INTRODUCTION:

Body art, including Tattooing and Body piercing have been prevalent for thousands of years in a variety of cultures. Tattoos have been found on a 5200-year-old Neolithic mummy, and body piercing was common during the Victorian era. Tattooing is described as the implantation of pigment in the skin. Body piercing is the practice of puncturing or cutting a part of the human body, creating an opening in which jewelry may be worn¹. Nowadays piercing and tattoos are common in all lifestyles and all strata of the society.

A tattoo is a puncture wound, made deep in the skin, that’s filled with ink. It’s made by penetrating the skin with needle and injecting ink into the area, usually creating some sort of design. The ink is injected into the dermis instead of epidermis. Tattooing can be done manually – that is the tattoo artist would puncture the skin with a needle and inject the ink by hand. But nowadays a tattoo machine is used. A tattoo machine is a handheld electric instrument that uses a tube and a needle system. On one end is a needle, which is attached to tubes that contain ink. A switch is used to turn on the machine, which moves the needle in and out while driving the ink about 1/8 inch (about 3 millimeters) into your skin. A tattooing machine can puncture the skin 3,000 times a minute and every one of those thousands of punctures creates a hole 1/64 to 1/16th of an inch into the dermis that literally invites infection and disease. ²

Tattoo shop operators do not generally work in a clean environment, wear clean clothing, face masks, or sterile gloves. Even when some of them do use disposable instruments, just by talking and touching a variety of objects while actually doing a tattoo, practically guarantee contaminating their customers’ skin, which in essence has hundreds of tiny open wounds caused by the tattooing needles. There exists no or very little federal or state laws enforcing any serious sterilization regulations

Since there is little regulation of tattoo artists, however, it is important to recognize that, as in any field, there may be unscrupulous or incompetent practitioners.

Recently tattooing and piercing have gained increasing popularity worldwide, through all social classes and age groups. Unfortunately, with this higher demand, the number of unprofessional tattooists and piercers has increased creating more complications due to frequent procedures carried out without any knowledge of health and hygiene rules. The scientific literature shows a wide range of health consequences both infectious (e.g. HIV, HBV and HCV, mycobacterial infections, abscess, endocarditis, tetanus) and non-infectious (e.g. dermatitis, hemorrhage, allergies) because most tattoo pigments are derived from metals, and these metals may cause some people to have an allergic skin reaction.³

Even when tattoos are well when it is done, problems may arise later and when the person wants to remove the pigment from your skin. In fact, it is estimated that of the 10% of the U.S. population with tattoos, almost half will eventually have them covered or removed. Tattoos can be removed by laser removal, excision and dermabrasion. Scar formation is a possible side effect, as it is incomplete removal of the tattoo.^(4,5)

In approximately the last twenty years, there has been a new trend of people getting tattoos. It is the sixth largest business in the United States. Adolescents are experimenting with their identities and they may be drawn to piercings or tattoos as a form of expression or rebellion. Tattoos and piercings can have harmful side effects that teens may not be aware of. ^{(6, 7)}

Tattooing poses health risks because the process exposes to blood and body fluids. These bloods borne diseases include hepatitis B, hepatitis C, tetanus and HIV. Hepatitis can be transmitted with as little as 0.00004ml of blood and can live on blood contaminated surfaces such as needles, tattoo machine, tables etc. for over two months. Tattoos can cause chronic skin disorders such as sarcoid, keloid scarring, allergic dermatitis, photosensitivity reactions, and psoriasis. Many people experience infection and allergic reaction to tattoo ink. Health risks associated with piercings include infections, scar tissue, uncontrolled bleeding, swelling and draining wounds.^{(8, 9)}

It is estimated that roughly 10% of the population are wearing tattoos globally. A survey conducted by American Academy of Pediatrics on undergraduate university students, found that 60% of females were pierced (ear lobes excluded) and 26% had tattoos .¹⁰

According to a report published in 2006 by the Food and Drug Administration (FDA) ,150 cases of 'adverse reactions' in the United States were reported due to tattooing. In the United States, the Red Cross prohibits a person who has received a tattoo from donating blood for 12 months.^(11,12)

According to a Preventive Medicine Specialist and a former official from the Centre For Disease Control Infection, “commercially acquired tattoos accounted for more than twice as many Hepatitis C infections as injection drug use.”

