to be reliable with Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.82. The Modified Nordic Musculoskeletal Questionnaire (NMQ) was used to identify pain sites and assess severity.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Irrelevant items were excluded to suit study objectives. The revised tool showed high reliability (Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.885) and strong content validity (CVI\u0026thinsp;=\u0026thinsp;0.95).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical and Laboratory Examinations\u003c/h3\u003e\n\u003cp\u003eAnthropometric measurements included height, measured using a stadiometer, and weight, recorded with a calibrated digital scale. Blood pressure was measured using a standard mercury sphygmomanometer, following the recommended protocol of taking two readings at rest and recording the average. Haemoglobin levels were estimated on-site using the HemoCue system, a portable photometric device that provides reliable point-of-care assessment of anaemia status.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Random blood sugar was measured with a glucometer (AccuChek), and in cases of elevated readings, further testing such as HbA1c (Afinion, Abbott) was recommended to assess glycaemic control.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eVision Screening\u003c/h2\u003e \u003cp\u003eVision assessment was a central component of the health evaluation, given the visual demands of embroidery work. The Titmus Vision Tester 2A/2S, a standardized instrument, was used to assess both distant and near visual acuity, as well as muscle balance, depth perception, colour perception, and binocular vision. Supplementary testing employed Snellen charts for distant vision and Jaeger charts for near vision, ensuring a comprehensive appraisal of visual function. Peripheral field vision was also tested to identify any deficits that might affect work performance or safety. All vision tests were conducted in a standardized manner under appropriate lighting conditions.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEnvironmental Measurements\u003c/h3\u003e\n\u003cp\u003eIllumination levels at embroidery workshops were assessed to evaluate workplace lighting adequacy. Measurements were conducted at 19 locations in the villages of Sumrasar (n\u0026thinsp;=\u0026thinsp;12) and Hodko (n\u0026thinsp;=\u0026thinsp;7) during typical work hours. A digital Illuminance Meter (Equinox Model 802) was used to record lux values in both horizontal and vertical planes at the workers\u0026rsquo; eye and positioned at level of work surface. Observations were made under varying lighting conditions, including natural daylight and artificial sources (tube light, bulb, or absence of artificial light).\u003c/p\u003e\n\u003ch3\u003eDefinitions and Classification Standards\u003c/h3\u003e\n\u003cp\u003eBMI was calculated as weight in kilograms divided by height in meters squared (kg/m\u0026sup2;) and categorised according to WHO Asia-Pacific guidelines: underweight (\u0026lt;\u0026thinsp;18.5), normal (18.5\u0026ndash;22.9), overweight (23.0\u0026ndash;24.9), and obese (\u0026ge;\u0026thinsp;25).[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Anaemia was defined as haemoglobin concentration\u0026thinsp;\u0026lt;\u0026thinsp;12 g/dL in women, in accordance with World Health Organization (WHO) criteria.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Blood pressure classification followed ISH/ESC guidelines, with hypertension defined as systolic\u0026thinsp;\u0026ge;\u0026thinsp;140 mmHg and/or diastolic\u0026thinsp;\u0026ge;\u0026thinsp;90 mmHg, and graded as Grade I (140\u0026ndash;159/90\u0026ndash;99 mmHg) or Grade II (\u0026ge;\u0026thinsp;160/100 mmHg).[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Diabetes was defined according to American Diabetes Association (ADA) thresholds, as random blood sugar\u0026thinsp;\u0026ge;\u0026thinsp;200 mg/dL or HbA1c\u0026thinsp;\u0026ge;\u0026thinsp;6.5% when available.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eVision impairment was classified following WHO ICD-10 definitions. Far vision impairment was categorised as mild (worse than 6/12 but equal or better than 6/18 in the better eye), moderate (worse than 6/18 but equal or better than 6/60), and severe (worse than 6/60 but equal or better than 3/60). Near vision impairment was defined as worse than N/6 at 40 cm.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Depth perception was assessed using the Titmus Vision Tester stereopsis evaluation, with scores\u0026thinsp;\u0026lt;\u0026thinsp;70% considered impaired. Peripheral vision deficits were recorded when participants failed to detect stimuli at the standard nasal or temporal field angles.\u003c/p\u003e \u003cp\u003eMusculoskeletal problems were defined using the Modified Nordic Musculoskeletal Questionnaire as self-reported pain, ache, or discomfort in any anatomical site during the last twelve months.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Illumination adequacy was assessed against the Indian Standard IS 3646 (Item 12.1.7, IS 3646 Part 1: 1992, reaffirmed 2003) for hand tailoring, which prescribes a recommended service illumination level of 1000\u0026ndash;2000 lux with provision for local task lighting.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eQuality Assurance\u003c/h2\u003e \u003cp\u003eAll data collection tools and techniques were standardized, and staff were trained in their administration to ensure consistency and reliability. Instruments were calibrated regularly, and pilot testing was conducted prior to the main study to refine procedures and ensure cultural appropriateness. Data were reviewed daily for completeness and accuracy, and any discrepancies were resolved through follow-up with participants where necessary.