2011.4-3.Skin

                                                                                                                            article in PDF  
Our Dermatol Online. 2011; 2(4): 189-195
Date of submission: 06.03.2011 / acceptance: 17.04.2011
Conflicts of interest: None
 

SKIN CANCER KNOWLEDGE, ATTITUDE AND BEHAVIOR TOWARDS SUN EXPOSURE AMONG YOUNG ADULTS IN LITHUANIA

WIEDZA NA TEMAT RAKA SKÓRY, POSTAW I ZACHOWAŃ WOBEC EKSPOZYCJI NA SŁOŃCE WŚRÓD MŁODYCH OSÓB DOROSŁYCH NA LITWIE

Ieva Laniauskaite1, Agne Ožalinskaite1, Rasa Strupaite1, Matilda Bylaite1,2

1Clinic of Infectious diseases, Dermatovenereology and Microbiology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
2Centre of Dermatovenereology, Vilnius University Hospital Santariški? Klinikos, Vilnius, Lithuania
 

Corresponding author: Dr. Matilda Bylaite   e-mail: matilda.bylaite@gmail.com


 

Abstract
Objective: The aim of the study was to assess young adult's knowledge about skin cancer and it’s risk factors, attitude towards sun exposure and the interactions of various behaviors in the sun. Material and methods: The anonymous questionnaire-based inquiry of 750 respondents was created according to the anonymous form filled-in during the annual Euromelanoma Day campaign. Results: 708 questionnaires were filled-in correctly: 328 (46.3%) by men, 380 (53.7%) by women. Median of age was 21 (women – 22, men – 21). During the sunny days 93.2% of respondents sometimes seek shade, 17.5% of young adults never try to get a tan from 11a.m. to 3p.m. Sunglasses are worn in 52.4% of cases, however 63.1% of them with UV filters. 8,1% of respondents always wear T-shirts, 30.6% cover head in the beach. While sun-bathing one third (32.9%) wear sun protection cream, while working or doing sports outdoors – 8.9%. Majority (57.4%) apply sun protection cream when coming to the beach, 31.4% of them don't use it repeatedly. Those who knew, what is melanoma, were more likely to wear sunglasses (p=0.003) with UV filters (p=0.006), T-shirts (p=0.046), covered head (p<0.0001) and seeked shadow (p=0.002) on the beach; used sun protection cream while working ≥1 hour outdoors (p=0.001) or sunbathing (p<0.0001), and choosed a sun protection cream according to SPF value (p<0.0001). Conclusion: The data of this study showed that respondents behave careless in the sun. One third of respondents always wear sun protection cream, the majority do not know how to use it properly. More responsible behavior in the sun depends on better knowledge of skin cancer.
 
Streszczenie
Cel: Celem pracy była ocena wiedzy młodych dorosłych na temat raka skóry i czynników ryzyka, w stosunku do ekspozycji na słońce i interakcji na ró?ne zachowania na słońcu. Materiał i metody: Stworzono anonimowy kwestionariusz badania oparty na 750 respondentach, którzy anonimowo wypełniali formularz w ciągu całorocznej kampanii Euromelanoma Day. Wyniki: 708 ankiet wypełniono prawidłowo: 328 (46,3%) przez mę?czyzn, 380 (53,7%) przez kobiety. Mediana wieku wynosiła 21 lat (kobiety – 22, mę?czyźni – 21). Podczas słonecznych dni w 93,2% respondenci czasami szukali cienia, 17,5% młodych ludzi nigdy nie starało się uzyskać opalenizny między godziną 11.00, a godziną 15.00. Okulary noszone były w 52,4% przypadków, jednak 63,1% z nich posiadały filtry UV. 8,1% respondentów zawsze nosiło T-shirty, a 30,6% nakrycia głowy na pla?y. Natomiast jedna trzecia (32,9%) zu?ywała krem ochronny przed słońcem, a w czasie pracy lub uprawiania sportu na świe?ym powietrzu – 8,9%. Większość (57,4%) stosuje krem przeciwsłoneczny, na pla?y, 31,4% z nich nie u?ywa go wielokrotnie. Ci, którzy wiedzieli, co to jest czerniak, byli bardziej skłonni nosić okulary (p = 0,003) z filtrami UV (p = 0,006), T-shirty (p = 0,046), nakrycia głowy (p <0,0001) i szukali cienia (p = 0,002) na pla?y, u?ywali krem ochronny przed słońcem podczas pracy ≥ 1 godziny na wolnym powietrzu (p = 0,001) lub opalania (p <0,0001) i wybierali krem ochrony przeciwsłonecznej SPF według wartości (p <0,0001). Wnioski: Dane z badania wskazują, ?e respondenci zachowywali się nieostro?nie na słońcu. Jedna trzecia respondentów zawsze nakładała krem ochronny przed słońcem, jednak większość nie wie jak go u?ywać prawidłowo. Bardziej odpowiedzialne zachowanie się na słońcu zale?y od lepszej wiedzy na temat raka skóry
 
