Sun Exposure And Sun Protection Behaviours

Preventive Medicine 33, 141–151 (2001) doi:10.1006/pmed.2001.0877, available online at http://www.idealibrary.com on

Sun Exposure and Sun-Protection Behaviors and Attitudes among U.S. Youth, 11 to 18 Years of Age Vilma E. Cokkinides, Ph.D.,*,1 Kourtney Johnston-Davis, Ph.D.,† Martin Weinstock, M.D., Ph.D,*,‡ Mary C. O’Connell, B.A.,* William Kalsbeek, Ph.D.,§ Michael J. Thun, M.D., M.P.H.,* and Phyllis A. Wingo, Ph.D.* *Department of Epidemiology and Surveillance and Department of Cancer Control, American Cancer Society, Atlanta, Georgia 30329; †Data Exploration Center, Medical Data Sciences, Glaxo Wellcome; ‡DermatoEpidemiology Unit, Veterans Administration Medical Center, and Department of Dermatology, Rhode Island and Brown University; Providence, Rhode Island; and §Survey Research Unit, Department of Biostatistics, School of Public Health, University of North Carolina Chapel Hill, North Carolina Published online July 30, 2001

Background. Adolescence is a high-risk period for the development of melanoma and nonmelanocytic skin cancers later in life. This study examines the prevalence and correlates of sun-protection practices among U.S. youth. Methods. During July–October, 1998, a national, population-based telephone survey was conducted (N ⴝ 1,192 paired interviews of youth and their parents). Weighted prevalence and adjusted prevalence odds ratios and 95% confidence intervals were estimated. Multiple logistic regression analyses examined associations between sociodemographics, attitudes, and other modifiable correlates to specific behaviors. Results. Routinely practiced sun-protection behaviors among youth on sunny days were wearing sunglasses (32%) or long pants (21%), staying in the shade (22%), and applying sunscreen (31%). Fifty-eight percent used a sunscreen with SPF ⱖ15 when at the beach or pool. Age, sex, and sun sensitivity were associated with substantial variation in some sun-protection behaviors. Factors associated with specific sun-protection behaviors included a lower appeal to tanning, a higher perceived benefit of sun protection, and information from family and friends about sun protection. Conclusion. Effective sun protection is practiced by less than one-third of U.S. youth. This baseline survey will help to monitor progress in skin cancer prevention in this critical age group in the future. 䉷 2001 American Health Foundation and Academic Press

Key Words: skin neoplasms prevention and control;

1 To whom reprint requests should be addressed at the Department of Epidemiology and Surveillance, American Cancer Society, National Home Office, 1599 Clifton Road, NE, Atlanta, GA 30329-4251.

adolescence; youth; adolescence behaviors; sun exposure; sunscreen agents; knowledge; attitudes; practice; health surveys.

INTRODUCTION

More than 1 million Americans may develop skin cancer and an estimated 47,700 persons may be diagnosed with melanoma, the most serious form of skin cancer, in 2000 [1]. While the incidence of melanoma continues to increase in the United States [2, 3], national measures to improve sun protection may have contributed to the reduction in the incidence of skin cancer in Australia [4–6]. Increased cumulative sun exposure and a tendency to burn rather than to tan are risk factors for nonmelanoma skin cancers. A history of sunburn during childhood and intense intermittent sun exposure have been shown to increase the risk of melanoma [7–13]. Primary prevention of skin cancer stresses the need to practice routine sun-protection behaviors by adults, youth, and children alike. Recommended sun-safety practices include avoidance of or limiting outdoor activities in the middle of the day; use of shade for sun protection; wearing of sun-protective clothing such as broadbrimmed hats, long-sleeved shirts, long pants, and sunglasses; and use of sunscreens with a sun protection factor (SPF) of 15 or greater on exposed skin and avoidance of tanning beds and sun lamps [1, 14]. Because childhood and teen years are high-risk periods for sun exposure, and melanoma has been linked in particular to childhood exposure [9, 15], it follows that heightened cancer control efforts should be directed at children and youth. Population-based national data regarding sun

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0091-7435/01 $35.00 Copyright 䉷 2001 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.

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protection behaviors among youth in the United States are sparse. One telephone-based survey in Illinois examined sun exposure and sun protection in a multiethnic cross section of youth [16], and two other populationbased studies surveyed parents about the sun-protection practices of their children under 13 years of age [17] or younger than 2 years of age [18]. The goal of the present survey was to measure the prevalence of sun-protection behaviors among U.S. youth, 11 to 18 years of age. In particular, this study assessed: (1) the patterns of sun exposure and sun-protection behavior in relation to age, sex, and sun sensitivity and (2) the relationship between modifiable correlates and sunprotection practices. METHODS

During July and October, 1998, the American Cancer Society (ACS) conducted a telephone-based, nationally representative survey of the noninstitutionalized civilian population of youth, 11 to 18 years of age, living in households in the contiguous United States to provide estimates of sun exposure, sun-protection behaviors, attitudes, and awareness of skin cancer and sun-protection information. The ACS Sun Survey consisted of a youth interview, requiring permission from a parent or caregiver, and an almost identical parent module asking questions about sun exposure and sun rotection. Parent/caregiver and youth questionnaires were developed using questions derived from pretested measures designed for use in similar studies [18–21]. Extensive pretesting of the Sun Survey questionnaire was performed, and to maximize accuracy of recall, the survey asked about the most recent summer experiences occurring about 1 to 3 months before interview and other events occurring in the past 12 months. The ACS survey used a two-stage national probability design stratified into seven geographic regions (characterized by levels of ultraviolet radiation exposure as determined by the National Weather Service) to derive a random sample of U.S. households with telephone numbers. Telephones numbers were proportionately allocated among the seven regions, based on population counts of the number of in-service residential phone lines. Two types of listings of 10-digit telephone numbers were used to identify selected households: (1) a stratified list-assisted random-digit dialing (RDD) sample of telephone numbers and (2) a stratified agetargeted sample of telephone numbers. The sample was chosen in two sampling stages: a household with a 10-digit residential telephone number as the sampling unit in the first stage and an age-eligible child within the household as the second-stage sampling unit. The sample of parents was chosen from the first stage. A household was defined as a place of residence for one