A survey report was published in the Journal of school health in 2001, the results of the study revealed that 70% of 642 adolescents reported hemorrhaging while being tattooed.¹³

A study recently published by University of Texas South Western Medical School in Dallas uncovered that the innocent commercial tattoo may be the number one distributor of Hepatitis C.¹⁴

A study was conducted by the 17^th annual conference of the Indian National Association for the Study of Liver. The conclusions of the study revealed that 20-40% of people are infected with HCV due to tattooing and piercing because of not properly sterilized needles. The key to successfully tackling the challenge of chronic Hepatitis lies in creating awareness and through better public education in India.¹⁵

A study published by the Indian National Association for the study of Liver, revealed that Hepatitis C is spreading fast in India, over 1 lakh people get infected by the deadly HCV virus every year. Nearly 12.5 million Indians are suffering from Hepatitis C disease. Every 15^th carrier of the Hepatitis C virus is an Indian according to a recent report.¹⁵

An article in Times of India has revealed that individuals with multiple tattoos that cover large parts of their bodies are at higher risk of contracting Hepatitis C and other blood borne diseases. The researchers from British Columbia University reviewed and analyzed 124 studies from 30 countries including Canada, Iran, Italy, Brazil and U.S and found the incidence of Hepatitis C after tattooing is directly linked with the number of tattoos an individual receives.¹⁶

A study was conducted in Andhra Pradesh state of India on 890 individuals. The conclusions of the study revealed that 46 samples were positive for HBV and 18 were positive for HCV. One of the potential reasons were cultural practices such as tattooing and body piercing.¹⁷

Unfortunately, in many countries including India, anyone can begin to tattoo or create an artificial opening for a jewelry after purchasing the necessary equipment. No knowledge of anatomy, sanitation, sterilization, infection control, or skin preparation or care are required. Though tattooing is legal, there is little or no government regulation to ensure and monitor safe tattooing practices.¹²

In the last 2 decades, tattoos and piercing have gained more and more acceptance in India. The investigator has seen many adolescents involved in tattooing and body piercing. Most of them did not know about the harmful effects or complications. So, the researcher felt the need to assess their knowledge and attitude and to ensure them safe practices in case they need it.

OBJECTIVES OF THE STUDY:

1. To assess the knowledge of adolescents on effects of tattooing and body piercing.

2. To assess the attitude of adolescents on effects of tattooing and body piercing.

3. To find the correlation between the knowledge and attitude of adolescents regarding effects of tattooing and body piercing.

4. To find the association between the knowledge of adolescents regarding the effects of tattooing and body piercing with selected demographic variables.

5. To find the association between the attitude of adolescents regarding the effects of tattooing and body piercing with selected demographic variables.

6. To develop an information booklet on effects of tattooing and body piercing.

HYPOTHESES:

H_1: There is a significant correlation between knowledge and attitude of adolescents regarding effects of tattooing and body piercing.

H_2: There is a significant association between knowledge of adolescents regarding effects of tattooing and body piercing and selected demographic variables.

H_3: There is a significant association between attitude of adolescents regarding effects of tattooing and body piercing and selected demographic variables.

CONCEPTUAL FRAMEWORK:

The conceptual framework chosen for this study is based on Health Belief Model which was developed in 1950 by Hochbaum, Beker and Rosenstock. The model comprises of:

INDIVIDUAL PERCEPTION:

Perceived Susceptibility: In the present study, adolescents have lack of knowledge regarding the effects of tattooing and body piercing.

Perceived Seriousness: It refers to the chances of spread of blood borne diseases and complications due to the disease.

Perceived Threat: Perceived threat refers to the diseases which are spread by tattooing and body piercing like Hepatitis, HIV infection, Tetanus, and Skin infections. To identify the perceived threat the knowledge of parents and attitude scale was adopted.

MODIFYING FACTORS:

It includes Demographic factors like Age, Gender, Income of The Family, Religion, Educational Status of The Father, Educational Status of The Mother, Occupation of The Father, Occupation of The Mother, Family Members or Friends with Tattooing and Body Piercing and Leisure Time Activities.

CUES TO ACTION:

Refers to the strategies to activate readiness. Here it refers to Health personnel’s, T.V, Radio, Friends, Magazines and Information booklet developed by the researcher.

LIKELIHOOD OF ACTION:

Perceived benefits: Here it refers to the adolescent’s knowledge regarding the effects of tattooing and body piercing.

Perceived barriers: Refer to one’s opinion of the tangible and psychological costs of the advised action. It refers to ignorance, peer influence and family background.

Recommendation for action: It refers to the measures like being up to date with the Immunization, reading health magazines related to health issues and avoiding practices like tattooing and body piercing.

METHODOLOGY:

The research approach was a qualitative survey in which the design was descriptive correlation design.

The setting of the study was in a college and the population consisted of adolescents of age 16-18 years. The sample size was 100 adolescents. The sampling technique was simple random sampling technique using random number table

The research variable was knowledge and attitude of adolescents on the effects of tattooing and body piercing. The demographic variables were age, gender, religion, income of the family, educational status of father, educational status of the mother, occupation of the father, occupation of the mother, family members or friends with tattooing or body piercing and leisure time activities.

A self-administered questionnaire for knowledge and 5-point Likert’s scale for attitude was prepared

Inference was drawn as below:

Adequate knowledge – A score more than 75 %

Moderately adequate knowledge –A score between 50% - 75%.