Key words:  skin cancer; melanoma; sun protection; health education; Euromelanoma Day
Słowa klucze:  rak skóry; czerniak; ochrona przed słońcem; edukacja zdrowotna; Euromelanoma Day

 

Introduction
Over the past few decades the incidence of skin cancer has been rising in Lithuania at an alarming rate. Skin cancer is the most common type of cancer in white population across the globe [1], whereas a nonmelanoma skin cancer (NMSC) – most expensive to treat [2]. In 2009, 2272 new cases of skin cancer and 269 of melanoma were registered in Lithuania, while the number of such cases in 1992 were only 938 and 147 respectively [3]. The increase is most likely a result of several factors: depletion of the protective ozone shield due to climate change [4] and people’s careless behavior in the sun [5]. Moreover, in the nearest future in Lithuania the incidence of skin cancer might increase even more because of the change in sunbathing habits, e.g. increased frequency of vacations in sunny resorts. It must be acknowledged that the growth in recorded numbers may also be due to better detection methods as well as campaigns for skin cancer prevention, such as annual “Euromelanoma Day” campaign in Lithuania. Melanoma is considered to be the most serious form of skin cancer due to it’s rapid metastasis and a rising morbidity among younger people [6]. This cancer is completely curable if detected at the early stage of disease, unfortunately it is fatal if allowed to progress and spread. The key risk factor for melanoma and NMSC is ultraviolet sun radiation [7]. The majority of lifetime UV exposure is received before the 18 years of age [8]. Extended sun exposure during childhood increase the probability of skin cancer in adulthood [9]. For instance, more than 1 severe sunburn in childhood is associated with a two-fold increase in melanoma risk [10,11]. A higher risk of developing skin melanoma is indicated in fair-haired, blue-eyed, freckled and prone to severe sunburns people, as well as in those who are living closer to the equator, who have experienced severe sunburns once or several times, and in those who are spending their holidays in hot climate zones [12]. Primary prevention through identification of people at high risk [13], as well as by health education programs aiming to modify behavior in the sun and to promote protective measures, is a long-term approach to avoiding skin cancer in the future [14]. The aim of this study was to ascertain and evaluate knowledge and attitudes of Lithuanian young adult's regarding skin cancer, sun exposure and the interactions of their various behaviors in the sun.
 
