Table of Content

Current Issue

Autumn 2020, Vol. 28 No. 3

Hong Kong J. Dermatol. Venereol. (2020) 28, 93-99


Original Article

Prevalence, attitude and risk knowledge towards body art among Hong Kong college students: a single institution study

形體藝術在香港大學生中的盛行率、看法和風險知識之單一機構研究

MYC Yau 游燕珍, PL Tang 鄧柏澧, NM Luk 陸乃明

Abstract

The prevalence, attitudes and risk knowledge towards tattooing and body piercing among young people in Hong Kong are unknown. Through a questionnaire survey, these aspects of body art in college students were studied. With a response rate of 84.7% (459/577), the prevalence of body art was estimated to be 4.75% (22/459). An egocentric motive, drinking habit and friend/family member with body art were found to be associated with those with body art. Knowledge of the related risk was mostly recognised. Compared with the western countries, our prevalence of body art is low while the associated factors are similar.

香港年輕人的紋身和身體穿孔盛行率、看法和風險知識,目前所知不多。通過問卷調查,我們研究了大學生的形體藝術以上提及的事項。回應率為84.7%(459/577),形體藝術的盛行率估計為4.75%(22/459)。個人自我中心、飲酒習慣以及家人朋友有著形體藝術等因素,皆被發現與形體藝術有相關聯。而相關風險知識絕不貧乏。對比西方國家,本地形體藝術的盛行率較低,而相關因素則類同。

Keywords: Attitude and risk knowledge, body art, college students, Hong Kong, prevalence

關鍵詞: 看法和風險知識、形體藝術、大學生、香港、盛行率

Introduction

Body art, the use of body as a medium for aesthetic purpose, is gaining popularity in the western societies.1,2 This is especially so among young people, with body piercing and tattooing being the more common forms.1 However, the increased popularity of body art is also accompanied with an increase in complications of these procedures.3 Infections such as hepatitis and human immunodeficiency virus infection can be acquired through contaminated needles,4 and rarely the ink.5 Long term consequences including allergic contact dermatitis, lichenoid dermatitis, granulomatous dermatitis, pseudo-lymphoma and even skin cancer.6-8 Hence it is important to have some understanding on this topic which may be of use for future health prevention planning. In Hong Kong, there have been no formal studies on the prevalence of body art among young people. Their attitudes towards this form of body art; knowledge of associated complications and risk are also unknown. As college students are part of the young population which has a faster increase in body art incidence, it can be used as proxy for the younger generation. The present study investigated these aspects among college students in a single institute in Hong Kong.

Method

The study was carried out in March 2019 in a tertiary institute in Hong Kong (Tung Wah College) which offers programs on nursing and medical science besides others. Subjects were recruited from students attending health education seminars. The participants were requested to complete the anonymous questionnaire and return at the end of the session. Participation was voluntary with no remunerations. The questionnaire consisted of three parts: (i) epidemiology: age, sex, smoking and drinking habits, religious belief, ethnicity and program of study; (ii) attitude towards of this form of art: motives, form of art and preferred sites, anticipated complications, sources of information, where was the body art performed, friends or family members with body art, parental approval, body art removal if cosmetically unacceptable; (iii) knowledge of associated risks (infectious and non-infectious), estimated risk (0-100%) and factors determining the risk. For those with body art, additional questions were asked on age of acquisition; any consent form signed; risk of complications explained by the artist and the hygiene conditions of the venue.

The study was approved by the Ethics Committee of Tung Wah College, Hong Kong.

Analysis
Descriptive statistics on age, sex, program of study, smoking and drinking habits, religious belief etc. The Chi square test was used to detect any association between various factors and those with and without body art. A p value of <0.05 was considered significant (https://www.socscistatistics.com/tests/chisquare2/default2.aspx). Odds ratio was calculated for significant factors (https://www.medcalc.org/calc/odds_ratio.php).

Results

Demographics
Five hundred and seventy-seven questionnaires were distributed and 459 of them were eligible for analysis, giving a response rate of 84.7% (459/577). The prevalence of body art was 4.79% (22/459). The demographics of the participants are shown in Table 1. Among these 459 students, 316 (68.8%) were female and 116 (25.3%) male. There were 245 (53.4%) students ≤20 years of age and 195 (42.5%) students aged 21 or above. Chinese (n=444, 96.7%) was the major ethnic group with only five were non-Chinese. With regard to the program of study, 404 (88%) was health-related, 42 (9.2%) was from the science stream e.g. forensic science, three (0.7%) from other programs e.g. psychology, finance. The majority of the participants (97.2%, n=446) were non-smokers and 85 (18.5%) participants were drinkers. Religious believers accounted for 76 (16.6%) of the total participants.

