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Body Art in 4277 Italian Secondary School Adolescents_ Prevalence

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					                                                                                                          Vol. 42, No. 4        273

Clinical Research and Methods



                  Body Art in 4,277 Italian Secondary School
                  Adolescents: Prevalence and Associations
                   With Personal and Family Characteristics
  Luca Cegolon, MD, FFPH; Giuseppe Mastrangelo, MD; Francesco Mazzoleni, MD;
Silvia Majori, MD; Tatjana Baldovin, PhD; Carla Xodo, MA, and VAHP Working Group


Background and Objectives: This study’s purpose was to investigate, in a large cohort of adolescents,
the prevalence and association of personal and family characteristics with having or considering
body piercing or tattoo. Methods: We surveyed students from the Veneto Region of northeast Italy
with a self-administered questionnaire that asked about body piercing and tattoo and about personal
and family characteristics. Multinomial weighted regression analysis was used to generate adjusted
relative risk ratios with 95% confidence interval (CI) for piercing and tattooing separately. Results:
A total of 4,277 of 4,524 surveyed students completed and returned a usable questionnaire. For
piercing, the prevalence was 20%. Girls, students with a less educated father, and those dissatis-
fied with their physical appearance were more likely to be interested in and to have undergone this
procedure. For tattooing, the prevalence was 6%. Boys and students whose father was younger than
48 were more likely to have experienced tattooing. A strong association was found between having
a piercing and having a tattoo. Fify-six percent of pierced students and 48% of tattooed students
were underage (<18 years). Conclusions: We found that male gender (for tattoo), female gender (for
piercing), dissatisfaction with physical appearance, positive attitudes toward either piercing or tat-
too, and having a younger and less educated father were associated with having or desiring body
modification. These factors could be considered for targeted patient education.

(Fam Med 2010;42(4):273-9.)




The most recent studies on tattooing and body pierc-                            Since secondary school students are normally un-
ing have focused on university students and have been                       derage, piercing and tattooing are often unavailable to
aimed at describing the characteristics (in terms of                        them. Nonetheless, the few studies involving secondary
body site involved, etc), prevalence and distribution (ac-                  school students, performed mostly in the United States
cording to gender, age, personality traits, and cultural                    and Canada, have found that these students do undergo
characteristics), and medical complications of these                        piercing and tattooing, with the reported prevalence of
practices. Studies of younger adolescents have been                         body piercing ranging from 27% to 42% and the preva-
limited to individuals in high-risk categories, such as                     lence of tattoos ranging from 4.5% to 10%.6,8,11,12
those in prison,1 those with character disorders,2-5 sub-                       The focus of the aforementioned studies has been
stance abusers,1,3,4 6,7 risk-taking individuals,3,8 or other               on the prevalence—despite being underage—of body
special categories.3,9,10                                                   piercing and tattooing, rather than on attitudes and
                                                                            future intentions. But, this segment of the population
                                                                            is likely to include a substantial number of non-pierced,
                                                                            non-tattooed subjects who are interested in or consid-
                                                                            ering these practices for the future. An understanding
From the Department of Environmental Medicine and Public Health (Drs        of the attitudes of these individuals could then be used
Cegolon, Mastrangelo, and Baldovin), Department of Medical and Surgical     to predict future trends toward tattoos/body piercing
Sciences (Dr Mazzoleni), Department of Educational Sciences (Dr Xodo),
University of Padua, Italy; and Department of Medicine and Public Health,   and assist in developing education campaigns about
University of Verona, Italy (Dr Majori).                                    piercing and tattooing.
274     April 2010                                                                                  Family Medicine