or more people and a household was eligible if it contained at least one youth 11 to 18 years of age. If there was one child, this child was the selected respondent. If there was more than one child in the eligible age range, the child with the most recent birthday was selected. The parent or guardian having primary caregiving responsibilities for the child was the selected parent respondent. To determine the prevalence of youth’s sun exposure and sun-protection behaviors, 1,200 youth from the general population of households were needed to be interviewed. A total of 17,160 telephone numbers were included in the study sample and it yielded 1,192 parent/ child interviews completed. Using standard response rate formulas for RDD [22], the overall screening rate was 90.7% and the overall response rate was 57.7%, the latter representing the percentage of the eligible population who completed either one or both child/parent interviews. Region-specific response rates were adequate (i.e., over 65%) in four of the seven regions. More details about the Sun Survey methodology can be made available upon request. Definitions Sun-sensitivity index. We used the sun-sensitivity index, a validated measure suitable for epidemiologic research [23], to categorize youth into high, medium, and low levels of phenotypic (physical) susceptibility to sun exposure. The phenotypic characteristics used in the sun-sensitivity index were: (1) the kind of skin reaction after 1 h exposure to the summer sun, (2) the kind of skin reaction after repeated exposure to the summer sun, (3) the natural color of the skin, and (4) the natural color of the hair. Sun exposure. Sun exposure was assessed from these four questions: (1) On average during this summer, about how many hours per week did you spend outdoors between 10 AM and 4 PM on weekdays only? (2) On average during this summer, about how many hours per week did you spend outdoors between 10 AM and 4 PM on weekends? (3) How many days in the past 12 months did you spend at the beach between 10 AM and 4 PM? and (4) How many days in the past 12 months did you spend at an outdoor pool between 10 AM and 4 PM? Sun-protective behaviors. Youth were asked to report how frequently they practiced the six recommended sun-protection behaviors (listed below) on a 5-point scale (1 ⫽ never, 2 ⫽ rarely, 3 ⫽ sometimes, 4 ⫽ often, 5 ⫽ always). To assess “routine” practice of each of these behaviors, youth were classified by whether they routinely (“often” or “always”) practiced the range of recommended sun-protective behaviors when going outside on a very sunny day during the

SUN PROTECTION BEHAVIOR AMONG U.S. YOUTH

summer for more than 1 h: (a) staying in the shade or under an umbrella, (b) wearing sunglasses, (c) wearing a wide-brimmed hat, (d) wearing a long-sleeved shirt, (e) wearing long pants, and (f) applying sunscreen lotion. In addition, youth that reported using sunscreen lotion were further classified by whether they “often” or “always” used a sunscreen lotion with SPF of 15 or greater when they were at the beach or at the pool. The sunscreen questions do not distinguish between the various types of sunscreen product that may be available in the market (i.e., sticks, lotions, or sprays). Youth were also classified by the number of recommended sun-protective behaviors practiced on a routine basis (“often” or “always”) as follows: (1) those practicing three to six sun-protective behaviors routinely, (2) those practicing one or two routinely practiced sunprotective behaviors, and (3) those not practicing any sun-protection behavior routinely. Other descriptive measures related to behaviors of sunscreen use were also examined among youth by asking how frequently they reapplied sunscreen when they had been out in the sun all day and what was their usual source of sunscreen lotion. Responses for the latter included “purchased their own,” “used the sunscreen lotion their parents bought,” and “borrowed sunscreen lotion from a friend or other person.” Psychosocial correlates related to sun protection. Based on the theories of planned behavior [24] and the Health Belief Model [25, 26], the following psychosocial factors were considered as potential correlates of sunprotection behaviors: being told by a health care professional to protect their skin from the sun (yes versus no), knowing someone who had skin cancer (yes versus no), the frequency of getting sun-protection-related information from friends and family members (categorized by how often they recently heard such information in a given week or a month), and attitudes about sun protection and sun exposure. To assess the latter, youth were asked 8 items on a 5-point Likert scale (ranging from strongly disagree to strongly agree) reflecting attitudes about sun exposure and protection. Factor analysis was used to reduce the number of potential attitudinal factors examined as predictors of sun-protection behaviors. This method produced two independent attitudinal factor scales reflecting barriers and benefits of sun protection. The first factor, termed barrier to sun protection, underlies youth’s attitudinal appeal for tan and was measured from these 2 items: “I feel healthy when I have a nice tan” and “I look better when I have a tan,” which had a reliability coefficient Cronbach ␣ ⫽ 0.69. The second factor, benefits of sun protection, was measured from 4 items: “protecting my skin from the sun is an easy way to stay healthy,” “using sunscreen lotion allows me to enjoy the outdoors with less