Table 1 Characteristics of participants (N=459)
  Body art No body art Total %
Age
18-20 9 236 245 53.4
21-30 13 182 195 42.5
Missing     19 4.1
      459  
Sex
Female 19 297 316 68.8
Male 3 113 116 25.3
Missing     27 5.9
Ethnicity
Chinese 22 422 444 96.7
Non-Chinese 0 5 5 1.1
Missing     10 2.2
Program of study
Health related 19 385 404 88.0
Science 2 40 42 9.2
Others 0 3 3 0.7
Missing     10 2.2
Smoking
Yes 3 1 4 0.9
No 425 21 446 97.2
Missing     9 2.0
Drinker
Yes 10 75 85 18.5
No 10 330 340 74.1
Missing     34 7.4
Religion
Yes 5 71 76 16.6
No 15 318 333 72.5
Missing     50 10.9

Attitudes towards body art
The motives for acquiring body art in order of frequency were: Like the way it looks (n=143, 39.7%), to make a personal statement (n=96, 26.7%), to be fashionable (n=78, 21.7%), to feel different (n=43,11.9%), parent(s) do not want them to have one (n=43,11.9%), to catch attention (n=30, 8.3%), for religious reasons (n=12, 3.3%), to be daring (n=12, 3.3%), friend(s) want them to have one (n=8, 2.2%) and parent(s) want them to have one (n=2, 0.6%) (Table 2).

Table 2 Motives for those with and without body art (N=360)
Body art (n) Total (%)
Like the way it looks 10 143 (39.7%)
To make a personal statement 9 96 (26.7%)
Other reasons 3 83 (23.0%)
To be fashionable 6 78 (21.7%)
To feel different 2 43 (11.9%)
Parent(s) don't want them to have one 0 43 (11.9%)
To catch attention 3 30 (8.3%)
For religious reasons 0 12 (3.3%)
To be daring 1 12 (3.3%)
Friend(s) want them to have one 0 8 (2.2%)
Parent(s) want them to have one 0 2 (0.6%)

Over half (65.5%, n=252) preferred tattooing while body piercing was favoured by 18.4% (n=71) of the participants and 16.1% (n=62) would accept both types (Table 3). The arms (45.3%) were the most favoured sites for body art followed by the covered parts of the body (34.1%), legs (25.2%), waist (21.1%), exposed parts of the body (14.1%), ear (13.5%), nose (2.1%), lips (2.1%) and navel (1.8%) (Table 4).

Table 3 Chi square correlation between those with/without body art and various parameters
    Body art No body art Total P value
(odd ratio)
Program Health care 19 385 404 0.989
  Non-health care 2 40 42  
Year of study 1 4 64 68 0.205
  2 6 201 207  
  3 8 99 107  
  4 0 19 19  
  5 4 41 45  
Sex Female 19 296 315 0.137
  Male 3 116 119  
Ethnicity Chinese 22 422 444 1.000
  Non-Chinese 0 5 5  
Religious Yes 5 71 76 0.449
  No 15 318 333  
Smoker Yes 1 3 4 0.182
  No 21 425 446  
Drinker Yes 10 75 85 0.001*
  No 10 330 340 (OR=4.39)
Motives for body art Egocentric 20 228 248 0.007*
  Non-egocentric 1 111 112 (OR=9.74)
Body art preferred Tattoo 15 237 252 0.554
  Body piercing 4 67 71  
  Both 2 60 62  
Sites preferred* Obvious 8 136 144 0.981
  Non-obvious 8 134 142  
  Indifferent 6 92 98  
Anticipated complications Yes 11 165 176 0.485
  No 11 228 239  
Where done Professional body art shop 17 251 268 0 .141
  Others 5 156 161  
Information source§ Media only 6 129 135 0.730
  More than media+ 15 272 287  
Parental approval Yes 9 238 247 0.117
  No 13 173 186  
Friends/family members have body art Yes 17 208 225 0.014*
  No 5 204 209 (OR=3.33)
If cosmetic unacceptable, consider removal Yes 17 267 284 0.272
  No 5 138 143  
Anticipate complications Yes 11 168 179 0.459
  No 11 232 243  
Removed if unacceptable Yes 17 272 289 0.269
  No 5 141 146  
Risk estimation Low (<5%) 6 86 92 0.571
  Med (5-20%) 3 76 79  
  High (>20%) 10 241 251  
Reason for body art: a) Egocentric motives: Like the way it looks, to be fashionable, to make a personal statement, to feel different, to catch attention and to be daring; b) Non-egocentric reasons: parent(s) want/don't want them to have one, friend(s) want them to have one, for religious reasons
* Preferred body sites
Obvious sites: ear, nose, lip, arm, exposed part of body; Non-obvious sites: waist, navel, leg, covered parts of the body; Indifferent=obvious + non-obvious
§Source of information: media only: media and/or internet

