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Tattoo EDU

State: NC Type: Promising Practice Year: 2018

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Forsyth County Department of Public Health
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Tattoo EDU
BRIEF DESCRIPTION OF LHD/WEBSITE: The Forsyth County Department of Public Health (FCDPH), located in Winston Salem, NC, has been in operation since 1916, and today consists of a staff of over 250 dedicated employees serving a community of 371,511 residents. (www.forsyth.cc/PublicHealth/) DESCRIPTION OF HEALTH ISSUE: Young people have shown great enthusiasm for tattoo practices but unfortunately with this higher demand the amount of unpermitted tattoo artists has increased (Quaranta, et al., 2011). This has created more complications because tattoo procedure are completed without suitable knowledge of health/hygiene risks/complications. These complications/infections include HIV, hepatitis, mycobacterial infections, and tetanus. Additionally, non-infectious diseases are also at risk of being experienced, such as dermatitis, hemorrhage, and allergic reactions (Houghton, Durkin, Parry, Turbett, & Odgers, 1996). Educational systems or programs are critical to induce positive health behavior and perception of tattoo-related risks/infections. There is limited data on rates of complications/tattoo regret or data on where tattoos are being performed/administered. It is important that tattoos are administered in sterile/permitted environments. The rise of unregulated tattoo parties” creates environments for non-permitted, illegal tattoo artists to administer tattoos in non-sterile environments to underage recipients. A 2015 study found that of 501 surveyed, 16.2% regret receiving their tattoo, and 17.6% had their tattoo administered somewhere other than a permitted tattoo parlor (Liszewski, et al., 2015). These statistics demonstrate need for tattoo/body art health education programs to reduce harmful practices/complications. Education is one of the best ways to stop unhealthy behavior before it manifest. If students are taught about improper/ unhealthy procedures, they can help stop the rise of unpermitted artists that can spread infectious diseases. Education on risks, infections, and proper precautions are all ways that students can make informed decisions on when/where to get body art (Tattoo, 2012). Over 33% of US adults aged 25-29 are tattooed, and despite growing popularity, little is known about tattoo toxicology (Quaranta, et al., 2011). In particular, inks used in tattoo processes are not regulated/ studied by any board/organization (Tattoo, 2012). Understanding risks of tattoos and the ink used to administer them is critical, because of the risk of nonmetal colorants such as arsenic, aluminum, chromium, or even lead (Tattoo, 2012). None are suitable for placing inside the body's living tissue. GOALS AND OBJECTIVES: The target program population is adolescents attending Winston Salem Forsyth County (WS/FC) high schools. Secondary populations include parents, guardians, teachers and peer groups of the target population. The goal is to educate/reduce risk associated with disease contracted from non-sterile tattooing as a result of being either illegally tattooed by permitted/ unpermitted artists. The program also aims to decrease illegal/unregulated tattoo practices. IMPLEMENTATION/PROGRAM ACTIVITY: Primarily, educational materials were presented in Google slides format to groups of 10th graders during their scheduled health classes by a FCDPH certified health education specialist. The presentation included tattoo history, NC regulations/laws, unsafe practices, risks/consequences and current removal options. This program aligns with the 10th grade ‘personal and consumer health' curriculum subject including evaluation of health information/ products and education to critique potential health/social consequences of body art. RESTULS/OUTCOMES: The pilot reached 1,241 students. Risk of overall health from tattoos was rated pre and post education: not risky” was selected by 12.9% pre-education and 4% post-education; little risky” was selected by 23.9% pre-education and 8% post-education; neutral” was selected by 34.4% pre-education and 19% post-education; risky” was selected by 21.8% pre-education and 37% post-education; very risky” was selected by 5.6% pre-education and 31% post-education. Pre-education 76.5% of students believed that tattoos transmit disease (18.2% unsure and 4.3% didn't know). Following education, 100% of students said tattoos transmit diseases. Pre-education, 79.1% of students indicated tattoo parties/instruments used there are not safe for tattooing (compared to 93% afterwards). In summary, an increased knowledge was observed. Initially, the pilot targeted all 15 local high schools, however scheduling conflicts prohibited deliver at 4 schools. The pilot reached 11 schools/73% of the target (49 classrooms). Success of this program is dependent on collaboration of the school system, ability to conduct research (pre/post test), and engagement of the students. PUBLIC HEALTH IMPACT OF PRACTICE: The program successfully resulted in an increased awareness of risks associated with tattooing. Of the 94.9% of students reporting they did not have a tattoo, 39.6% are planning on receiving one in the future and 26.5% are maybe considering a tattoo in the future. If/when these young folks follow through with getting a tattoo, their decision as to where and how to have the tattoo administered will be informed, reducing the risk of infection.