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worry,” “spending time in the sun without any protection can increase my chances of developing cancer,” and “my skin won’t wrinkle as fast if I spend less time in the sun.” These 4 items had a Cronbach ␣ of 0.58. The directionality of the scale for the first factor, barriers to sun protection, was reversed; thus, youth scoring low on this scale were those with a lower attitudinal barrier on sun protection because they perceived a tan to be less desirable. By averaging the responses from the relevant items for each factor, separate overall average scores assessing barriers and benefits of sun-protection attitudes were derived. Quartile distributions of the scores for each factor were used to categorize youth scoring high, medium–high, medium–low, or low. Analysis Analytic study sample. The analytic study sample consisted of 1,192 youth ages 11 to 18. This study concentrates on the youth sun-protection behaviors and their correlates (i.e., age, sex, race, Hispanic ethnicity, sun sensitivity, attitudes toward sun protection, attitudinal benefits and barriers to sun protection, and family and social influences). For purposes of assessing and controlling for confounding, we examined various sociodemographic variables from the parent/caregiver data as potential confounders. Sample weighting. Sample weights were computed using standard methods [27, 28]. Sample weights incorporated the following three types of adjustments: (1) a weighting class adjustment that corrected for sample imbalance among strata due to differential response rates, (2) a poststratification adjustment that corrected for other sample imbalance due to incomplete frame coverage and additional variation in response rates, and (3) a normalizing adjustment to rescale the weights so that they summed to the respondent sample size. This weighting process yielded two separate sets of weights—one for the child respondent records and another for the parent records. All statistical analyses were conducted using SUDAAN [29] to appropriately compute the standard errors of the prevalence estimates and 95% confidence intervals (95% CI) of the prevalence odds ratios. Descriptive weighted statistics were used to describe the study sample. Next, patterns of youth’s sun-protection behaviors, attitudes, and modifiable correlates were examined by age, sex, and sun-sensitivity index and tested for statistical significance using ␹ 2 tests with ␣ ⫽ 0.01. Univariate logistic regression analyses were used to examine the crude association between factors of interest (attitudes and modifiable correlates) and each of the outcomes (sun-protection behaviors): staying in the shade, using sunscreen with SPF ⱖ15, and practicing three or more sun-protection behaviors. Based on the

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literature [16, 23, 30, 31], age, sex, race, parental education, and sun sensitivity were assessed as potential confounders. After assessing these results, we conducted separate multivariate logistic regressions for each of the three outcomes to obtain adjusted prevalence odds ratios (OR) and 95% CI for the covariates and to determine the strength of the association of these covariates with each selected outcome. To determine the final set of covariates of interest after adjusting for the core set of potential confounders, a stepwise backward elimination process was used and statistical significance was assessed by the Wald statistic. RESULTS

Descriptive Characteristics In this sample survey of U.S. youth, 40.5% were 11 to 13 years of age, boys and girls were equally represented, most were white (78.2%), and 1 in 10 were of Hispanic ethnicity (Table 1). The youth’s parent/caregiver characteristics showed that 64.8% had at least some collegelevel education, 84.9% were married (or living as married), and more than half were living in the suburbs or in the city (Table 1). Youth were predominantly fair and light skinned (63.3%) and exhibited prevalent high-risk phenotypic characteristics; specifically, 40.3% of youth reported that their typical skin reaction after 1-h exposure to the summer sun was either severe sunburn with blisters or severe sunburn with peeling. Given such phenotypic characteristics, over two-thirds of youth exhibited moderate to high levels of sun sensitivity (i.e., higher susceptibility) (Table 1). On average during the summer, youth spent a total of 12 to 14 h outdoors during the midday hours (between 10 AM and 4 PM) on weekdays and 7 to 8 h total during the midday hours of weekends. Among youth, the average sun exposure at the pool was over two times greater (between 17 and 20 days) than that received when at the beach (between 6 and 8 days). The patterns of sun exposure by age, sex, and sun sensitivity did not vary significantly. Sun-Protection Behaviors Among U.S. youth, 10.2% reported practicing three or more sun-protection behaviors routinely (often or always) and nearly 60% practiced one or two routinely; however, about one-third of the youth overall did not practice any recommended sun-protection behavior routinely when going outside on a sunny day during the summer. Girls were found to practice more recommended sun protective behaviors routinely than were boys (Table 2). Among U.S. youth, using sunscreen lotion (31.4%) and wearing sunglasses (32.2%) were the most common sun-protection behaviors practiced routinely when outside on a very sunny day during the summer for more than 1 h. On the other hand, under

the same situations, youth infrequently wore a widebrimmed hat (3.8%) or a long-sleeved shirt (3.8%). Significant age, sex, and sun sensitivity differences were noted for general use of sunscreen. Among youth who had ever used sunscreen lotion, 58.4% reported using sunscreen lotion with SPF ⱖ15 often or always when being at the beach or pool; this prevalence was highest among youth with high sun sensitivity (69.0%). About one in two youth reported that they often or sometimes reapply sunscreen lotion when being out in the sun all day, and girls were more likely to do so than boys. Older youth, girls, and youth with low sun sensitivity were more likely to report buying their own sunscreen lotion; on the other hand, younger youth, boys, and those with high sun sensitivity reported using the sunscreen lotion their parent bought (Table 2). Attitudes and Other Modifiable Correlates Younger youth, ages 11 to 13 (83.6%), girls (80.9%), and those with a high sun sensitivity (85.8%) were more likely to strongly agree or agree with the opinion that using sunscreen lotion allows them to enjoy the outdoors with less worry; youth with moderate to high sun sensitivity were more likely to strongly agree or agree with the opinion that spending time in the sun without any protection can increase their chances of developing cancer (87.1 and 89%). Also, older youth and girls were more likely to strongly agree or agree with the notion that their skin will not wrinkle as fast if they spend less time in the sun (58.1 and 64.6%, respectively). In contrast, youth also hold significant attitudes toward perceived benefits of tanning (underlying appeal for having a tan). Specifically, girls were less likely to agree or strongly agree that they feel healthy when they have a nice tan compared to boys (37.9% versus 42.8%, respectively). Also, younger youth, ages 11 to 13, and youth with high sun sensitivity were less likely to strongly agree or agree with the opinion that they look better when they have a tan (49.8 and 44.9%, respectively) (Table 3). About one-third of U.S. youth have received health care professional advice to protect skin from the sun. Surprisingly, this prevalence did not differ significantly by sun-sensitivity status. Nearly one in two parents of youth (48.7%) reported having difficulties in protecting their child from the sun. In particular, parents of older youth (14 to 18), boys, and youth with low sun sensitivity had the greatest levels of difficulty in providing sun protection for their children against the sun. One in two youths received information about sun protection from friends and family; girls (57.2%) and youth with high sun sensitivity (57.6%) were more likely to receive this information than either boys or those with moderate or low sun sensitivity, respectively (Table 3).