The professional body art shop (79.3%) was most chosen venue for acquiring body art, followed by shops in malls (14.5%), hospital or medical clinic (13.5%), friend (3.0%), self (2.6%) and finally parent (2.1%) (Table 5). Over half (57.0%, n=247) of the participants would seek parental approval before acquiring body art while 43% (n=186) would not (Table 3).

Table 4 Preferred sites of body art (N=384)
  Total (%)
Arm 174 45.3
Covered part of the body 131 34.1
Legs 97 25.2
Waist 81 21.1
Exposed part of the body 54 14.1
Ear 52 13.5
Nose 8 2.1
Lip 8 2.1
Navel 7 1.8
Others 43 11.2
Table 5 Favoured venue for body art (N=429)
  Total (%)
Professional body art shop 340 79.3
Shop in mall 62 14.5
Hospital or medical clinic 58 13.5
Friend 13 3.0
Self 11 2.6
Parent 9 2.1
Other 22 5.1

Slightly more than half of the participants (51.8%, n=225) had friends or family members with body art (Table 3). While 66.5% (n=284) of participants would remove the body art if the cosmetic results were not acceptable, 33.5% (n=143) preferred to leave them alone (Table 3).

Knowledge of the risks of body art
The top three complications recognised by the participants were infections (88.2%), bleeding (75.2%) and allergic reaction (69.7%). The less commonly recognised complications included hepatitis (30.3%), tetanus infection (14.1%) and cyst formation (13.9%) (see Table 6). Almost 60% (n=251) of the respondents considered the procedure risky (>20%) and 21.8% (n=92) believed that it was of low risk (≤5%) (Table 3).

The more recognised risk factor of causing complications was the hygiene conditions of the workplace (75.2%), followed by the type of body art (56.7%), who performed the procedure (56.0%), place where the body art was done (43.3%) and lastly the price of the procedure (40.1%) (Table 7).

Those with body art
For the 22 students with body art, there were 19 females and 3 males (Table 3). The mean age of acquiring body art was 17.6 years (n=21, mode=18 years, range 11-23 years). Twelve (54.5%) were informed about the potential risk of the procedures but only 4 (18.2%) were asked for written consent. The hygiene conditions of the venues were rated as very clean in 7 (35%) and clean in 14 (65%).

Table 6 Complications recognised by the participants (N=439)
  Total (%)
Infection 387 88.2
Bleeding 330 75.2
Allergic reaction 306 69.7
Bruising 167 38.0
Keloid 159 36.2
HIV 153 34.9
Hepatitis 133 30.3
Tetanus 62 14.1
Cyst 61 13.9
Other 10 2.3
None 10 2.3
Table 7 Risk factors recognised by respondents (N=439)
  Total (%)
Hygiene conditions of the venue 330 75.2
Type of body art 249 56.7
Who performed the procedure 246 56.0
Place where it is done 190 43.3
Price of the procedure 176 40.1
Others 15 3.4

Chi square analysis

It was found that egocentric motives (OR=9.74 p=0.007), drinking habit (OR=4.59, p=0.001) and those with friends/family members have body art (OR=3.33, p=0.014) were significantly associated with acquisition of body art (Table 3).

