Development and Validation of the Epidemiological Tattoo Assessment Tool to Assess Ink Exposure and Related Factors in Tattooed Populations for Medical Research: Cross-sectional Validation Study
Authors: Foerster Milena , Dufour Lucas , Bäumler Wolfgang , Schreiver Ines , Goldberg Marcel , Zins Marie , Ezzedine Khaled , Schüz Joachim 
Published: October 2022

Background
Tattooing, whose popularity is growing worldwide, is an invasive body art that involves the injection of chemical mixtures, the tattoo ink, into the upper layer of the dermis. Although these inks may contain environmental toxins, including known human carcinogens, their long-term health effects are poorly studied. To conduct the urgently required epidemiological studies on tattoos and their long-term health effects, a validated method for assessing the complex tattoo exposure is needed.

Objective
We aimed to develop and validate the Epidemiological Tattoo Assessment Tool (EpiTAT), a questionnaire to self-assess tattoo ink exposure in tattooed populations suitable for application in large epidemiological cohort studies.

Methods
One of 3 preliminary versions of the EpiTAT using one of the alternative tattoo measurement units hand surface, credit card, or body schemes was randomly filled in by tattooed volunteers in Lyon, France. To identify the most suitable unit of tattoo self-assessment, a validation study was conducted with the selected respondents (N=97) to compare the self-assessments of tattoo surface, color, and coverage with validation measurements made by trained study personnel. Intraclass correlation, the Kendall rank correlation, and 2-tailed t tests were used to statistically compare tattoo size, color area, and tattoo coverage separately for each questionnaire version. Participants’ opinions on the alternative measurement units were also considered in the overall evaluation. For quality control of the validation measures, digital surface analysis of 62 photographs of selected tattoos was performed using Fiji/ImageJ.

Results
In general, the results revealed overestimation of self-assessed measures compared with validation measures (eg, mean tattooed body surface 1768, SD 1547, cm2 vs 930, SD 1047, cm2, respectively, for hand surface; P<.001) and validation measures compared with digital image analysis (mean individual tattoo surface 147, SD 303.9, cm2 vs 101, SD 154.7, cm2, respectively; P=.05). Although the measurement unit credit card yielded the most accurate measures for all variables of interest, it had a much lower completion rate (78/129, 60.5%) than hand surface (89/104, 85.6%) and body schemes (90/106, 84.9%). Hand surface measured total tattoo size more accurately than body schemes (absolute agreement intraclass correlation coefficient: 0.71 vs 0.64, respectively).

Conclusions
The final version of the EpiTAT contains 21 items and uses hand surface as a visual unit of measurement. Likert scales are used to assess color and coverage as a proportion of the total tattoo area. The overestimation of tattoo size by self-reporting merits further research to identify potential influential factors or predictive patterns that could be considered when calculating exposure.