STATEMENT OF PROBLEM/PUBLIC HEALTH ISSUE; TARGET POPULATION: Young people have shown great enthusiasm for tattoo practices but unfortunately with this higher demand the amount of unpermitted tattoo artists has increased (Quaranta, et al., 2011). This has created more complications because the tattoo procedure is being completed without suitable knowledge of health and hygiene risks and complications. These complications and infections can include HIV, hepatitis, mycobacterial infections, and tetanus. There are many more non-infectious diseases that are also at risk of being experienced, such as dermatitis, hemorrhage, and allergic reactions (Houghton, Durkin, Parry, Turbett, & Odgers, 1996) . It is becoming increasingly important that an educational system or program exists to induce positive health behavior and perception of tattoo-related risks and infections. There is very limited data on the rates of complications and tattoo regret, as well as data on where tattoos are being performed and administered. It is increasingly important to make sure that tattoos are being administered in sterile environments that are permitted by state regulations through county departments of public health. The rise of unregulated tattoo parties” creates an environment for non-permitted, illegal tattoo artists to administer tattoos in non-sterile environments to both of-age and underage recipients. A study completed in 2015 found that of 501 surveyed participants, 16.2% regret receiving their current tattoo, and 17.6% of the participants had their tattoo administered somewhere other than a permitted tattoo parlor (Liszewski, et al., 2015). These statistics show there is a need for tattoo and body art health education program to help reduce harmful practices and complications. There are many ways to reduce risk of infection. Education is seen as one of the best ways to stop unhealthy behavior before it has time to manifest. If students can be taught about improper and unhealthy procedures, they can help stop the rise of unpermitted artists that can spread infectious diseases. Education on risks, infections, and proper precautions are all ways that students can make an informed decision on when and where to get body art (Tattoo, 2012). Over a third of US adults aged 25-29 are tattooed, and despite the growing popularity there is little known about the toxicology of tattoos (Quaranta, et al., 2011). In particular, the inks used for the tattoo process are not regulated or studied by any board or organization (Tattoo, 2012). It is important that we understand the risks behind tattoos and the ink that is used to administer them, because of the risk of nonmetal colorants such as arsenic, aluminum, chromium, or even lead (Tattoo, 2012). None of these are suitable for placing inside the body's living tissue. The primary purpose of the Tattoo Education (EDU) program is to educate 10th graders on the dangers of unsafe tattoo practices in Forsyth County, NC. The program's target population is adolescents aged 13-18 years old in Forsyth County, NC. The secondary population is parents, guardians, and peer groups of adolescents aged 13-18 years old in Forsyth County, North Carolina. The main objective of the program is to change health behavior, reduce unsafe tattoo-related infections, and decrease illegal tattoo practices in Forsyth County, North Carolina. Stakeholders in this program include a variety of groups and populations found in Forsyth County and presumably across the state of North Carolina. These include but are not limited to: adolescents at risk for contracting disease from non-sterile tattooing as a result of being either legally tattooed by a permitted artist, or by being illegally tattooed by an unpermitted artist. Stakeholders also include parents, guardians, and teachers of adolescents, as well as legally permitted tattoo artists. Another stakeholder is our multi-faceted healthcare system in Forsyth County, who is at risk of non-payment of healthcare services provided to patients for infected skin or blood borne pathogen disease treatment. The Forsyth County Department of Public Health and the Winston-Salem Forsyth County Schools system (WS/FCS) are also perceived stakeholders. 73% of WS/FC High Schools were visited with 1,241 students in 49 classrooms receiving the training. WHAT HAS BEEN DONE IN THE PAST TO ADDRESS THE PROBLEM: Previously some students received brief information from WS/FCS regarding potential health and social consequences of body art via the personal and consumer health 10th grade curriculum. There was no known curriculum for this demographic group that addressed the risk for contracting a disease from non-sterile tattooing as a result of being either illegally tattooed by a permitted or permitted artist. WHY THE CURRENT/PROPOSED PRACTICE IS BETTER: Tattoo Edu is a process, including (1) program design and supporting research, (2) data collection and evaluation goals (research approval through WS/FCS, (3) program implementation and (4) program evaluation and data analysis. The program had a positive impact. We observed an increase in knowledge about tattoo risk, disease and infections, and current rules/regulations in North Carolina. We presented information on common misconceptions and information that is readily available to teenagers and we collected data on current perceptions of tattoos, knowledge of tattoo risk and current level of students with tattoos. Finally, data collected via pre/post test indicate significantly greater awareness regarding