Discussion

Our study shows that body art among college students in Hong Kong is not as high as that in Western society.1,2 The estimated prevalence is only 4.79% (22 out of 459) which is much lower than that in a similar study by Greif et al9 of more than 700 college students.8,9 In their study, the prevalence of tattoos was 73% (n=561) and that of body piercing was 51% (n=391). This could be due to ethnic difference as Chinese culture emphasises inner beauty over outward appearances. If we take the population between 15 to 29 years of age in Hong Kong in 2018 as 1,208,300 (https://www.censtatd.gov.hk/hkstat/sub/sp150.jsp?tableID=002&ID=0&productType=8), the estimated number of people with body art is 57, 800. On the other hand, our study only focused on college students which is a more educated group among all youngsters and may, therefore, underestimate the prevalence of this age group as a whole. According to an American study, those with a Bachelor's degree had a lower prevalence (22.5%) compared with those who did not complete high school (42%).1 The former may have a better understanding of the potential risks and hence more cautious about body art.

To establish one's individuality or identity seems to be the most important motive for acquiring body art in our participants. We tried to group the motives into an 'egocentric' domain which includes motives as: Like the way it looks, to be fashionable, to make a personal statement, to feel different, to catch attention and to be daring. All these motives focus on individuality. This egocentric domain as a whole, correlates significantly with body art acquisition (p=0.006, OR=9.74). This is understandable as young people are keen to express themselves and explicit body art could serve as an effective means. This motivation is stronger than those to satisfy other's wishes (parent, friend) or for spiritual reason (religious). Our result echoes with the motives given by western youth who want 'to be myself, I don't need to please or impress anyone'.8,9

In this study, drinking habits are found to be associated with acquisition of body art (p=0.001 OR=4.39) which is similar to the study in the United States.1 There has been suggestions that tattooing is associated with high risk behaviours such as alcoholism, sexual promiscuity, drug abuse etc.9,10 though the association was found to be weak in a recent Italian study.2,10 In our study, we did not enquire these high-risk behaviours. Yet we know that some people acquired body art in certain social circumstances (e.g. during party gathering) though how common it is needs to be further investigated.

The other significant factor associated with acquisition of body art is having friends / family members with body art (p=0.014, OR=3.33). This is in line with other studies8,9 Again, this is obvious as youngsters are more prone to peer influence. On the other hand, more than half of our participants would seek their parent's approval (57%) which is higher than that among western youngsters (24%).8,9 This may again reflect an ethnic difference between Chinese and the West. Among Chinese, close family ties are fostered and parents are expected to care for the child lifelong. In return, children have to respect their parents' wishes.

In this study, arm was the most preferred site of body art in our respondents while ear, nose, lips and navel were the less preferred sites. This may well correlate with the lower preference of body piercing by our participants as these sites (ear, nose, lips, navel) are more popular for body piercing.

In our study, most of the participants were able to recognise the potential complications of body art. These include infectious (infection, HIV, tetanus, hepatitis) and non-infectious causes (allergic reaction, keloid scar, cyst, bleeding and bruising). This could be due to the fact that most of the participants are studying health-related programmes (88%). Infectious complications such as (88.2%), hepatitis (30.3%) and even human immunodeficiency virus infection (34.9%), were the more frequently recognised complications yet the risk of contracting tetanus (14.1%) is much less appreciated. Also, while keloid and hypertrophic scar (36.2%) are easily recognised non-infectious complications, the risk of acquiring a cystic complication (13.9%) was often overlooked. Based on these observations, future education strategies should emphasis more on these under-appreciated complications.

The body art-related risk estimated by our respondents is rather high (78.2% moderate to high risk), only 21.8% would regard the risk as low (i.e. ≤5%). This is in line with other studies.11 This could be due to the fact that the young are less experienced than adults and so over-estimates the risk. On the other hand, despite the anticipated risks, youngsters still want to acquire body art which may well be taken as a show of courage and a sign of being 'different from the others'.

For those with body art, we did not specifically ask for their complications and the details of the procedures performed by their artists e.g. use of sterile and disposable needles, proper hand washing etc. This information may be useful when laying down regulations for qualified professional artists. Future studies may look into this important aspect.

Limitations

College students may not be typical of all youngsters in Hong Kong and the results obtained in this study should not be over-generalised. Convenient samples adopted in this study, again, may not be representative of the all college students: obviously students from humanistic faculties were less presented in our sample in whom a higher prevalence of body art has been documented.11

Conclusion

In this study, we found a comparatively low prevalence (4.79%) of body art among Hong Kong college student. Participants were knowledgeable about the potential complications of body art. Like all youngsters, their motives for acquiring body art were more egocentric, being prone to peer influence. The reason why drinking is associated with acquisition of body art is unclear. Probably the alcohol may provide courage. Future study may recruit a larger sample size and document the complications among those with body art.

References

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