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Management and Statistical Analysis\u003c/h2\u003e \u003cp\u003eData were entered into a secure digital database with double-entry verification and cleaning before analysis. Descriptive statistics were calculated for all variables, with frequencies and percentages for categorical variables and means, standard deviations, or medians with ranges for continuous variables. Associations between exposures such as work duration with vision impairment was assessed using chi-square tests. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY). Health outcome measures and environmental exposure data were interpreted with reference to established occupational health standards and national/international guidelines.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 101 female embroidery workers participated in the study. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the workforce was predominantly older, with over one-third (35.6%) aged above 50 years and a mean age of 45.93\u0026thinsp;\u0026plusmn;\u0026thinsp;17.18 years. Most participants were currently married (84.2%) and belonged to the Scheduled Caste community (97.0%). Educational attainment was low, with 72.3% being illiterate and only 5.9% having completed higher secondary school or above. More than half (51.5%) resided in pucca houses, although a significant proportion (33.7%) lived in kutcha structures. Most households accessed piped tap water (78.2%), yet more than half (52.5%) did not treat their drinking water. The median household size was five members, and the median monthly family income was INR 10,000, reflecting modest socio-economic conditions.\u003c/p\u003e \u003cp\u003eOccupational and lifestyle characteristics are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All participants were engaged in hand embroidery, working an average of 4.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96 hours daily. Nearly two-thirds (64.4%) had more than ten years of work experience, with an overall mean work duration of 21.57\u0026thinsp;\u0026plusmn;\u0026thinsp;15.16 years. Approximately half (49.5%) possessed an artisan card, indicating formal recognition of their skills. Vegetarianism predominated (87.1%), tobacco chewing was reported by 8.9% of workers, and none reported smoking or alcohol consumption.\u003c/p\u003e \u003cp\u003eNutritional status, non-communicable disease profile, and anaemia prevalence are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Malnutrition was evident at both ends of the spectrum, with 19.8% underweight and 34.6% classified as obese (Obese I or II), in line with the Asian BMI classification. Hypertension was observed in 15.9% of workers, with an additional 12.9% categorised as having high-normal blood pressure. Diabetes prevalence was low at 4.0% based on random blood sugar levels. Anaemia was highly prevalent, affecting 61.4% of participants.\u003c/p\u003e \u003cp\u003eSelf-reported symptoms and musculoskeletal complaints are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Respiratory symptoms were relatively rare, reported by 3\u0026ndash;4% of workers. Conversely, ocular symptoms were common, affecting 60.4% overall, most frequently watering of the eyes (39.6%), itching (31.7%), and burning sensation (23.8%). Musculoskeletal problems were also prominent, with 58.4% reporting at least one site of pain, most commonly in the lower back (39.6%), followed by the neck (27.7%) and knees (22.8%).\u003c/p\u003e \u003cp\u003eVision assessment findings are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Among workers tested, 54.9% exhibited some degree of far vision impairment, predominantly mild (40.9%), while 36.6% had near vision deficits. Only 5.4% of those assessed passed the depth perception test, indicating significant stereopsis impairment. Peripheral vision loss was observed in 38.6% of participants. These visual deficits, coupled with high rates of musculoskeletal complaints, underscore the occupational health risks associated with prolonged, detailed embroidery work.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eWorkplace exposure assessment\u003c/h2\u003e \u003cp\u003eIllumination levels varied widely across the embroidery workplaces (n\u0026thinsp;=\u0026thinsp;19). In Sumrasar, three of the twelve assessed locations achieved adequate lighting as per IS 3646 standards, while two locations exceeded recommended levels due to direct sunlight glare. The remaining seven locations demonstrated inadequate lighting, requiring installation or improvement of local light sources. In Hodko, all seven locations recorded lux values below the prescribed range, indicating consistently poor illumination conditions.\u003c/p\u003e \u003cp\u003eOverall, the findings highlight substantial deficits in workplace lighting, with only 16% (3/19) of locations meeting adequacy standards, while 74% (14/19) were inadequate, and 10% (2/19) excessive. Such inadequate illumination is likely to contribute to visual strain, musculoskeletal discomfort, and reduced occupational efficiency among embroidery workers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and household characteristics of embroidery workers (n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge group (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (17.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (24.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (21.