Despite potential long-term health risks, body piercing remains popular among people of all ages, occupations, and social classes. In the 18- to 23-year-old age range, current estimates of piercing prevalence range from 30% to 50%.1
Several reasons for piercing have been identified, including: identifying with a particular group of people; identifying with a specific age group or social ranking; belief in magical powers; desire to appear ferocious and attractive; and sexual stimulation.2 Body piercing is a way for people to identify themselves uniquely or as part of a group, and it attests to the perceived importance of outward appearance and inner desires.3
Reported risk factors associated with body piercing have also increased. Common and uncommon concerns include local infection, bleeding, metal hypersensitivity, increased risk of infective endocarditis, Ludwig angina, cerebellar brain abscess, critical upper-airway compromise, mucogingival deformities, periodontal destruction, and Pseudomonas aeruginosa.4,5 However, body piercers may not always provide information on risks associated with piercing procedures. Many healthcare professionals have not kept abreast of complications associated with body piercings.
Despite a plethora of information on the subject, evidence-based scientific information on decisions regarding body piercing has been limited. There are few documented client education programs related to body piercing. To balance thrill-seeking behavior and peer pressure, and provide optimal care for clients, healthcare providers should provide fact-based education about body piercing to all clients. With knowledge of the associated risks, clients can make the best decisions about piercings.
The purpose of our study was to determine whether young adult women between the ages of 18 and 26 who received a risk reduction, health promotion program would have greater confidence in conflict decision-making concerning body piercing.
Body-piercing risks
Based on an integrative research review of 12 studies focused on body-piercing risks, researchers observed several key findings. Ear piercing was associated with hepatitis in six studies; two studies found percutaneous exposure to be a risk factor for hepatitis; and reusing piercing devices or unsterile needles may be a route of transmission for hepatitis infections. In these studies, sample sizes ranged from 114 to 7,271 cases. Based on this body of research, recommendations included public and professional education regarding risk factors, regulating the body-piercing industry, and using better sterile devices and sterilization procedures.6
Recent research has also focused on risks associated with body piercing. In a study of 118 people who had undergone 186 ear piercings, seven people developed confirmed P. aeruginosa infections, one had Staphylococcus aureus, and one had both infections. In addition, there were 18 cases of suspected infection. Of the 186 piercings, 63 were done in upper-ear cartilage. Those with P. aeruginosa had abscess formation with associated pain, bleeding, and drainage. The researcher concluded that ear cartilage piercing carried a higher risk than lower-ear lobe piercing.7
Motivations for body piercing
Body image and expression of individual identity within a subgroup were observed as motivating factors in several studies.8-11 Fashion consciousness was also observed as a determining factor in piercing decisions.12
Attitudes and practices regarding body piercing were studied among 103 urban undergraduates to determine the following factors: social acceptability of body piercing; personal experiences and attitudes on piercing as a form of body art; and knowledge of health risks. The results indicated that 50% of the undergraduates had piercings, 78% liked piercings on others, 52% liked their piercings, and 43% knew someone who experienced a health problem as a result of a piercing.13
A recent study of 63 women and 83 men from general populations focused on decision factors and health problems related to intimate body piercings. Results revealed that people who had body piercings were significantly younger, less ethnically diverse, better educated, less likely to be married, more often homosexual or bisexual, and initiated sexual activity at a younger age. Reasons for choosing to body pierce included uniqueness, self-expression, and sexual expressions.3 Other factors that may be related to body piercings were anger;14 overall risk-taking behavior, such as suicide attempts and cigarette, alcohol, and marijuana use;15 and sexual intercourse.16 These negative body-piercing motivators included deviant or antisocial behaviors. Researchers have concluded that the presence of tattoos or body piercings in adolescents does not necessarily indicate risk-taking behaviors, but their presence should alert parents, teachers, and healthcare providers of the possibility of greater health risks.
Conflict decision-making
Interest in informed decision making has intensified over the past several years. Although patient involvement in decision making has been theoretically linked to improved quality of healthcare, there is minimal research in this area.