risks following the training. For example, pre-education, 76.5% indicated that tattoos could transmit disease compared to 100% post-education. IS THE CURRENT PRACTICE INNOVATIVE: Tattoo Edu is an innovative practice as it is new to the field of public health, not just Forsyth County Department of Public Health. Prior to the development, there was no other related education program for this demographic. Much interest has been shown in replicating this program in other areas. IS THE CURRENT PRACTICE EVIDENCE-BASED? This practice is not evidence based. It does however include the development, implementation and evaluation of an effective program through application of principles of scientific reasoning, including systemic uses of data and information systems and appropriate use of behavioral science theory and program planning models (definition source: Brownson, Ross C., Elizabeth A. Baker, Terry L. Leet and Kathleen N. Gillespie, Editors. Evidence-Based Public Health. New York: Oxford University Press, 2003). The following domains were defined: target population, secondary population, stakeholders, resisting audience, mission, objectives, implementation and program activity, implementation strategies, target implementation timeline, primary evaluation strategies, and program replication.
HIV in the U.S.
GOALS AND OBJECTIVES: The target program population is adolescents attending Winston Salem Forsyth County (WS/FC) high schools. Secondary populations include parents, guardians, teachers and peer groups of the target population. The goal is to educate/reduce risk associated with disease contracted from non-sterile tattooing as a result of being either illegally tattooed by permitted/ unpermitted artists. The program also aims to decrease illegal/unregulated tattoo practices. STEPS TO ACHIEVE THE GOALS/OBJECTIVES: The following steps were taken to achieve the goals/objectives: 1. Program design and supporting research A program objective was identified as was the target and secondary population. Research was conducted regarding complication rates, tattoo regret/mistakes, underground” locations, tattoo parties and the availability of equipment/ink/misinformation. Curriculum developed o Topics Covered ? What is a tattoo? What does tattooing include? ? What types of regulations and laws exist in NC? Are they different in Forsyth County? What are common misconceptions with these rules? ? Why are these rules and regulations in place/ Who do they protect and why? ? What are common unsafe practices? ? What types of diseases can be transmitted? What about infections? ? What makes an artist reputable? How can I decide that? ? Are tattoos removable? 2. Data collection and evaluation goals including research approval through WSFCS Designed pre-post test to measure: o What students are learning o Retention of information o Information/misconceptions prior to education o Program impact o Introducing new learning v. reinforcement of known information 3. Program Implementation Program implemented at 11 of 15 WS/FC high schools over the course of two months 4. Program evaluation and data analysis Pre and post tests were analyzed and program evaluation occurred. Curriculum adjustments were made where warranted. CRITERIA FOR WHO WAS SELECTED TO RECEIVE THE PRACTICE: All 10th grade classes in WS/FC high schools were invited to participate in the program. TIME FRAME FOR THE PRACTICE: The pilot program was implemented during two months in the spring of 2017. Planning is occurring for the program to be repeated spring of 2018 (same target population), and biannually thereafter. OTHER STAKEHOLDERS/ROLES: The WS/FC school system was an active stakeholder in this program. They provided access to the target population, prepared teachers for engagement, assisted with coordinating scheduling, provided curriculum review/feedback and hosted the research/evaluation. The FCDPH Public Health Educator worked extensively the Health and Physical Education Programs Director for WS/FCS to plan, implement, and evaluate the program. Additionally, presentations were made prior to implementation to the FCDPH Board of Health and a group of WS/FC High School Chairs. Both groups supported implementation of the program. Other stakeholders in this program include a variety of groups and populations found in Forsyth County and presumably across the state of North Carolina. These include but are not limited to: adolescents at risk for contracting a disease from non-sterile tattooing as a result of being either illegally tattooed by a permitted artist, or by being illegally tattooed by an unpermitted artist. Stakeholders also include parents/guardians and teachers of adolescents at risk, and legally permitted tattoo artists. Another stakeholder is our multi-faceted healthcare system in Forsyth County, who is at risk of non-payment of healthcare services provided to patients for infected skin or blood borne pathogen disease treatment. The Forsyth County Department of Public Health and the Winston-Salem Forsyth County Schools system are also perceived stakeholders. Subsequent to implementation, and per their request, a presentation was made to the Association of North Carolina Boards of Health where there was interest in replicating the program. FUNDING: There were no significant start up or in-kind costs or funding associated with this practice. Because an existing FCDPH employee developed, implemented, and evaluated the program, the only new costs are the minimal expenses associated with printing materials.