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (35.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (Min, Max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.93\u0026thinsp;\u0026plusmn;\u0026thinsp;17.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScheduled Caste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (97.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Backward Class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot literate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (72.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (14.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher secondary \u0026amp; above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of housing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePucca\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (51.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKutcha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (33.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSemi-pucca\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (14.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian household size\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (range 1\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian family income (INR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10,000 (range 4,000\u0026ndash;40,000)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOccupational profile and personal habits of embroidery workers (n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork hours per day (\u003c/b\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork experience in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (18.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (16.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (64.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (Min, Max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.57\u0026thinsp;\u0026plusmn;\u0026thinsp;15.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHas artisan card\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (49.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiet\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVegetarian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (87.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTobacco use (current)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlcohol use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNutritional status, non-communicable disease profile, and anaemia prevalence (n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (Asian classification)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderweight (\u0026lt;\u0026thinsp;18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (19.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal (18.5\u0026ndash;22.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (32.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight (23.0\u0026ndash;24.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObese I (25.0\u0026ndash;29.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (27.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObese II (\u0026ge;\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (6.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood pressure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72 (71.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade I hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade II hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes (RBS\u0026thinsp;\u0026ge;\u0026thinsp;200 mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnaemia (Hb\u0026thinsp;\u0026lt;\u0026thinsp;12 g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62 (61.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-reported symptoms and musculoskeletal problems (n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny respiratory symptom\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic cough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyspnoea (all grades)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny eye symptom\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61 (60.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWatering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (39.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (31.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRedness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny musculoskeletal problem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59 (58.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (39.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeck pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (27.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnee pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (22.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVision assessment outcomes among embroidery workers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVision parameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFar vision (n\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (45.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild impairment (worse than 6/12, equal or better than 6/18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (40.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate impairment (worse than 6/18, equal or better than 6/60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (14.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNear vision (n\u0026thinsp;=\u0026thinsp;93)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59 (63.