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TABLE 1

TABLE 1—Continued

Characteristics of Study Population with Estimates for U.S. Youth, Ages 11 to 18, Sun Survey, 1998 Sample size (n ⫽ 1,192) Sociodemographics Age 11–13 years 14–15 years 16–18 years Sex Boys Girls Race White Black Asian/Pacific Islander Native American Other Hispanic origin Yes No Parent’s education Less or equal to high school Some college College graduate Graduate school Parent’s marital status Married Other Family income ⱕ$30,00 $30,001–50,000 ⬎$50,000 Refused/unknown Residence Farm/rural area Small town Suburb City Phenotypic sensitivity to sun exposure Skin reaction after 1 h exposure to summer sun Severe sunburn with blisters Severe sunburn with peeling Mild sunburn, some tanning Turning darker, no sunburn No sunburn, tanning Skin reaction after repeated exposure to summer sun Repeated sunburns No suntan; freckles Mild tan Moderate tan Deep tan

Weighted %a

(95% CI)

503 289 400

40.3 24.6 35.1

(37.1, 43.5) (21.8, 27.4) (32.0, 38.2)

600 592

50.7 49.3

(47.5, 53.9) (46.1, 52.5)

1,016 58 24

78.2 7.3 3.4

(75.3, 81.1) (5.4, 9.2) (1.9, 4.9)

26 68

3.1 8.0

(1.9, 4.3) (6.1, 10.0)

103 1,035

10.6 89.4

(8.4, 12.8) (87.2, 91.6)

375

35.1

(32.0, 38.2)

323 281 211

27.1 21.5 16.2

(24.2, 30.0) (18.9, 24.1) (13.9, 18.5)

1,045 145

84.9 15.1

(82.5, 87.3) (12.7, 17.5)

Sample size (n ⫽ 1,192) Natural skin color Very fair Fair Olive Light brown Dark brown Sun sensitivity index Low Moderate High Sun-exposure characteristics Mean No. of hours spent outdoors on weekdays,b weighted mean Mean No. of hours spent outdoors on weekends,b weighted mean Mean No. of days in past 12 months at the beach, weighted mean Mean No. days in past 12 months at an outdoor pool, weighted mean a b

176 263 534 219

20.9 21.3 40.1 17.7

(18.1, (18.7, (37.0, (15.3,

23.7) 23.9) 43.2) 20.1)

204 298 412 276

18.7 24.8 33.0 23.5

(16.2, (22.0, (30.0, (20.8,

21.2) 27.6) 36.0) 26.2)

127

11.5

(9.3, 13.7)

353

28.8

(25.9, 31.7)

384

31.0

(28.0, 34.0)

156

14.0

(11.7, 16.3)

163

14.6

(12.2, 17.0)

286 73 291 325 202

23.7 6.3 25.3 27.9 16.9

(20.3, (4.7, (22.4, (25.0, (14.5,

25.9) 7.9) 28.2) 30.8) 19.3)

Weighted %a

(95% CI)

163 633 146 214 27

14.3 49.0 12.0 21.5 3.2

(11.9, (45.9, (9.8, (18.7, (1.9,

16.5) 52.3) 14.0) 24.3) 4.5)

316 589 287

29.8 46.6 23.6

(26.8, 32.8) (43.4, 49.8) (20.9, 26.3)

13.2

(12.5, 13.9)

7.3

(6.8, 7.8)

6.7

(5.9, 7.5)

18.2

(16.8, 19.6)

May not add to total sample size or 100% due to missing data. Between 10 AM and 4 PM per week.

Correlates of Sun-Protection Behaviors This study reports the analytic results for three outcomes related to sun-protection behaviors: staying in the shade, using sunscreen lotion with SPF ⱖ15, and practicing three or more sun-protection behaviors routinely. For the other sun-protection behaviors, the univariate analyses did not demonstrate significant associations between the correlates of interest and the respective sun-protection behaviors. Compared with youth never staying in the shade or under an umbrella, youth who did so routinely were more than 4 times (OR ⫽ 4.6, 95% CI 2.6, 8.2) less likely to perceive a tan as beneficial and 1.7 times (95% CI 1.1, 3.0) more likely to perceive sun protection as beneficial (Table 4). African American and Native American youth were 2.7 and 3.5 times more likely, respectively, to stay in the shade or under an umbrella than their white counterparts. Receiving advice from a health care provider had a slight effect on staying in the shade or under an umbrella although this was of borderline statistical significance (Table 4). Compared with nonusers of sunscreen with SPF ⱖ15 when at the beach or pool, youth who reported using sunscreen with SPF ⱖ15 were 6 to 8 times more likely

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TABLE 2 Prevalence of Sun Protection Behaviors among U.S. Youth Ages 11 to 18, by Gender, Age, and Sun Sensitivity, Sun Survey, 1998 Age

a

Sun sensitivity

Total % (95 CI)a

11–13 % (95 CI)a

14–15 % (95 CI)a

16–18 % (95 CI)a

Boys % (95 CI)a

Girls % (95 CI)a

Low % (95 CI)a

Moderate % (95 CI)a

High % (95 CI)a

10.2 (⫾2.1) 58.7 (⫾3.2) 31.1 (⫾3.0)

11.3 (⫾3.3) 58.2 (⫾5.0) 30.5 (⫾4.7)

7.8 (⫾4.1) 57.2 (⫾6.5) 35.0 (⫾6.2)

10.7 (⫾3.5) 60.3 (⫾5.3) 29.0 (⫾4.9)

9.5 (⫾2.8) 53.6 (⫾4.6) 36.9 (⫾4.4)

11.0 (⫾3.1) 63.9 (⫾4.4) 25.0 (⫾3.8)*

10.7 (⫾4.4) 54.6 (⫾6.2) 34.7 (⫾5.9)

9.3 (⫾2.6) 58.4 (⫾4.5) 32.3 (⫾2.2)

11.6 (⫾4.4) 64.3 (⫾6.4) 24.1 (⫾5.7)