Material and methods
The method employed was anonymous questionnaire-based inquiry. The questionnaire, consisting of 47 questions, was created according to the anonymous form filled in during annual Euromelanoma Day campaign. A pilot study phase enabled us to make possible choices more relevant and appropriate. Exclusion criteria used in this study were: respondents younger than 18 and older than 75; mental or movement disorder that would impair the ability to understand and complete the questionnaire. The following demographical data was asked: gender, age, education and profession. The respondents were asked to evaluate their skin type (Fitzpatrick classification) [15]. In order to check basic knowledge of skin cancer and sun exposure we asked the participants what is melanoma, ABCD criteria, SPF letters on cosmetics, whether skin cancer is contagious and which factors increase the probability of it. The opinion if tanned people are more beautiful and healthier, as well as if respondents pay enough attention to sun protection was also asked. We found out such peculiarities of respondents behavior in the sun: if they wear sun glasses (with or without UV filter) during a sunny day, seek shade in order to avoid direct sun rays, avoid sunbathing from 11 a.m. until 3 p.m., wear T-shirts and head covers (hats, caps, kerchiefs or wide-brimmed sunbonnets) in the beach. We also ascertained the duration of time spent outside on weekdays and weekends as well as whether they experienced sunburns to blisters under 18 years old. Study included 708 respondents: students of Vilnius University, Vilnius Gediminas Technical University, and Vilnius Pedagogical University, pupils of Vilnius Lyceum, Vilnius High School of Salomeja Neris, Vilnius Jesuit and Garliava Jonuciai High Schools as well as randomly selected 18-75 years old people. The statistical analysis was performed using SPSS 17.00. Distribution of bias was graphically assessed. Analysis of data was performed using X2 test or Mann-Whitney test. A p value of <0.05 was considered statistically significant.
 
Results
708 (94.4%) questionnaires out of 750 were filled in correctly and included into data analysis. 328 (46.3%) respondents were men and 380 (53.7%) women. The age of participants ranged between 18 and 75 years, vast majority of them (87.4% (619/708)) were younger than 30 years old. Median of age was 21 (for women – 22 and men – 21). 71.3% (505/708) of participants were either pupils or students. Majority of respondents (80.5% (570/708)) attributed themselves to II or III skin type according to Fitzpatrick scale (Fig. 1).
 
Figure 1. Skin type according to Fitzpatrick
 
Overall, 45.3% (321/708) of respondents did not know that melanoma is a skin cancer. 83.3% (583/708) did not consider that ABCD criteria define appearance of the atypical mole. Less than half of respondents (46.9% (332/708)) explained that SPF letters on cosmetics is abbreviation of “sun protection factor”, only 7.5% (53/708) correctly converted sun protection cream’s with SPF30 duration of protection from harmful sun’s rays. Only 3.2% (23/708) correctly named all mentioned skin cancer risk factors (Tabl. 1), 98.6% (698/708) of them knew that skin cancer is not contagious. The number of females, who answered that melanoma is a type of skin cancer, was significantly greater than men: 70.3% (267/380) and 36.6% (120/328) respectively (p<0.0001). Women significantly more frequently correctly answered that skin cancer is not contagious 94.2% (358/380) compared to men 83.2% (273/328) (p<0.0001). Females also more often named all skin cancer risk factors (females 5.0% (19/380) vs. males 1. 2% (4/328)) (p=0.005). Males better answered the question, what ABCD criteria define, (female 76.3% (290/380) vs. male 88.1% (289/328) (p<0.0001) and counted sun protection cream’s with SPF30 duration of protection from harmful sun’s rays (female 50.0% (190/380) vs. male 74.4% (244/328) (p<0.0001)). The number of respondents, who were ≥30 years old more often correctly named all risk factors of skin cancer (7.9% (7/89)) than people who were 18-29 years old (2.6% (16/619) (p<0.0001)). Respondents, who correctly answered what is melanoma, had significantly higher education degree (graduated/still studying at university) 59.9% (224/374) compared to the people who graduated/still learning at high school 48.6% (161/333) (p=0.003). Furthermore, people with higher education claimed more often that skin cancer is not a contagious disease (respectively 93.1% (350/376) vs. 84.6% (281/332) (p<0.0001)) and correctly answered what is SPF (respectively 96.5% (363/376) vs. 93.1% (309/332) (p=0.036)). No other significant differences were noticed among demographical data, skin type and knowledge about skin cancer and sun exposure. Respondents, considering that tanned people are more beautiful, think more frequently that tanning is healthy compared to people who believe that suntan is not related to beauty standards: 31.0% (149/480) and 8.0% (7/87) respectively (p<0.0001) (Fig. 2). Almost half (47.1% (263/708)) of respondents have been sunburned to blisters at least once before they reached 18 years old. Majority of respondents usually spend ≥1 hour in the sun in a typical weekday 66.4% (470/708), whereas on weekend this number reached 85.3% (604/708). 55.9% (396/708) of respondents admited not paying enough attention to skin cancer prevention. During the sunny days 84.0% (595/708) of respondents sometimes and 9.2% (65/708) of respondents always seek shade and only 17.5% (124/708) never try to get a suntan from 11 a.m. to 3 p.m. Sunglasses are worn in 52.4% (371/708) of cases, however, only 63.1% of them (234/371) have UV filters. Only 8.1% (57/708) of respondents always wear T-shirts and about one third of them (30.6% (217/708)) cover head on the beach. While sunbathing 32.9% (233/708) wear sunscreen, while working or doing sports outdoors – only 8.9% (63/708). 33.3% (172/516) use sunscreen with SPF 12-30. Majority (57.94% (296/516)) of respondents apply sunscreen when coming to the beach, 31.4% (162/516) of them don't use it repeatedly. Respondents, who correctly answered what is melanoma, were more likely to wear sunglasses (p=0.003) with UV filters (p=0.006), to wear T-shirts (p=0.046), to cover their head (p<0.0001) and to seek shadow (p=0.002) on the beach, to use sunscreen while working ≥1 hour outdoors (p=0.001) or sunbathing, and to choose sunscreen according to SPF value (p<0.0001) (Fig. 3) (Tabl. 2).
 