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpaired (worse than N/6 at 40cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (36.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepth perception (n\u0026thinsp;=\u0026thinsp;37)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePass [Shepard\u0026ndash;Fry percentage more than 70% (Angle of Stereopsis in seconds of arc 50)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFail [Shepard\u0026ndash;Fry percentage less than 70% (Angle of Stereopsis in seconds of arc 50)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (94.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeripheral vision (n\u0026thinsp;=\u0026thinsp;57)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePass [Left \u0026amp; Right Peripheral (85\u0026deg;,70\u0026deg;,55\u0026deg;), Nasal 45\u0026deg; - response yes]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (61.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFail [Left \u0026amp; Right Peripheral (85\u0026deg;,70\u0026deg;,55\u0026deg;), Nasal 45\u0026deg; - response no]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (38.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis cross-sectional study provides a comprehensive assessment of occupational exposures and health outcomes among female embroidery workers in Kutch-Bhuj, Gujarat, a population typically overlooked in occupational health research. The findings reveal significant health challenges affecting this artisanal workforce, most notably a high burden of malnutrition, anaemia, musculoskeletal pain, and vision impairment. These results highlight the vulnerability of women engaged in traditional craft sectors and underscore the urgent need for targeted preventive strategies and policy interventions.\u003c/p\u003e \u003cp\u003eThe demographic profile of the embroidery workers indicates a predominantly older, socially marginalized, and socioeconomically disadvantaged workforce, reflecting national trends seen among Indian craftswomen.[\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] With more than one-third above 50 years of age and the majority being illiterate, these women face intersecting vulnerabilities related to age, caste, and education\u0026mdash;factors consistently linked to adverse health outcomes and reduced healthcare access in India and other low- and middle-income countries (LMICs).[\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] The high prevalence of illiteracy and limited monthly income further restrict these women\u0026rsquo;s ability to access preventive and healthcare services, mirroring findings from studies on informal sector workers in South Asia.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOccupationally, the workforce was highly experienced, with two-thirds having more than a decade of engagement in embroidery. The mean daily work duration of 4.6 hours, though seemingly modest, involved persistent, repetitive fine-motor activity under suboptimal ergonomic conditions. The high prevalence of musculoskeletal pain, particularly in the lower back, neck, and knees, aligns with previous research on home-based handcraft workers, which documents increased risk of musculoskeletal disorders due to prolonged static postures, repetitive motion, and inadequate workstations.[\u003cspan additionalcitationids=\"CR27 CR28 CR29\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] These patterns have been consistently demonstrated in studies of female artisanal and garment sector workers in India, Bangladesh, and Southeast Asia.[\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eVisual morbidity represents another critical occupational hazard. Over half of the sample demonstrated either mild or moderate far vision impairment, more than one-third had near vision deficits, and nearly all those assessed had impaired depth perception. These findings corroborate earlier reports of high rates of visual fatigue and deterioration among needlecraft workers, where sustained close-up work, poor lighting, and lack of corrective eyewear drive cumulative ocular strain and function loss.[\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] The high prevalence of eye-related symptoms such as watering, burning, and itching further reflects this cumulative burden.\u003c/p\u003e \u003cp\u003eNutritional status was also concerning, with a dual burden of underweight (19.8%) and overweight/obesity (34.6%)\u0026mdash;an increasingly recognized phenomenon among women in poverty-affected households with shifting dietary patterns. Anaemia was widely prevalent (61.4%) in line with national data on rural and disadvantaged Indian women, and likely undermines work capacity, productivity, and quality of life. The presence of hypertension (15.9%) and diabetes (4%) underscores the non-communicable disease (NCD) risk now well-documented among women in the informal sector, exacerbated by age, nutrition transitions, and limited healthcare access.\u003c/p\u003e \u003cp\u003eThe home-based, informal nature of embroidery work exacerbates risk exposure, as workers lack protection under formal occupational safety regulations, have limited bargaining power, and minimal access to health surveillance or benefits. This finding is consistent with global reports highlighting the occupational invisibility of women in artisanal value chains and the gendered impacts of informal labour structures.