Inadequate knowledge level – A score less than 50%

A modified Likert’s 5-point scale is used to measure adolescent’s attitude. It consists of 16 items and 5 columns such as strongly agree 5, agree 4, uncertain 3, disagree 2, strongly disagree 1. There are 8 positive statements with the total score of 40 and 8 negative statements with total score of 40. The maximum score is 80 and minimum score is 16. The resulting scores were ranged as follows

Favorable Attitude: >50% Unfavorable Attitude <50%

Reliability of the Tool was assessed using split – half method under Spearman Brown’s prophecy formula. The reliability of the tool of the self-administered questionnaire was 0. 87 and attitude was 0.97. It was statistically significant and thus the tool was reliable.

RESULTS:

Findings related to the demographic characteristics:

It is observed that the proportion of adolescents belonged to the age group of 18 years were 34(34%), 17 years were 33(33%) and 16 years were 33(33%). 50 (50%) were male and 50(50%) were female. The religion of the adolescents were Hindus 52(52%) Christians 28(28 %) and Muslims 20(20 %).In the income of the family, 27(27%) of them had family income of less than or equal to Rs.5000 per month, 36(36%) of them had income of Rs.5,001-10,000 per month , 21(21%) of them had family income of Rs.10001-15000 per month and 16(16%) of them had family income of Rs.15,001 and above per month .In the educational qualification of the fathers, most of them had completed secondary education 30 (30%), 26(26 %) of them were graduates and above, 17(17%) of them had primary education, 16(16%) of them studied up to PUC and 11(11%) of them had only non-formal education. Most of the mothers had only non-formal education 35(35 %), 10(10 %) had primary education, 11(11%) had secondary education, 19(19%) had studied up to PUC and 25(25%) of them were graduates and above. The Fathers employed in Private sector were 56 (56%), 22(22%) in Government sector and 22(22%) in Business sector. Majority of the mothers were private employees 57(57%), 40(40%) of them were housewives, 3(3%) of them were Government employee and none of them were involved in business. Adolescents with friends or family members with tattooing or body piercing were 57(57%) and 43(43%) of them did not have friends or family members with tattooing or body piercing. 43(43 %) adolescents spent their leisure time in reading books, 32(32%) of them watched movies, 13(13%) of them browsed the internet, and 12(12 %) were interested in playing sports.

Table 1: This table shows the aspect wise distribution of subjects according to the level of knowledge on effects of tattooing and body piercing.

LEVEL OF KNOWLEDGE
Sl. No	Aspects	Inadequate	Moderately adequate	Adequate
1	Knowledge on Tattooing and Body piercing	73(73%)	24(24%)	3(3%)
2	Knowledge on mode of spread of diseases and diseases spread by tattooing and body piercing.	91(91%)	9(9%)	-
3	Knowledge on Prevention and Management	84(84%)	14(14%)	2(2%)
	OVERALL	94(94%)	6(6%)	-

Table 2: Range, Mean, Mean percentage and Standard Deviation of the aspect wise knowledge of adolescents on the effects of tattooing and body piercing.

SL No.	Aspects	Maximum Score	Range	Mean	Mean%	Standard Deviation
1	Knowledge on tattooing and body piercing	5	1-4	1.87	37.4	0.767
2	Knowledge on mode of spread of diseases by tattooing and body piercing	10	2-7	4.11	41.1	1.04
3	Knowledge on Prevention and management of diseases by tattooing and body piercing	13	3-11	5.47	42.07	1.315
	OVERALL	18	9-18	11.45	40.89	2.175

Table 3: Attitude of adolescents on the effects of tattooing and body piercing.

Sl.No	Level of attitude	Favorable attitude	Unfavorable attitude
1	Attitude level	33(33%)	67(67%)

Table 4: Range, mean, mean percentage and standard deviation for the attitude of adolescents on the effects of tattooing and body piercing.

N=100

Sl.

Max.

score

Range

Mean

Variables

21-64

38.76

48.25

11.14

SD= Standard deviation

· The correlation between knowledge and attitude was assessed using Spearman’s correlation “R” which was 0.173.

· Association of knowledge with demographic variables revealed that a significant correlation was found between knowledge and Gender, Income of the family and Educational status of the father, Educational status of the mother, occupation of the father and Family members or friends with tattooing and body piercing.

· It was also found that there was no statistically significant correlation between attitude and demographic variables

DISCUSSION:

1. The first objective of the study was to assess the knowledge of adolescents on effects of tattooing and body piercing: The overall knowledge was assessed and tabulated. It is inferred that 94(94%) of them had Inadequate knowledge, 6(6%) of them were having moderate knowledge and none of them had adequate knowledge.