21.8 32.2 20.1 3.8 3.8

24.0 23.6 18.0 5.0 5.0

19.4 30.4 18.7 2.0 2.0

20.8 43.3 23.4 3.5 3.5

21.6 26.2 22.6 3.8 3.8

21.9 38.4 17.5 3.8 3.8

22.7 34.5 23.9 5.1 5.1

20.7 31.7 18.7 2.9 2.9

22.6 30.4 17.9 3.8 3.8

(⫾2.7) (⫾3.0) (⫾2.7) (⫾1.3) (⫾1.3)

(⫾4.4) (⫾4.3) (⫾4.0) (⫾2.4) (⫾2.3)

(⫾5.6) (⫾6.0) (⫾5.5) (⫾2.2) (⫾2.2)

(⫾4.5) (⫾5.4)* (⫾4.8) (⫾2.2) (⫾2.2)

(⫾3.9) (⫾4.0) (⫾3.9) (⫾1.8) (⫾1.8)

(⫾3.9) (⫾4.4)* (⫾3.6) (⫾2.0) (⫾2.0)

(⫾5.5) (⫾6.0) (⫾5.6) (⫾3.2) (⫾3.2)

(⫾3.8) (⫾4.2) (⫾3.6) (⫾1.5) (⫾1.5)

(⫾5.5) (⫾6.1) (⫾5.3) (⫾2.7) (⫾2.7)

31.4 (⫾3.0)

41.9 (⫾5.0)

26.5 (⫾6.0)

2.9 (⫾4.5)*

25.1 (⫾4.0)

37.9 (⫾4.4)*

21.0 (⫾5.0)

30.7 (⫾4.2)

46.1 (⫾6.7)*

58.4 (⫾3.5)

63.8 (⫾5.4)

58.6 (⫾7.1)

52.0 (⫾6.2)

56.1 (⫾5.2)

60.4 (⫾4.7)

50.6 (⫾7.3)

57.0 (⫾5.0)

69.0 (⫾6.7)*

11.5 (⫾2.4) 19.2 (⫾2.9) 50.9 (⫾3.6)

10.2 (⫾3.5) 15.3 (⫾4.0) 52.6 (⫾5.5)

13.1 (⫾4.9) 24.6 (⫾6.5) 47.2 (⫾7.3)

12.0 (⫾4.4) 20.3 (⫾4.9) 51.5 (⫾6.3)

16.0 (⫾4.2) 25.0 (⫾4.7) 42.0 (⫾5.4)

7.8 (⫾2.6)* 14.5 (⫾3.4) 58.1 (⫾4.8)

13.8 (⫾5.3) 20.9 (⫾5.8) 45.5 (⫾7.5)

13.0 (⫾3.5) 20.0 (⫾4.1) 49.0 (⫾5.0)

6.6 (⫾3.8) 17.0 (⫾5.6) 60.0 (⫾7.1)

18.4 (⫾2.7)

21.9 (⫾4.4)

15.1 (⫾5.0)

16.2 (⫾4.4)

17.0 (⫾3.7)

19.6 (⫾3.9)

19.8 (⫾5.8)

18.0 (⫾3.7)

16.4 (⫾5.1)

14.3 (⫾2.5) 78.0 (⫾3.0) 7.7 (⫾2.0)

8.1 (⫾3.1) 86.5 (⫾3.9) 5.4 (⫾2.7)

11.7 (⫾4.7) 79.5 (⫾5.8) 8.7 (⫾3.9)

24.1 (⫾5.4)* 66.1 (⫾6.0) 9.8 (⫾3.8)

7.1 (⫾2.6) 83.9 (⫾3.9) 9.0 (⫾3.2)

20.3 (⫾4.0)* 73.1 (⫾4.4) 6.6 (⫾2.5)

17.4 (⫾6.0) 70.8 (⫾7.0) 11.9 (⫾5.0)

13.1 (⫾3.4) 79.9 (⫾4.0) 7.0 (⫾2.6)

13.3 (⫾4.6) 82.1 (⫾5.2) 4.6 (⫾2.9)

(95 CI), plus or minus 95 % confidence interval value calculated as (1.96⫻ standard error of the prevalence estimate). Proportion of youth practicing a given number of these sun-protective behaviors—stay in the shade; wear sunglasses; wear a wide-brimmed hat, long-sleeved shirt, pants, or sunscreen lotion—that were reported as “often” or “always.” c When outside on a very sunny day during the summer for more than 1 h. d Question asked only of youth reporting wearing sunscreen lotion. *␹ 2 test for heterogeneity is statistically significant at P ⬍ 0.001. b

COKKINIDES ET AL.

Proportion of youth practicing a specific number of behaviors “often” or “always”b 3 to 6 practiced routinely 1 to 2 practiced routinely None practiced routinely Proportion of youth practicing specific behaviors “often” or “always”c Stay in the shade or under an umbrella Wear sunglasses Wear long pants Wear a wide-brimmed hat Wear a long-sleeved shirt Proportion of youth applying or wearing sunscreen lotion “often” or “always”c Proportion of youth who, at the beach or pool, use a sunscreen lotion with SPF greater or equal to 15d Proportion of youth who reapply sunscreen lotion when out in the sun all dayd Never Rarely Sometimes/often Not necessary, because using waterproof sunscreen Source of sunscreen lotiond Purchase your own Bought by parent Borrowed from friend/other

Gender

TABLE 3 Prevalence of Attitudes and Correlates of Sun Exposure and Protection among U.S. Youth Ages 11 to 18, by Age, Gender, and Sun Sensitivty, Sun Survey, 1998 Age

Sun sensitivity

Total % (95 CI)a

11–13 % (95 CI)a

14–15 % (95 CI)a

16–18 % (95 CI)a

Boys % (95 CI)a

Girls % (95 CI)a

Low % (95 CI)a

Moderate % (95 CI)a

High % (95 CI)a

76.5 (⫾2.8)

77.4 (⫾4.4)

76.6 (⫾5.6)

75.3 (⫾4.8)

72.8 (⫾4.2)

80.2 (⫾3.7)*

71.0 (⫾5.7)

76.6 (⫾4.0)

83.3 (⫾4.9)*

76.2 (⫾2.8)