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStudy strengths and limitations\u003c/h2\u003e \u003cp\u003eStrengths of this study include its robust sample size, use of validated tools, and careful measurement of occupational and health parameters. Limitations include the cross-sectional design, reliance on self-reported morbidity for some outcomes, and the restriction to selected artisan clusters, which may limit generalizability. Future research should explore longitudinal associations and the impact of targeted workplace interventions, ergonomic improvements, and vision care programs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePolicy implications\u003c/h2\u003e \u003cp\u003eThis study was conducted in response to a priority request from the Development Commissioner (Handicrafts), Ministry of Textiles, and was supported by the National Health Mission (NHM) of Gujarat. Drawing from field data and stakeholder consultations, the study developed occupational Standard Operating Procedures (SOPs) tailored to the unique risks encountered by female embroidery workers in informal, home-based settings. These SOPs encompass practical recommendations to improve workplace lighting, ergonomic redesigns of workstations, scheduled rest breaks, access to periodic occupational health screening (vision tests, nutritional and anaemia assessment, blood pressure monitoring) integrated into the primary healthcare system, and culturally sensitive health education modules. The initial adoption of these SOPs by DC Handicrafts and NHM Gujarat establishes a replicable model for embedding occupational health services within other informal and traditional craft sectors. Policies focused on women-centred outreach, social security enrolment, and occupational health literacy are particularly critical for safeguarding the health and livelihoods of this highly vulnerable female workforce.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe findings from this study highlight the significant vulnerability of women in the hand embroidery sector, resulting from intersecting challenges related to gender, caste, socioeconomic marginalization, and informal work conditions. These artisans face both elevated occupational health risks and a lack of workplace protections. Integrating occupational health screening and preventive care into primary healthcare\u0026mdash;particularly via community health workers\u0026mdash;offers a practical and equitable means to support this high-risk group. Policy priorities should include accessible health education, social security enrolment, ergonomic improvements, and regular vision and nutrition assessments targeted to women in the informal artisan workforce. Advancing these measures is essential for promoting women\u0026rsquo;s health equity and preserving the economic independence and cultural heritage upheld by these artisans.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Human Ethics Committee of ICMR-National Institute of Occupational Health (ICMR-NIOH/EC/2023/2) and conducted in accordance with the Helsinki Declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants, who were assured of confidentiality, anonymity, and their right to withdraw at any time.\u0026nbsp;Participants identified with health problems during clinical assessments were referred to nearby government hospitals for further evaluation and management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of anonymized data was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe datasets generated are not publicly available due to privacy concerns but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was funded by the State Health Systems Resource Centre (SHSRC), Gujarat, under the National Health Mission. The funder had no role in the study design, data collection, analysis, interpretation, or in the writing of the manuscript. The funding supported field implementation and the development of craft-specific occupational health SOPs for submission to relevant authorities. The authors being full time research faculties of the non-profit occupational health research institutes, conducted and reported this study within their independent capacity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAS, NK, RB and AV conceived and designed the study and contributed to data collection. All authors contributed to data interpretation and manuscript revision. AS, NK and AV performed the data analysis. AS drafted the manuscript. All authors approved the final version of manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the support of Dr. A. M. Kadri, Dr. Harsh Bakshi, and Dr. Aastha Vala from SHSRC Gujarat for their facilitation, guidance, and coordination throughout the study. We extend our sincere thanks to Mr. Raviveer Choudhary and Mr. Shekhar Sharma from the office of DC Handicrafts, Bhuj, for their support during fieldwork and stakeholder engagement. We are deeply thankful to all participating copper bell makers for their time and cooperation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration:\u003c/strong\u003e Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ePlanning Commission. 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Singapore: Springer Nature Singapore; 2024. p. 1-22.\u003c/li\u003e\n \u003cli\u003eScrase TJ. From Marginalized Worker to Impoverished Entrepreneur: The Globalization of the Trade in Crafts and Its Impact on Indian Artisans. In: Gillan M, Pokrant B, editors. Trade, Labour and Transformation of Community in Asia. London: Palgrave Macmillan UK; 2009. p. 102-26.\u003c/li\u003e\n \u003cli\u003eMeher AK, Venkatachalapathy TK, Panda PK. Musculoskeletal disorders among the handloom weavers in odisha, India: A cross-sectional study. Clinical Epidemiology and Global Health. 2025;33:101965.