   The need for such educational interventions is af-           The institutional review board of Postgraduate
firmed by the health risks commonly associated with          Training Institution for Secondary School Teachers
body piercing (infection, pain, bleeding, hematoma           of the Veneto Region (and the schools’ head teachers)
formation, cyst formation, allergic reaction, hyper-         approved the study protocol. Since the questionnaire
trophic scarring, and keloid formation13-17) and tattoos     was anonymous and self-administered, and the subject
(infections, phototoxicity, allergic reaction, pseudo-       of the interview was deemed nonintrusive, parental
lymphomatous reaction, and immunological rejection           consent for participants younger than 18 years was
of the tattoo).18,19 In a study of 2,145 Canadian high       waived. No incentives were provided for completing
school adolescents, of those who had a tattoo, 7% re-        the questionnaire.
ported infections and 5% reported allergies as a result
of the tattoo.6                                              Data Collection
   Determinants of body art might differ between those          The survey was carried out in 2007. In each class-
who have already undergone tattoo/piercing and those         room, before the interview, a researcher explained the
merely considering it. Since the issue has seldom been       purpose and methods of the study, the time necessary to
explored, our study investigated, in a large sample of       complete the questionnaire, and that the results would
secondary school adolescents, the prevalence and the         remain fully confidential. The fact that participation
association between personal and family characteristics      was free was emphasized and also that a written in-
and the propensity to either have a piercing or a tattoo     formed consent was not required. The questionnaire
or to be considering either of those procedures.             was returned in a sealed envelope after its comple-
                                                             tion.
Methods
Sampling Strategy                                            Statistical Analysis
   This study was conducted in the seven provinces of           Since the key outcome variable (attitude toward body
the Veneto Region in northeastern Italy. We selected         art) was categorical with more than two levels (already
six schools (representing each of the six types of Italian   experienced, interested/keen to try, indifferent/not
public secondary schools) in each of the seven prov-         interested), multinomial logistic regression analysis
inces, for a total of 42 schools. After individual nego-     was used, reporting relative risk ratios (RRR) with a
tiations with the respective schools’ head teachers, 41      95% confidence interval (CI), separately for piercing
schools agreed to take part in the study. Within each of     and tattooing. The regression analysis was weighted for
the participating schools, two sections of pupils attend-    age and gender, using 2007 census data of the Veneto
ing the first, third, and fifth years of secondary school    Region as a reference.
were randomly selected, for a total subject population          In building up the final regression model, variables
of 4,524 students.                                           were selected by backwards stepwise selection using
                                                             a P<.05 criterion. Nevertheless, some of the variables
Questionnaire                                                whose likelihood ratio (LR) test was not statistically
   We used a structured 22-item questionnaire that took      significant (P>.05) were still retained in the model if
approximately 10 minutes to complete. This question-         this resulted in them being a substantial confounder (ie,
naire contained a set of questions (that prompted for yes/   a variable whose omission from the model resulted in
no or multiple choice) on place of residence (“city”: any    at least one stratum specific RRR of another variable
province capital, “town”: >15,000 inhabitants, “small        changing by at least 10% of its original value).
town”: <15,000 inhabitants), province of residence,             Missing values were excluded, and complete case
single parent household, number of siblings, gender          analysis was performed. Stata 10 software (Stata Cor-
and age of each sibling, father’s/mother’s age, education    poration) was used for the analysis.
level of father/mother (low=junior secondary school,
corresponding in Italy to going to school until 13 years     Results
of age, medium=secondary school, high=university                All 4,524 students returned the questionnaire, but
or postgraduate degree), satisfaction with physical          responses from only 4,277 (95%) interviewees were
appearance (yes, fairly, no), and attitude toward tattoo     usable. Table 1 shows that strata were of roughly similar
and piercing separately (indifferent or not interested,      size regarding age, school year, province of residence,
interested or keen to try, already experienced). Unlike      age of mother and father, and satisfaction with physical
boys, body piercing on a girl was defined as any pierc-      appearance. Most students resided in small towns, in
ing of the body, excluding the earlobe.                      families with both parents, with more than two chil-
   The survey was trialed on a convenience sample            dren, and of a low or medium level of socioeconomical
of 100 secondary school students of the same region.         status as shown by the education level of their respec-
Based on their feedback, adjustments were made to            tive parents.
the survey instrument to clarify instructions and the
wording of the questions.
Clinical Research and Methods                                                                    Vol. 42, No. 4        275