83.6 (⫾3.8)

75.0 (⫾5.6)

68.4 (⫾5.3)*

71.5 (⫾4.2)

80.9 (⫾3.6)*

66.2 (⫾6.0)

77.6 (⫾3.8)

85.8 (⫾4.7)*

84.1 (⫾2.5)

82.7 (⫾3.8)

83.1 (⫾5.3)

86.5 (⫾3.9)

81.6 (⫾3.6)

86.7 (⫾3.3)

75.5 (⫾5.5)

87.1 (⫾3.1)

89.0 (⫾4.2)*

53.2 (⫾3.2)

47.3 (⫾5.1)

55.8 (⫾6.6)

58.1 (⫾5.4)*

42.0 (⫾4.6)

64.6 (⫾4.4)*

47.1 (⫾6.2)

56.7 (⫾4.5)

54.0 (⫾6.7)

40.4 (⫾3.2) 56.9 (⫾3.2) 55.8 (⫾3.2)

37.1 (⫾4.9) 49.8 (⫾5.1) 49.9 (⫾5.1)

43.2 (⫾6.5) 62.8 (⫾6.4) 57.5 (⫾6.6)

42.1 (⫾5.4) 60.7 (⫾5.4)* 61.3 (⫾5.4)*

42.8 (⫾4.6) 58.2 (⫾4.5) 53.9 (⫾4.3)

37.9 (⫾4.3)* 55.5 (⫾4.5) 57.7 (⫾4.5)*

45.5 (⫾6.2) 58.7 (⫾6.2) 56.2 (⫾6.3)

40.9 (⫾4.5) 61.7 (⫾4.4) 58.9 (⫾4.5)

32.8 (⫾6.4) 44.9 (⫾6.6)* 49.0 (⫾6.7)

37.8 (⫾3.2)

35.0 (⫾4.9)

43.8 (⫾6.6)

36.8 (⫾5.2)

36.4 (⫾4.4)

39.2 (⫾4.5)

41.0 (⫾6.1)

38.6 (⫾4.5)

32.3 (⫾6.3)

33.4 (⫾3.1)

24.8 (⫾4.4)

35.9 (⫾6.3)

41.3 (⫾5.3)*

31.8 (⫾4.3)

35.0 (⫾4.4)

31.9 (⫾5.7)

34.4 (⫾4.4)

33.1 (⫾6.3)

33.6 (⫾3.6)

30.1 (⫾4.6)

35.9 (⫾6.2)

35.8 (⫾5.2)

31.1 (⫾4.2)

36.1 (⫾4.4)

34.1 (⫾5.9)

31.6 (⫾4.3)

36.6 (⫾6.5)

48.7 (⫾3.3)

42.3 (⫾5.0)

55.2 (⫾6.5)

51.5 (⫾5.4)*

52.1 (⫾4.6)

45.3 (⫾4.5)*

48.3 (⫾6.2)

52.7 (⫾4.6)

41.5 (⫾6.5)*

49.8 (⫾3.2)

48.9 (⫾5.1)

49.0 (⫾6.6)

51.5 (⫾5.4)

42.7 (⫾4.5)

57.2 (⫾4.5)*

49.7 (⫾6.2)

46.0 (⫾4.6)

57.6 (⫾6.6)

SUN PROTECTION BEHAVIOR AMONG U.S. YOUTH

Proportion of youth reporting “strongly agree” or “agree” with attitudes toward benefits of sun protectionb Protecting my skin from the sun is an easy way to stay healthy Using sunscreen lotion allows me to enjoy the outdoors with less worry Spending time in the sun without any protection can increase my chances of developing cancer My skin won’t wrinkle as fast if I spend less time in the sun Proportion of youth reporting “strongly agree” or “agree” with attitudes toward benefits of tanb I feel healthy when I have a nice tan I look better when I have a tan The sun feels good on my skin Avoiding the sun takes the fun out of being outdoors Other modifiable correlates Youth who knew someone with cancer Youth whose health professional advised to protect skin from the sun Parents having difficulty in protecting child from the sun Youth who received information about sun protection from friends and familyb

Gender

a

(95 CI), plus or minus 95% confidence interval value calculated as (1.96⫻ standard error of the prevalence estimate). Once or few times per week or daily. *␹ 2 test for heterogeneity is statistically significant at P ⬍ 0.05. b

147

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TABLE 4 Correlates of Sun-Protective Behaviors among U.S. Youth, Ages 11–18, Sun Survey, 1998 Stay in the shadea

Age group, years 11–13 14–15 16–18 Sex Boys Girls Race Black Asian/Pacific Islander Native American Other White Parent education Graduate school College graduate Some college ⱕHigh school Sun sensitivity index High Medium Low Perceived benefit of tanning Low Medium–low Medium–high High Perceived benefits of sun protection High Medium–high Medium–low Low Health care provider advice Yes None Parental difficulty in protecting from sun Yes No Information from friends and family Daily or almost daily Once–few times per week Once–few times per month Not heard

Use sunscreen with SPF 15b

Practiced three or more sun-protective behaviorsc

Unadjusted OR (95% CI)

Adjusted OR (95% CI)

Unadjusted OR (95% CI)

Adjusted OR (95% CI)

Crude OR (95% CI)

Adjusted OR (95% CI)

1.8 (1.2, 2.6) 1.1 (0.7, 1.8) 1.0

1.7 (1.1, 2.7) 1.3 (0.8, 2.2) 1.0 Referent

2.1 (1.4, 3.1) 1.5 (0.9, 2.3) 1.0

2.5 (1.5, 4.1) 1.6 (0.9, 2.8) 1.0 Referent

1.0 (0.6, 1.7) 0.6 (0.3, 1.2) 1.0

0.6 (0.3, 1.1) 0.5 (0.2, 1.1) 1.0 Referent

0.9 (0.7, 1.3) 1.0

1.2 (0.8, 1.8) 1.0 Referent

0.3 (0.3, 0.5) 1.0

0.3 (0.2, 0.5) 1.0 Referent

0.6 (0.4, 0.9) 1.0

0.8 (0.5, 1.3) 1.0 Referent

2.9 1.6 2.5 1.8

5.9) 4.8) 6.1) 3.5)