 
No
Knowledge statements
Correct 
answer
No (%) 
(n = 708)
1
Light skin
True
266 (37.6) 
2
Presence of family members skin cancer
True
425 (60.0)
3
Fungal disease of face skin
False
49 (6.9)
4
>50 body skin moles
True
343 (48.4)
5
Acne during adolescence 
False
20 (2.8)
6
Moles and freckles 
True
244 (34.5) 
7
Severe skin sunburn during childhood 
True
204 (28.8) 
8
Long duration sunbathing
True
564 (79.7) 
9
Frequent visits of tanning salons 
 
595 (84.0)
 
Overall, correctly answered
 
23 (3.2)
Table I. Knowledge regarding risk factors of skin cancer
 

Figure 2. Respondents, who consider that tanned body is a beauty standard, statistically more often think that it is also healthy (31.0% (149/480) vs. 8.0% (7/87) (p<0.0001)
Figure 3. Respondents, who correctly answered what is melanoma, were more likely to wear sunglasses (p=0.003) and T-shirt (p=0.046), to cover head (p<0.0001) and seek shadow (p=0.002) on the beach, to use sunscreen while sunbathing, to choose sunscreen according to SPF value (p<0.0001) 
 
 
When you go to the beach do you use sun protection cream? No (%) (n = 708)
1. Never
192 (27.1) 
2. Seldom
283 (40.0)
3. Always
233 (32.9)
When do you apply sun protection cream?
No (%) (n = 516)
1. Half an hour before going outside 
137 (26.6)
2. When I go outside
41 (7.9)
3. On the beach
296 (57.4)
4. When I get suntan or sunburn
42 (8.1)   
Do you repeatedly apply sun protection cream? 
No (%) (n = 516)
1. No
162 (31.4)
2. Yes, once in 2 hours 
279 (54.1)
3. Yes, once in 4 hours 
75 (14.5)   
Table II. Peculiarities of sun protection cream usage