                                                                  Prevalence of Body Piercing or Tattoo
                                                                    The prevalence of body piercing was 20%. The
                           Table 1                                prevalence of tattoo was 6%. Of those without piercing,
                                                                  25% were considering it. Of the non-tattooed students,
 Frequency Distribution of 4,277 Secondary School                 47% considered getting a tattoo. More than half (56%)
        Students by Explanatory Variables                         (=470/840) of those with a piercing were underage; the
                                                                  equivalent percentage for tattoo was 48% (125/258).
Terms                                                 # (%)       One hundred sixty-six individuals reported both pierc-
Gender
                              Female              2,789 (65.18)   ing and tattoo, and 87 (52%) of these were underage
                              Male                1,488 (34.82)   (data not shown).
                              <16                 1,494 (34.89)
Age (years)                   17–18               1,501 (35.12)   Attitude Toward Body Piercing
                              19+                 1,282 (29.99)
                                                                     Table 2 shows the results of the final model of
                              First               1,566 (36.61)
                                                                  weighted multinomial logistic regression. Despite the
School year                   Third               1,478 (34.56)
                                                                  RRRs cross unity, age had to be retained in the model as
                              Fifth               1,233 (28.83)
                                                                  a substantial confounder. Gender, school year, father’s
                              City center           850 (20.74)
Residence                                                         education, satisfaction with physical appearance, and
                              City outskirt         979 (23.89)
(missing: 179)                                                    attitude toward tattoos showed a significant association
                              Town                  412 (10.05)
                                                                  with the outcome. In particular, boys were less likely
                              Small town          1,857 (45.31)
                              Belluno               509 (11.97)
                                                                  than girls to be interested in piercing and less likely to
                                                                  have undergone piercing. A similar pattern was found
                              Verona                674 (15.90)
                                                                  for students reporting to have a father of a medium/
Province of residence         Vicenza                402 (9.46)
(missing: 32)
                                                                  high level of education. Conversely, those who declared
                              Padua                 739 (17.42)
                              Venice                554 (13.05)
                                                                  themselves as dissatisfied with their physical appear-
                              Treviso               621 (14.60)
                                                                  ance and those having a tattoo, or considering having
                              Rovigo                746 (17.59)
                                                                  one, were more likely to have or to be considering
                              Yes                 1,511 (35.93)
                                                                  a piercing. A strong association was found between
Satisfaction with
physical appearance           Fairly              2,258 (53.65)   having a piercing and having a tattoo. This model of
(missing 69)                  No                    439 (10.42)   multinomial logistic regression was fitted on 3,828
                              No                  3,806 (88.99)   complete observations.
Single parent household
                              Yes                   471 (11.01)
                              0                     779 (18.63)   Attitude Toward Tattoo
Number of siblings
                              1                   2,349 (56.17)      Table 3 shows the results of the final model of
(95 missing)
                              2+                  1,054 (25.20)   weighted multinomial logistic regression on the out-
Senior sibling                No                  3,963 (92.66)   come variable “attitude toward tattoo.” Age, school
of same gender                Yes                    314 (7.34)   year, satisfaction with physical appearance, and senior
Father’s age (years)          <49                 1,824 (47.16)   sibling of same gender were retained in the model as
(missing: 409)                49+                 2,044 (52.84)   confounders, whereas gender, father’s age, and attitude
Mother’s age (years)          <47                 2,058 (52.23)   toward piercing showed significant associations with
(missing: 337)                47+                 1,882 (47.77)   the outcome. In particular, students interested in pierc-
                              Low                 1,456 (35.23)   ing or having undergone this practice were more likely
Mother’s education
(missing: 144)
                              Medium              2,007 (48.56)   to be interested in tattoo. Males and students whose
                              High                  670 (16.21)   father was younger than 48 were more likely to have
                              Low                 1,353 (33.32)   experienced tattooing. A strong association was found
Father’s education
(missing: 216)
                              Medium              1,917 (47.21)   between having a piercing and having a tattoo. This
                              High                  791 (19.48)   model of multinomial logistic regression was fitted on
                              Indifferent/        2,276 (54.49)   3,650 complete observations.
                              not interested
Attitude toward piercing
                              Interested/         1,061(25.40)
(missing: 100)
                              keen to try                         Discussion
                              Done                 840 (20.11)       Our results show that students desiring a piercing
                              Indifferent/not     1,900 (46.50)   or tattoo were more numerous than those who actually
Attitude toward               interested                          underwent these practices and that piercing was more
tattoo                        Interested / Keen   1,928 (47.19)   common than tattoo. The higher prevalence of piercing
(missing: 191)                to try                              as compared to tattoo has already been reported6,8,14,21
                              Done                   258 (6.31)
                                                                  and should not be surprising as piercing might be
                                                                  viewed as a transitory experience due to the fact that
                                                                  holes typically close after jewelry is removed.8,22
276      April 2010                                                                                                              Family Medicine




                                                                      Table 2

                              Weighted Multinomial Logistic Regression Analysis* on the “Attitude
                                  Toward Piercing” (Outcome): 3,828 Complete Observations

                                                                                   Attitude Toward Piercing

                                             Indifferent/Not
                                                                              Interested/Keen to Try                         Piercing Done
                                          Interested (Baseline)

Terms                                             # (%)                 # (%)             RRR (95% CI)               # (%)           RRR (95% CI)

                     Female                   1,247 (54.79)          793 (74.74)            Reference             694 (82.62)           Reference
Gender
                     Male                     1,029 (45.21)          268 (25.26)         0.41 (0.34; 0.51)        146 (17.38)       0.22 (0.17; 0.29)