2.7 (1.2, 5.9) 2.0 (0.6, 6.6) 3.5 (1.5, 8.6) 1.7 (0.8, 3.5) 1.0 Referent

0.2 0.9 0.6 0.6

0.4) 2.3) 1.6) 1.2)

0.2 0.9 0.7 0.6 1.0

(0.1, 0.4) (0.3, 2.8) (0.3, 1.8) (0.3, 1.2) Referent

0.9 2.6 3.0 2.3

0.7 5.1 4.4 1.6 1.0

(0.2, 2.7) (1.2, 21.0) (1.2, 15.5) (0.5, 5.0) Referent

0.4 (0.3, 0.8) 0.8 (0.5, 1.4) 0.9 (0.6, 1.4) 1.0

0.4 (0.2, 0.7) 0.7 (0.4, 1.1) 0.8 (0.5, 1.3) 1.0 Referent

2.7 (1.6, 4.5) 3.9 (2.2, 7.0) 1.8 (1.2, 2.8) 1.0

2.7 4.8 2.0 1.0

(1.3, 5.6) (2.5, 9.4) (1.2, 3.4) Referent

1.3 (0.6, 2.8) 1.3 (0.7, 2.5) 1.3 (0.7, 2.4) 1.0

1.0 1.1 1.4 1.0

(0.3, 2.3) (0.5, 2.2) (0.7, 2.8) Referent

1.4 (0.9, 2.3) 1.0 (0.7, 1.6) 1.0

1.3 (0.7, 2.4) 1.2 (0.7, 2.0) 1.0 Referent

3.9 (2.3, 6.6) 2.2 (1.5, 3.2) 1.0

2.6 (1.4, 4.9) 1.9 (1.1, 3.1) 1.0 Referent

1.6 (0.8, 3.1) 0.9 (0.5, 1.7) 1.0

1.5 (0.6, 3.5) 1.0 (0.5, 2.2) 1.0 Referent

5.7 (3.4, 9.7) 3.9 (2.4, 6.1) 3.4 (1.9, 6.0) 1.0

4.6 (2.6, 8.2) 4.0 (2.5, 6.6) 3.3 (1.8, 6.0) 1.0 Referent

1.3 (0.8, 2.2) 1.6 (1.1, 2.4) 1.5 (0.9, 2.6) 1.0

1.7 1.4 1.2 1.0

(0.9, 3.4) (0.8, 2.4) (0.6, 2.4) Referent

5.2 (2.5, 10.8) 3.0 (1.5, 5.9) 3.2 (1.4, 7.0) 1.0

6.6 4.4 3.9 1.0

(2.8, 15.4) (2.1, 8.9) (1.6, 9.5) Referent

1.6 (1.0, 2.6) 1.7 (1.0, 2.9) 1.0 (0.7, 1.6) 1.0

1.7 (1.1, 3.0) 1.8 (0.9, 3.3) 1.0 (0.6, 1.5) 1.0 Referent

7.8 (4.3, 14.2) 8.8 (4.1, 19.1) 3.6 (2.4, 5.4) 1.0

6.3 8.3 3.0 1.0

(3.1, 12.6) (3.3, 21.1) (1.8, 4.8) Referent

2.7 (1.4, 5.2) 1.9 (0.9, 3.9) 0.7 (0.4, 1.3) 1.0

3.2 1.8 0.6 1.0

(1.5, 6.8) (0.7, 4.3) (0.3, 1.3) Referent

1.3 (0.9, 1.9) 1.0

1.4 (1.0, 2.1) 1.0 Referent

1.7 (1.2, 2.6) 1.0

1.6 (1.0, 2.7) 1.0 Referent

0.5 (0.3, 0.9) 1.0

0.5 (0.3, 0.9) 1.0 Referent

2.9 (1.5, 5.7) 2.3 (1.2, 4.4) 0.8 (0.4, 1.6) 1.0

4.0 3.0 0.6 1.0

(1.4, (0.5, (1.0, (0.9, 1.0

(0.1, (0.3, (0.2, (0.3, 1.0

3.4 (2.0, 5.7) 2.6 (1.6, 4.4) 1.0 (0.6, 1.5) 1.0

2.7 2.1 0.7 1.0

(1.4, 5.0) (1.2, 3.9) (0.4, 1.2) Referent

(0.3, (0.7, (0.8, (1.0, 1.0

2.6) 10.1) 12.3) 5.5)

(1.9, 8.5) (1.5, 6.0) (0.3, 1.5) Referent

a

Staying in the shade or under an umbrella “often” or “always” compared with those reporting “never” or “rarely.” Sunscreen with SPF ⱖ15 use: users compared with nonusers of sunscreen. c Practiced three to six sun-protective behaviors “often” or “always” compared with no single sun-protective behavior practiced routinely (“often” or “always”). b

to perceive greater benefits of sun protection, more than 2 times (95% CI 1.5, 5.3) more likely to receive information about sun protection from friends and family either daily or almost daily, and 1.6 times (95% CI 1.0, 2.6) more likely to have received advice from a health care provider (Table 4). Also, users of sunscreen with SPF ⱖ15 were more 2.5 times more likely to be younger

(95% CI 1.5, 4.1) and 2.6 times more likely to have high sun-sensitivity index (95% CI 1.4, 4.9). Boys were 70% less likely to use sunscreen with SPF ⱖ15, but youth whose parents had at least some college were 2 or more times more likely to use sunscreen with SPF ⱖ15 (Table 4). Compared with youth who reported not practicing