In a systematic review of 186 audiotaped consultations in the United Kingdom, researchers reported that decision making was a major factor to get patients to participate in healthcare.17 Decisional aids have also been considered important to prepare people to participate in preference-sensitive decisions. Based on studies of more than 200 decisional aids used in randomized controlled trials of people facing healthcare decisions, researchers found that these aids resulted in greater knowledge, more realistic expectations, lower decisional conflict, increased patient participation in decision making, and fewer participants who were undecided after the intervention. Researchers concluded that the availability of decision aids is expanding and that trials indicate decision aids improve knowledge and realistic expectations.18
In another review of randomized trials, it was determined that decision aids improved knowledge, reduced decisional conflict, and stimulated patients to be more active in decision making. Decision aids produced higher knowledge scores, lower decisional conflict scores, and more active patient participation in decision making. There was no difference in anxiety, satisfaction with decisions, or satisfaction with the decision-making process.19
Young adults facing body-piercing decisions are likely to experience decisional conflict. Researchers have indicated that decisional aids may improve knowledge and prevent unintended consequences. Increased knowledge and reducing conflicts in body-piercing decisions may improve clinical outcomes. No previous studies have been conducted to evaluate the effect of a risk reduction, health promotion education program about body piercing on the decisional conflict of young adult women.
Study methods. An exploratory one-group pretest posttest design was used to determine changes in perceived decision making associated with a risk reduction, health promotion program. The setting for this study was at two gynecologic offices located in Texas. Both sites provide healthcare services to insured, Medicaid, Medicare, and self-pay clients in an urban area. The education program included viewing a 12-minute DVD titled "Your Body, Your Choice" and reviewing a brochure titled "Body-Piercing."
Decisional Conflict Scale (DCS). The DCS includes 16 items to elicit information regarding the following: uncertainty making a choice; modifiable factors that contribute to uncertainty, including lack of information, unclear values, and inadequate social support; and perceived effective decision making. High scores indicate greater decisional conflict. The DCS has five subscales: uncertainty, informed, values clarity, support, and effective decision. Validity and reliability have been evaluated and reported in previous research with the DCS; the overall reliability coefficient was 0.78 to 0.92.20,21
Research procedures. Women between the ages of 18 to 26, with or without body piercings, who presented for healthcare services at the two sites were offered information regarding the study. A medium effect size of 0.30 was chosen to use in the calculations of the power analysis. Based on a one-tailed test with a power of 0.80, an effect size of 0.3, and a 0.05 level of significance, the appropriate total sample size for this study was 66. Women who expressed an interest in participating were escorted to the conference room and introduced to the primary researcher. To avoid distractions, there were no telephones in the room, and a "do not disturb-interview in process" sign was placed on the door.
Data collection. After signing informed-consent forms, participants completed the demographic data form and the pretest DCS was administered. Then, the risk reduction, health promotion education program on body piercing began. A body-piercing brochure developed by the primary researcher was verbally reviewed and given to the subject. Education in the brochure included piercing risks, choosing a safe body piercer, ways to reduce piercing risks, peer-pressure issues, and taking time to consider the options with body piercing.
Content validity was assured with an expert panel that included a body-piercing researcher/educator, a health literacy expert/educator, two women's health NPs, and an RN. The subject viewed the patient education program DVD, which included a discussion between a group of young adults concerning body piercing and tattooing peer pressure, risks, questions to ask before participating in body modification, and the importance of taking time with these decisions. After reviewing the brochure and completing the DVD, participants received the posttest DCS and were asked to evaluate the education program for knowledge gained.
Reviewing results. There were 70 study participants, ranging in age between 18 and 26, with a mean age of 21.61 years (SD 2.64). Of these participants, 97.1% reported English as their primary language, whereas 2.9% reported being bilingual in English and Spanish. The participants' ethnicity included Hispanic women (71.4%), followed by whites(20%), African American (5.7%), and 2.9% for other groups. Marital status was reported as 56.7% of women being single and never married. Unemployed participants consisted of 35.7%, 14.3% were homemakers, 10.0% were students, and 8.6% were professionals. Thirty-seven percent reported 12 years of formal education.