                     <16                       828 (36.38)           405 (38.17)            Reference             224 (26.67)           Reference

Age (years)          17–18                     734 (32.25)           402 (37.89)         1.30 (0.75; 2.25)        332 (39.52)       1.44 (0.77; 2.72)

                     19+                       714 (31.37)           254 (23.94)         1.62 (0.77; 3.42)        284 (33.81)       1.61 (0.72; 3.62)

                     First                     857 (37.65)           430 (40.53)            Reference             239 (28.45)           Reference

School year          Third                     733 (32.21)           386 (36.38)         0.77 (0.44; 1.33)        329 (39.17)       1.05 (0.56; 1.97)

                     Fifth                     686 (30.14)           245 (23.09)         0.40 (0.19; 0.86)        272 (32.38)       0.78 (0.35; 1.76)

                     Yes                       903 (40.13)           317 (30.13)            Reference             260 (31.40)           Reference
Satisfaction
with physical        Fairly                   1,168 (51.91)          603 (57.32)         1.08 (0.87; 1.34)        448 (54.11)       0.97 (0.78; 1.21)
appearance
                     No                        179 (7.96)            132 (12.55)         1.49 (1.08; 2.06)        120 (14.49)       1.48 (1.06; 2.06)

                     Low                       643 (29.50)           354 (35.40)            Reference             326 (41.21)           Reference

Father’s
                     Medium                   1,048 (48.07)          487 (48.70)         0.81 (0.65; 1.01)        344 (43.49)       0.64 (0.50; 0.81)
education

                     High                      489 (22.43)           159 (15.90)         0.68 (0.51; 0.90)        121 (15.30)       0.58 (0.43; 0.80)

                     Indifferent/
                                              1,504 (68.77)          238 (22.65)            Reference             151 (18.17)           Reference
                     not interested
Attitude toward      Interested/
                                               639 (29.22)           767 (72.98)         7.88 (6.56; 9.46)        514 (61.85)       7.49 (5.85; 9.60)
tattoo               keen to try

                     Done                       44 (2.01)             46 (4.38)         9.87 (6.15; 15.84)        166 (19.98)      52.05 (31.93; 84.84)


RRR—relative risk ratio
CI—confidence interval

The rows show the variables entered into the final model of weighted multinomial logistic regression, and the columns show the categories of the outcome
variable “attitude toward piercing.” Only the number of subjects and percentage are displayed under the baseline category (Indifferent/not interested),
while RRR and CI are also shown under the headings of the other two categories (Interested/keen to try and Piercing done).

* RRRs weighted for gender and age to make the results more representative of the adolescents of the Veneto Region aged 14–22 years.
Clinical Research and Methods                                                                                           Vol. 42, No. 4                277



                                                                      Table 3

                            Weighted Multinomial Logistic Regression Analysis* on the “Attitude
                                 Toward Tattoo” (Outcome): 3,650 Complete Observations
                                                                                    Attitude Toward Tattoo
                                      Indifferent/Not Interested
                                                                          Interested/Keen to Try                           Tattoo Done
                                              (Baseline)

Terms                                           # (%)                   # (%)              RRR (CI)             # (%)                RRR (CI)

                   Female                   1,139 (59.85)           1,358 (70.44)          Reference         172 (66.67)             Reference
Gender
                   Male                      761 (40.15)            570 (29,56)         1.08 (0.90; 1.30)     86 (33.33)          1.76 (1.19; 2.62)

                   <16                       733 (38.58)             619 (32.11)           Reference          66 (25.58)             Reference

Age (years)
                   17–18                     607 (31.95)            740 (38.38)         1.05 (0.65; 1.72)     91 (35.27)          1.79 (0.53; 6.01)

                   19+                       560 (29.47)            569 (29.51)         1.10 (0.58; 2.09)    101 (39.15)         3.11 (0.70; 13.69)

                   First                     764 (40.21)            650 (33.71)            Reference          73 (28.29)             Reference

School year        Third                     599 (31.53)            733 (38.02)         1.33 (0.82; 2.16)     88 (34.11)          0.76 (0.22; 2.56)

                   Fifth                     537 (28.26)            545 (28.27)         1.18 (0.62; 2.27)    105 (37.60)          0.62 (0.14; 2.68)

                  Yes                        732 (39.00)            612 (32.06)            Reference         105 (41.50)             Reference
Satisfaction with
physical
                  Fairly                     988 (52.64)            1,070 (56.05)       1.16 (0.96; 1.40)    113 (44.66)          0.80 (0.55; 1.17)
appearance