RESTATED OBJECTIVES: The target program population is adolescents attending Winston Salem Forsyth County (WS/FC) high schools. Secondary populations include parents, guardians, teachers and peer groups of the target population. The goal is to educate/reduce risk associated with disease contracted from non-sterile tattooing as a result of being either illegally tattooed by permitted/ unpermitted artists. The program also aims to decrease illegal/unregulated tattoo practices. WHAT DID YOU FIND OUT? TO WHAT EXTENT WERE YOUR OBJECTIVES ACHIEVED: Via administration of a pre-test, it was confirmed that some students had a tattoo (received illegally via permitted and unpermitted artists) and others were considering obtaining a tattoo. Students had misconceptions/misinformation regarding the transmission of diseases via tattooing. Confirmed via post-test, students better understood associated risks associated with tattooing following administration of the Tattoo EDU curriculum. Risk of overall health from tattoos was rated pre and post education: not risky” was selected by 12.9% pre-education and 4% post-education; little risky” was selected by 23.9% pre-education and 8% post-education; neutral” was selected by 34.4% pre-education and 19% post-education; risky” was selected by 21.8% pre-education and 37% post-education; very risky” was selected by 5.6% pre-education and 31% post-education. Pre-education 76.5% of students believed that tattoos transmit disease (18.2% unsure and 4.3% didn't know). Following education, 100% of students said tattoos transmit diseases. Pre-education, 79.1% of students indicated tattoo parties/instruments used there are not safe for tattooing (compared to 93% afterwards). In summary, students are better informed to make decisions that reduce associated risks after participating in the program. PROGRAM EVALUATION: Students educated by the program were given a total of two surveys. One survey was completed prior to the education session, and measured incoming knowledge and perception of tattoo regulations, unsanitary tattooing, and disease transmission related to risky tattoo behavior. The post-survey was administered after the education session, and measured outgoing knowledge that students learned during the presentation and discussion. The primary reason for this research was to evaluate the effectiveness of the Tattoo EDU program. It was extremely important to measure the impact of the educational information presented, especially during the pilot, as feedback was used to make modifications where warranted. Post-pilot changes were largely confined to logistic around scheduling and effectively relaying teacher roles. Data was solely collected by the FCDPH Public Health Educator, via test/survey, at the beginning and end of each program implementation. Pre versus post -test responses were compared to measure increased knowledge/awareness. Test/surveys follow. TATTOO EDU Pre-education program survey WS/FCS Spring 2017 Please answer each question honestly and to the best of your ability. None of your answers will be shared or reported; all information is kept confidential. Do not place your name or any other identifying information on this survey. Survey responses are used to improve program delivery and content. 1. On a scale of one to five, how risky to your overall health is it to get a tattoo? (please circle only one option- 1 is not risky at all, and 5 is very risky) 1 (not risky at all) 2 (a little) 3 (neutral risk) 4 (risky) 5(very risky) 2. Can tattoos transmit infectious diseases? a. Yes b. No 3. Can tattoos transmit non-infectious diseases? b. Yes b. No 4. Are permitted tattoo parlors/shops in NC and the instruments used there safe for tattooing? a. Yes b. No 5. Are tattoo parties and the instruments used there safe for tattooing? a. Yes b. No 6. Are tattoos a permanent practice? a. Yes b. No 7. Do you have a tattoo? Yes (please make sure to answer questions 9-16) No (please skip questions 9-15 and go to question #17) If you have a tattoo, please answer the following: 8. If you have a tattoo, at what age did you get it? 9. Who did you seek advice from before you got your tattoo? 