The majority (85.7%) had body piercings, and 78.6% had no problems after receiving piercings. Sites of piercings varied, with ears being the primary site (51.4%). More than one piercing site was reported by 44.3%. Thirty-two participants received their piercings at tattoo or piercing parlors, while 38.6% had piercings at a mall. (Demographic characteristics of the participants and background data on body piercings are included in Sample characteristics.)
After receiving the educational intervention, participants acknowledged two areas of gained information. This information included risks associated with piercing activities and questions to ask before considering a piercing. More than 65% stated they would not be likely to consider piercing in the future. Of these, several reported they would have made different decisions on previous piercing activities had they known the risks involved. (See Posteducation responses.)
DCS results. Researchers calculated means and standard deviations for the pre- and posttest total DCS and subscale scores and evaluated differences in DCS scores from pre- to postintervention. Controlling for pretest scores, results indicated a statistically significant difference in the DCS total scores after participants completed the risk reduction, health promotion education program. There also were significant differences in four of the five subscales: uncertainty subscale, values clarity subscale, support subscale, and decision making. (See Decisional conflict scores pre- and postintervention.)
There was a significant difference in decisional conflict scores in young women who received the risk reduction, health promotion body-piercing education program. In addition, the participants reported that the educational intervention provided information on risks associated with body-piercing activities and questions to ask before piercing activities. Some people indicated they might reconsider previous piercing activities.
Discussion. This study was conducted with a sample of women between the ages of 18 and 26 who were patients in two West Texas obstetric/gynecologic clinics. The sample was culturally homogeneous and not representative of the entire adult population. Both sites had a large Hispanic patient base as well as a large number of unemployed young women. A more culturally diverse subject group could help generalize the significant results to larger populations within Texas and throughout the United States.
The results of this study provide useful information for healthcare professionals working in clinical settings. Despite documented health risks, body-piercing practices continue to grow. The prevalence of body piercing has been reported as high as 51% in young adult populations.1 With various body-piercing activities, women across the lifespan continue to be at risk. Also, 43% of the women had body piercings in infancy (before age 1), and 83% had piercings before the age of 17. In most states, the legal age of consent is 18 years old; thus, the majority of these women likely had parental permission for the piercings.
Healthcare providers should promote a risk reduction, health promotion program that encompasses body-piercing education, questions to ask before piercing, and explanations of postpiercing care. Educating young women is critical, as they will likely make decisions about body piercings for their infants, young children, and adolescents. The cultural and parental influences related to body piercings are important considerations in clinical practice and future research.
Future research should be focused on investigating the differences among men and women of all ages and cultural groups using larger samples in both rural and urban settings. Educational interventions regarding risks associated with body piercings at a young age are equally important. Data collected in locations where people participate in piercing activities, such as body piercing and tattoo parlors, shopping malls, and department stores, could provide valuable information. Prenatal clinics can provide an important venue to educate women who might be considering body piercings for their infants.
Through education, participants have learned about risks associated with body-piercing activities, such as Hepatitis B or C, HIV, skin infections, bleeding, allergies, tetanus, and scarring. Participants received a list of questions to ask before receiving future piercings, such as: does the piercer have appropriate training and a license; how long have they been participating in piercing activities; have they experienced problems with piercing activities; what's the procedure for piercing activities; do they use sterile equipment; and do they provide aftercare instructions and procedures if problems arise. Consistency and congruency of education programs should be compared with future studies.
Advanced practice nurses have the potential to influence the population at risk for long-term health risks associated with body-piercing activities. As healthcare providers, NPs can provide education to reduce risks and possibly prevent long-term health problems. Identifying risky behaviors provides healthcare professionals with an opportunity to educate women and the population on possible effects stemming from body-piercing activities. Providing knowledge enables individuals to recognize the risks and empower them to make safer decisions on potentially risky behavior. In turn, this awareness can lead to healthier lifestyles.
Health risks associated with body piercing continue to be reported and are expected to increase in numbers and long-term complications. This study determined that decisional conflict can be reduced when participants complete a risk reduction, health promotion body-piercing educational program.
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