\u003c/li\u003e\n \u003cli\u003eKoiri P. Occupational health problems of the handloom workers: A cross sectional study of Sualkuchi, Assam, Northeast India. Clinical Epidemiology and Global Health. 2020;8(4):1264-71.\u003c/li\u003e\n \u003cli\u003eDas D, Kumar A, Sharma M. A systematic review of work-related musculoskeletal disorders among handicraft workers. 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Prevalence of work related musculoskeletal disorders (WMSDs) and ergonomic risk assessment among readymade garment workers of Bangladesh: A cross sectional study. PLoS One. 2018;13(7):e0200122.\u003c/li\u003e\n \u003cli\u003eGarg P, Raj P, Chellaiyan VG, Singh A. A Cross-Sectional Study on Visual Problems among Zari Artisans of North India. Journal of Surgical Specialties and Rural Practice. 2023;4(1):23-7.\u003c/li\u003e\n \u003cli\u003eKhan MA. Assessment Of Refractive Error Among Zari Artisans Of Uttar Pradesh. African Journal of Biomedical Research. 2024:963-70.\u003c/li\u003e\n \u003cli\u003eMarmamula S, Narsaiah S, Shekhar K, Khanna RC. Visual impairment among weaving communities in Prakasam district in South India. PLoS One. 2013;8(2):e55924.\u003c/li\u003e\n \u003cli\u003eMadraswala ME, Moodley VR, Mashige KP. Visual Status, Ocular Profiles and Associated Quality of Life of Workers in the Weaving Community of Salem District, Tamil Nadu, South India. Indian J Occup Environ Med. 2025;29(1):65-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Occupational Health Services, Vision Screening, Ergonomics, Lighting, Female, Musculoskeletal Pain, Primary Health Care","lastPublishedDoi":"10.21203/rs.3.rs-8486548/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8486548/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eHand embroidery is a culturally significant craft and key source of livelihood for women in rural India, particularly in regions like Kutch-Bhuj, Gujarat. Despite its socioeconomic value, the sector is dominated by informal, home-based work arrangements lacking occupational safety measures and consistent health surveillance. Artisans, predominantly women, are exposed to multiple occupational hazards, yet systematic data on these exposures and associated health outcomes are limited.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaterials and methods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA cross-sectional observational study was conducted among 101 female embroidery workers from artisan clusters in Kutch-Bhuj. Eligible participants were women aged 18 years or older with at least two years of embroidery experience. Data were collected using structured interviews and validated tools, including adapted ATS and Nordic Musculoskeletal Questionnaires. Anthropometric measurements, vision screening, blood pressure, haemoglobin, and random blood sugar were assessed using standardized protocols. Workplace illumination was measured against Indian standards.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe workforce was predominantly older (mean age 45.9 years), socially disadvantaged, and largely illiterate. Nearly two-thirds had over ten years of work experience. High burdens of health problems were identified: anaemia (61.4%), overweight/obesity (34.6%), and hypertension (15.9%). Musculoskeletal complaints affected 58.4%, chiefly the lower back and neck. Eye-related symptoms were widespread (60.4%), with 54.9% exhibiting far vision impairment and 36.6% near vision impairment; depth perception and peripheral vision deficits were also common. Suboptimal workplace lighting and ergonomics were noted.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWomen embroidery workers in Kutch-Bhuj face a substantial burden of occupational exposures and related health morbidities, shaped by informal work arrangements and limited access to health interventions. Findings underscore the urgency of integrating occupational health services with primary care, improving ergonomic and environmental conditions, and developing gender-responsive health education and social security programs to protect this vulnerable population.\u003c/p\u003e","manuscriptTitle":"Work Related Health Risks Among Women Embroidery Artisans in India’s Informal Economy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 09:17:56","doi":"10.21203/rs.3.rs-8486548/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-11T17:29:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T18:15:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-04T18:52:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-28T11:05:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178644070423887888657431868170848466325","date":"2026-01-15T05:08:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312727692920095936531560699532776458644","date":"2026-01-15T05:00:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259557180823606852519099098737409555762","date":"2026-01-14T15:32:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-14T14:48:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-14T14:42:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-13T13:39:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-07T18:18:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-01-07T18:13:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"911bd7cb-84c9-457f-b813-28abb5ec6c8d","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T06:55:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-19 09:17:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8486548","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8486548","identity":"rs-8486548","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}