Discussion
The results of the performed study showed that careless behavior, such as staying on the beach between 11 a.m. and 3 p.m. (the dangerous time period for exposure to the highest UVR intensity) without sunprotective clothing was very common. With regard to sun protection cream and it’s usage, the situation was terrifying as the vast majority of present study respondents used sunscreen infrequently, inconstantly and incorrectly. The main reason for such behavior might be insufficient knowledge concerning sun’s effect on health and the measures which help to protect the skin from harmful sun exposure. This should be a matter of great concern. Furthermore, 82.4% of respondents were not aware of a simple self-examination ABCD rule for atypical mole and melanoma. Self-examination of moles is important because a mole which is changing in size, shape or colour may develop into melanoma [16]. It is necessary to know how to distinguish mole from melanoma. The results of this study are comparable to similar studies worldwide. We found that the respondents from Lithuania seem to be less knowledgeable as far as melanoma is concerned. While only 55% of the participants reported knowing what is melanoma, in other countries the percentage of those with this knowledge was much higher (in Australia – 66% [20], in New Zealand – 75% (21), in USA – 80% [22] (Fig. 4). The generalization of the results also showed that in our country the frequency of sunscreen usage while being on the beach is not high (only 32.9%) compared to other countries (e.g. Israel, Australia, USA) [23-25]. For instance, the reported frequency of sunscreen usage in USA is 83.0%. It is recommended to use sunscreen in order to protect from sun exposure and to prevent sunburn [26]. The usage of sunscreen can prevent squamous cell carcinoma [27] and reduce the number of acquired nevi that are associated with sun exposure as a risk marker for melanoma [28]. Likewise, Lithuanians wear sun-protective clothing and sunglasses with UV filter disappointingly rarely. For instance, a wide-brimmed sunbonnet (a head cover, which gives the best sun protection) was worn on the beach only by 11.6% of young adults. These findings are similar to Lithuanian schoolchildren’s. They wear sunbonnets in 10.8% of the cases [29]. In accordance with the results of similar studies, the findings show that a great part of population in many countries fails to avoid intensive sun exposure, and Lithuanians are not an exception. It has been determined that 49% of the present study participants experienced sunburn at least once till 18 years old. These results are similar to the sunburn incidence reported in the studies from France (46%) [30] and Greece (56%) [31]. In similar study performed in USA [32], a sunburn incidence percentage was very high – 83% (Fig. 5). The majority of the respondents reported that a tanned body is a beauty standard (67.7%). The present findings are identical with the results of study conducted in Greece (67.7%) [31]. Young people from all over the world are likely to stay in the sun for extended periods, especially those aged 13-19 years [33]. Since it has been shown that adults have the lowest probability for change in behavior [33,34], educational efforts should focus mainly on students [25]. A review of recent activities of Lithuanian dermatologists shows that great efforts are being made to assess one’s knowledge, attitude and to understand UVR and it’s effects on the skin as well as to implement education programs. A health education program “Let's know the sun better” was implemented in several Kaunas city secondary schools. The evaluation of it’s results proved both the efficiency and the necessity of the prepared educational program [29]. Furthermore, the annual pan-European campaign of free skin examination “Euromelanoma” was successfully organized in Lithuania for the third time. It’s goal, which is consistent with WHO [35] guidelines, is to raise awareness of extended sun exposure risks and to educate the public about the protective measures [36]. On the basis of present study results, we recommend the national cancer prevention program to devote special attention to skin cancer prevention in children (through school curricula) and in the rest of the society through mass media, as it is the main source of information [35]. A few limitations of the study should be noted. A larger sample size and country-wide participation of adult respondents would provide more data about the knowledge about skin cancer and attitude towards sun exposure. The interview of other groups (e.g. younger pupils, parents and teachers) would allow the comparison of their beliefs with the present study participants.
 

Figure 4. Knowledge of what melanoma is, according to country 
*Adapted from M. Saridi et al article [31] 
Figure 5. Sunburn incidence, according to country 
*Adapted from M. Saridi et al article [31]

 
Conclusion
The knowledge about skin cancer and harmful effects of the sun among Lithuanian young adults is insufficient. The irresponsible behavior in the sun should be a matter of great concern. Furthermore, many young Lithuanians associate suntans not only with beauty but also with health. To sum up, poor knowledge, risky behavior and a dangerous standpoint must be challenged by health education and promotion programmes in order to reduce the epidemic of skin cancer in Lithuania in the nearest future (Fig. 4). Knowledge of what melanoma is, according to country *Adapted from M. Saridi et al article [31] (Fig. 5). Sunburn incidence, according to country *Adapted from M. Saridi et al article [31]
 
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