2. The second objective of the study was to assess the attitude of adolescents on effects of tattooing and body piercing: 33(33%) of them had Favorable attitude and 67 (67%)of them have Unfavorable attitude.

3. The third objective was to find the correlation between the knowledge and attitude of adolescents regarding effects of tattooing and body piercing : The Spearman’s correlation ‘R ’value was calculated which was 0.173 which was found to be significant at P< 0.05 with weak positive correlation, which states that as the knowledge increases the attitude of adolescents also increases on effects of tattooing and body piercing. Hence the stated hypothesis H1is accepted.

4. The fourth objective was to find the association between the knowledge of adolescents regarding the effects of tattooing and body piercing with selected demographic variables: There was significant association between knowledge and variables like Gender, Income of the family, Educational status of the father, Educational status of the mother, Occupation of the father, Family members or friends with tattooing and body piercing and hence H2 is accepted for these variables. There was no significant association between knowledge and variables like Age, Religion, Occupation of the mother and Leisure time activities.

5. The fifth objective was to find the association between the attitude of adolescents regarding the effects of tattooing and body piercing with selected demographic variables: There was no significant association between knowledge and demographic variables. Hence the hypothesis H3 is rejected.

6. The sixth objective was to develop an information booklet on effects of tattooing and body piercing: A short information booklet was prepared which contains information regarding risks involved and diseases spread by tattooing and body piercing, causes and precautionary measures

CONCLUSION:

Based on the above findings of the study, implications and recommendations were drawn for nursing service, administration, education and research. The study concluded that the majority of Pre-University College adolescents had inadequate knowledge and unfavorable attitude on the effects of tattooing and body piercing.

RECOMMENDATIONS:

1. The same study could be undertaken in large samples, where findings can be generalized.

2. A comparative study can be undertaken to compare the knowledge and attitude of adolescents on the effects of tattooing and body piercing between urban and rural adolescents.

3. A structured teaching program can be given to the adolescents on the effects of tattooing and body piercing.

4. Orientation programs could be planned, implemented and evaluated to find out the effectiveness on reducing the harmful effects of tattooing and body piercing.

REFERENCES:

1. Body piercing URL http://www.sccs.swarthmore.edu/users/08/ajb/tmve/wiki100k/docs/Body_pie rcing.html

2. Chroma tattoo. URL http://www.chromatattoo.com/index.php/en/group2/whatis

3. AlessiaQuaranta, Christian Napoli Body piercing and tattoos: a survey on young adults' knowledge of the risks and practices in body art URLhttp://www.biomedcentral.com/1471-2458/11/774

4. URLhttp://brownskin.net/tattoos.htm

5. Tattoo removal. URLhttp://www.rejuvemedical.com/ services/tattoo_removal.html

6. Tattoos art or disaster. URLhttp://amerids.blogspot.in/2009/03/tattoos-art-or- disaster.html

7. Piercing and self-expression. URLhttp://www.megaessays.com/viewpaper/476.html

8. Tattoos and diseases. URLhttp://bodyart.iloveindia.com/tattoo-risks/diseases.html

9. Tattoos deadly secret. URLhttp://www.biblebelievers.com/watkins_tattoos/health.html

10. Tattooing and body piercing. AAP-Official Journal of the AAP. May 2003:Vol 111 [5]:1126 URL:http://pediatrics.aapublications.org/cgi/content/full/111/5/

11. Marc G. Ghany, Doris B. Strader. Diagnosis, Management, and Treatment of Hepatitis C:An Update URLhttp://www.aasld.org/practiceguidelines/documents/hepatitis%20c%20update.pdf

12. URLhttp://www.av1611.org/tattoos/health.html

13. Donald Staffo. Journal of School Health. Tuscaloosa Times. Jan 10 2001

14. Haley R.W,FischerR.P.Commercial tattooing as a potential source of hepatitisC infection . Journal Medicine. March 2000(80):134-50 URL:http://biblebelivers.com/watkins-tattoos/health.html

15. Hepatitis C in India-An emerging scourge. Friday April 3 2009 6:20. URL:http://www.dancewithshadows.com/pillscribe/hepatitis-C-india-an-emerging- scourge

16. Tattooing linked to higher hepatitis C risk. ANI.Aug 13,2010 ,12.00am URL:http://timesofindia.indiatimes.com/lifestyle/healthfitness/health/Tattooing-linked-tohigherhepatitisC/articleshow/6270383.cms

17. Chandra. M, Khaja.M.N, Farees N ,et al. Prevalence, risk factors and genotype distribution of HCV and HBV infection in the tribal population: a community based study in south india Centre for Liver Research and Diagnostics, URL:http://www.ncbi.nlm.nih.gov/pubmed15164530

Received on 04.06.2019 Modified on 10.08.2019

Asian J. Nursing Education and Research. 2020; 10(2):115-120.

DOI: 10.5958/2349-2996.2020.00026.9