1. My parents/guardians 2. My friends 3. My siblings 4. The internet 5. No one 10. Did you tell your parents or guardians about your tattoo? a. Yes b. No 11. Did you sign a consent or permission form before receiving a tattoo? a. Yes b. No 12. WHO did you receive your tattoo from? a. From an artist in a tattoo shop/parlor in North Carolina b. A friend or family member c. Myself d. Other (please describe below) ___________________________________________________________ 13. In what type of setting did you receive your tattoo? a. Your home b. At a tattoo party in someone else's home c. At school d. A tattoo parlor/Shop in NC e. A tattoo parlor/Shop in another state besides NC f. A correctional facility g. Other (please describe below) ___________________________________________________________ 14. How did you find your tattoo artist? a. Social media post (includes Facebook, Twitter, Instagram, Vine, Snapchat, etc. Does NOT include direct messages on these apps) b. Word of mouth, message, or text (text message, imessage, whats app, direct messages on social media apps, etc) c. Other (please describe below) ___________________________________________________________ 15. Did the tattoo artist use sterile instruments for your tattoo? a. Yes b. No c. I don't know 16. What complications did you experience after your tattoo? a. Blood infection b. Skin rash or dermatitis c. Rejection of tattoo d. No complications were experienced e. Other (please describe below) ___________________________________________________________ 17. How would you describe the location you received your tattoo? a. Very clean b. Clean c. Dirty d. Very dirty 18. If you do not have a tattoo, are you considering one in the future? a. Yes b. No c. I don't know Please fill in the following information: What is your age? What is your grade level? What is your race? What is your gender? TATTOO EDU Post-education program survey WS/FCS Spring 2017 Please answer each question honestly and to the best of your ability. None of your answers will be shared or reported; all information is kept confidential. Do not place your name or any other identifying information on this survey. Survey responses are used to improve program delivery and content. 1. On a scale of one to five, how risky to your overall health is it to get a tattoo? (please circle only one option- 1 is not risky at all, and 5 is very risky) 1 (not risky at all) 2 (a little) 3 (neutral risk) 4 (risky) 5(very risky) 2. Can tattoos transmit infectious diseases? a. Yes b. No 3. Can tattoos transmit non-infectious diseases? a. Yes b. No 4. Are permitted tattoo parlors/shops in NC and the instruments used there safe for tattooing? a. Yes b. No 5. Are tattoo parties and the instruments used there safe for tattooing? a. Yes b. No 6. Are tattoos a permanent practice? a. Yes b. No 7. What types of infections can be transmitted via tattoos? (circle all that apply) a. HIV b. MRSA c. Hepatitis A, B, C d. Tuberculosis e. Tetanus 8. What are some other risks of unpermitted tattoos? 9. What types of things should you look for in a permitted tattoo shop or parlor? 10. What did you like about the program? 11. What would you add to the program? 12. What part of the program was the least informative? 13. What parts of the program did you already know? 14. What other questions do you have about tattoos and body art?
LESSONS LEARNED Via implementation pilot, it was confirmed that high school students in Forsyth County have tattoos, illegally administered through permitted and non-permitted artists. It was also confirmed that students have misconceptions and misinformation regarding the risks of transmission of diseases associated with tattooing. Body art is of interest of the target population and they were largely an engaged audience. Teacher engagement and commitment is critical to successful delivery of the program as s/he must maintain classroom control. Significant time must be committed to successfully coordinate program implementation dates/times as these are individually negotiated with the classroom teachers (50+ classrooms). Attention must also be paid to not schedule on teacher workdays, holidays, early release days and test administration days. A cost/benefit analysis was not conducted as many of the benefits of this program are intrinsic and inherently difficult to monetarily quantify and the cost are primarily fixed and adequately addressed through existing resources. Stakeholder commitment is sufficient to maintain this practice. A second round of implementation is being planned for spring 2018, with biannual implementation thereafter. Because the program is administered with existing resources, financial sustainability is assured. Tattoo EDU aligns with the 10th grade ‘personal and consumer health' curriculum subject including evaluation of health information/ products and education to critique potential health/social consequences of body art and therefore compliments and supplements teacher instruction. The FCDPH Board of Health and school leadership supports the program. Additionally, there is interest from the Association of North Carolina Health Boards for expanded implementation in other North Carolina counties.
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