                   No                        157 (8.36)              227 (11.89)        1.26 (0.94; 1.70)     35 (13.83)          1.47 (0.85; 2.52)

                   No                       1,740 (91.58)           1,810 (93.88)          Reference         235 (91.09)             Reference
Senior sibling
of same gender
                   Yes                       160 (8.42)              118 (6.12)         0.99 (0.72; 1.37)      23 (8.91)          1.47 (0.80; 2.72)

                   <49                       777 (44.91)            835 (48.10)            Reference         135 (56.96)             Reference
Father’s age
(years)
                   49+                       953 (55.09)            901 (51.90)         0.94 (0.79; 1.12)    102 (43.04)          0.64 (0.45; 0.92)

                   Indifferent/
                                            1,504 (79.45)           639 (19.57)            Reference         166 (69.17)             Reference
                   not interested
Attitude toward    Interested/
                                             238 (12.57)            767 (39.95)         7.61 (6.19; 9.36)     46 (19.97)         9.92 (5.85; 16.86)
piercing           keen to try

                   Done                      151 (7.98)             514 (26.77)         7.29 (5.69; 9.33)     44 (17.19)        47.05 (28.93; 76.52)


RRR—relative risk ratio
CI—confidence interval

The rows show the variables entered into the final model of weighted multinomial logistic regression, and the columns show the categories of the outcome
variable “attitude toward tattooing.” Only the number of subjects and percentage are displayed under the baseline category (Indifferent/not interested),
while RRR and CI are also shown under the headings of the other two categories (Interested/keen to try and Tattooing done).

* RRRs weighted for gender and age to make the results more representative of the adolescents of the Veneto Region aged 14–22 years.
278     April 2010                                                                                                  Family Medicine

   We also found that girls were more likely to have or to      involved in engaging and dealing with schools’ head-
be considering body piercing, whereas boys were more            teachers and obtaining their collaboration.
likely to have experienced tattoo. The preponderance of
body piercing among young females is consistent with            Conclusions
other studies,3,4,6,7,14,21,23-27 as well as the predominance      We found that male gender (for tattoo), female gender
of tattoo among males.7,25 Others have reported that            (for piercing), dissatisfaction with physical appearance,
women comprise 45% to 65% of the tattooed popula-               positive attitudes toward either piercing or tattoo, and
tion.28,29 Roberts4 found that tattooing was not signifi-       having a younger and less educated father were as-
cantly associated with gender, while Carroll3 found that        sociated with having or desiring body modification.
both practices were more common in females.                     These factors could be considered for targeted patient
   We also found that those with tattoos were more              education.
likely to desire a piercing and especially to have one
and vice versa. Similar findings have been reported by          Acknowledgments: The Veneto Adolescents Health Promotion (VAHP)
                                                                Working Group includes the authors and Mirca Benetton, Melania Bor-
others.23,26,27 Most importantly, our data indicate that        tolotto, Enrico Miatto (Department of Educational Sciences, University
in the future, the incidence of either piercing or tattoo       of Padua, Italy); Vincenzo Baldo, Marta Cecilia Busana (Department of
could be close to 60% among the cohort of students              Environmental Medicine and Public Health, University of Padua, Italy); and
                                                                Francesca Capretta (Department of Medicine and Public Health, University
we studied.                                                     of Verona, Italy).
   In our cohort, 47% of the non-tattooed considered                We thank Daisy Alice Dunger for editing the manuscript.
tattooing, and a remarkable percentage of interviewees              Financial Support: This study was funded by the Postgraduate Training
                                                                Institution for Secondary School Teachers of Veneto (SSIS Veneto, Italian
had obtained a piercing or tattoo before the age of 18.         acronym).
The concern with the high number of underage people
obtaining tattoos is that despite advances in laser             Corresponding Author: Address correspondence to Dr Cegolon, University
                                                                of Padua, Department of Environmental Medicine and Public Health, Via
technology, removal is a painstaking process, usually           Giustiniani 2, 35128 Padova, Italy. 0039-049-8212543. Fax: 0039-041-
involving several treatments and considerable expense           4532434. mrcegolon@hotmail.com.
and is impossible without scarring.30.31
   Tattoos may be satisfactory at first, but they some-                                         References
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Description: Body art is a human body outside of the United States, significant and can enjoy. When people reach a certain state of thought when that appreciation can be called art, body art is more than just sticking out of the body bare, bare this alone is not included among the arts. But the real art is known as the human body beyond, people have been approved for smoking cessation have been representative of toothpaste could be called an art.