SUN PROTECTION BEHAVIOR AMONG U.S. YOUTH

any recommended sun-protection behavior routinely, youth who practiced three or more behaviors routinely were 6.6 times (95% CI 2.8, 15.4) more likely to have low scores on perceived benefits of tanning and 3.2 times (95% CI 1.5, 6.8) more likely to score higher on perceived benefits of sun protection. Other important associations included youth having a 0.5 (95% CI 0.3, 0.9) likelihood of having a parent reporting difficulties in protecting them from the sun and 4.0 times (95% CI 1.9, 8.5) more likely to be informed frequently by friends and family about protecting themselves from the sun (Table 4). DISCUSSION

This study assessed sun-protection behaviors practiced among a population-based sample of U.S. youth ages 11 to 18 years, an age group for which sparse data exist on sun exposure and sun-protection behaviors. Our findings can be used as baseline measures for current and future behavioral interventions for skin cancer prevention targeted at youth. We found that less than one-third of U.S. youth, ages 11 to 18, practice routine (defined as often or always) sun protection on sunny days during the recent summer and about 1 in 10 youths practiced three or more sunprotection behaviors. Wearing long-sleeved shirts and wide-brimmed hats were infrequently practiced behaviors of sun protection among youth. It is possible that while these behaviors were rare, other practices (i.e., wearing short-sleeved shirts covering the trunk area) may have been more pragmatically practiced by youth. Fashion trends and other factors may explain the variability in these practices among youth today. In an Australian study of adolescents, attitudes and barriers for wearing a wide-brimmed hat were examined; it was reported that youth’s ownership of a broad-brimmed hat, attitudes relating to discomfort of wearing a hat, and self-image perception with peers, among other factors, were related to practicing adequate levels of sun protection [32]. Future research needs to focus on fashion trends and other factors (source availability of sunprotective clothing) that influence youth’s adoption of recommended sun-protection practices. Our results on low prevalence of routine sunscreen use among youth is consistent with previously reported studies among children in select community samples [16, 33, 34]. As for sun exposure, our data and previous studies [16] indicate that children and youth spend extended periods of time outdoors on weekends and weekdays during the summer. Additionally, we found that among youth who ever used a sunscreen, slightly under two-thirds used a lotion with SPF ⱖ15 routinely during periods of high solar exposure to uncovered body regions (i.e., recreational activities at the beach or pool) and many did not reapply it when they stayed outside all

149

day. Clearly, the low frequency of sun-protection behaviors, including routine sunscreen use and the extended time periods of sun exposure among youth during the summer are likely to result in frequent experiences of sunburns, thereby increasing the lifetime risk of skin cancers. With regard to attitudinal factors associated with sun-protection behaviors, our study suggested that youth who found tanning less appealing and who perceived benefits of sun protection were more likely to seek the shade and to practice three or more recommended sun-protection behaviors. However, only one of these two factors, the perceived benefits of sun protection, was independently associated with use of sunscreen with SPF ⱖ15. Although our findings cannot be directly compared with previous reports [16, 32, 34–36] because of age-related developmental differences in the study samples, and other methodological differences, including ability to control for confounding, our results are generally consistent with previously reported findings. Our findings and those of others [34, 36] are generally concordant with theoretical formulations of health behaviors [25, 37] that relate attitudinal factors to predictors of observed behaviors. However, our findings did not support any evidence for these attitudinal factors as predictors of wearing protective clothing or a widebrimmed hat. This may be because some of these attitudes are behavior-specific since we used a pretested attitudinal scale that was developed for studies of sunscreen use [21]. Future research using formative techniques need to focus on addressing specific attitudinal barriers, benefits, and intentions of other types of recommended sun-protection behaviors (i.e., wearing longsleeved shirt, or long pants, or a wide-brimmed hat). Our findings and previous research [16, 35, 38–40] suggest other potentially modifiable determinants of specific sun-protection behaviors among adolescents: receiving a health care provider’s advice to protect from the sun, frequently getting sun-protection information from friends and family, and having a parent who is able to protect their child from the sun. The role of parents and friends in children’s health and disease prevention has been suggested as perhaps more influential than other sources such as school curricula [41]. In addition, health care providers can offer an opportune influence on adolescent behaviors, which may occur in two ways: directly as a result of providing effective counseling to youth and indirectly by imparting sun safety guidance to the youth’s family [42]. Our study relied on self-reported measures, the validity and reliability of which are unknown. A previous study explored the validity of self-report by adolescents in relation to parental/guardian reports (the standard criterion), and the results suggested that adolescent’s self-report of solar protection was relatively valid [43]. In the absence of gold standard measures that can be

150

COKKINIDES ET AL.

feasibly applied to large samples, we must rely on selfreport. In addition, we minimized the potential for recall bias by asking youth about their most recent experiences with practicing sun protection. Our study sample was mostly represented by white youth (a group generally exhibiting high sun sensitivity) living in higher socioeconomic households. In addition, due to budgetary constraints our survey did not sample those youth living in Hawaii and Puerto Rico. This limited our ability to perform race-specific subanalyses due to lack of sufficient power. Racial/ethnic differences in attitudes toward and practice of skin cancer prevention are an important and growing area of research [44, 45]. Our study’s strengths include the ability to generalize to U.S. youth living with caregivers in households with telephones. With exception of some race/ethnic populations, the estimated telephone coverage in U.S. households exceeds 87% [46]. This study addresses the extent of sun-protection practices among U.S. youth and in particular among those exhibiting high susceptibility to sun damage. In addition, this study examined the influence of important attitudinal and modifiable correlates of sun-protection behavior while controlling for multiple potential confounding. In conclusion, while new efforts are under way to intervene and improve children’s sun-protection behaviors [47], perhaps, few specially designed skin cancer prevention programs are directed at adolescents. Thus, program development should focus on the infrequently practiced sun-protection habits of youth in general and among certain subgroups in particular (i.e., older youth and boys). Moreover, the data presented in our study could serve as benchmarks by which these programs could chart their progress toward measurable improvement in youth’s sun-protection behaviors. Future work using longitudinal studies and program evaluation of skin cancer prevention efforts should address program effectiveness in terms of the ultimate reduction in the frequency of sunburns and other physical determinants (e.g., number of nevi) of excessive sun exposure among youth.

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