Sun-Protection Behaviors Among African Americans

doi:10.1016/j.amepre.2009.10.041

American Journal of Preventive Medicine

Volume 38, Issue 3, March 2010, Pages 288-295

https://doi.org/10.1016/j.amepre.2009.10.041 Get rights and content

Background

Data suggest that the prevalence of sun-protection behaviors is low (44%) among African Americans; the samples in such studies, however, tended to be small or nonrepresentative.

Purpose

This article aims to examine the prevalence and correlates of sun-protection behaviors among a large, random, statewide sample of African-American adults living in California to ascertain behavioral patterns and highlight directions for targeted interventions.

Methods

From September 2006 through May 2008, an anonymous health survey collected data on sunscreen, sunglasses, and wide-brim hat use among a random sample of 2187 African-American adults, and assessed demographic, regional, skin type, and other potential correlates of these behaviors. The analysis was conducted in 2009.

Results

Only 31% engaged in at least one sun-protection behavior; of the three behaviors, sunscreen use was the least prevalent, with 63% never using sunscreen. Multivariate logistic regressions revealed that gender, SES, and skin type were significant predictors of sun-protection behaviors.

Conclusions

Tailored interventions to increase sun-protection behaviors among African Americans (men in particular) are needed.

Introduction

The incidence of melanoma is more than ten times higher in whites than in African Americans, but the 5-year survival rate for African Americans (78%) is significantly lower than that of whites (92%); hence, skin cancer is one of many African-American–white cancer disparities that need to be reduced or eliminated.¹ Possible reasons for skin cancer disparities may be that African Americans are more likely to present with an advanced stage of disease and have a poorer prognosis.2, 3, 4, 5, 6 Further, there may be genetic differences in tumor presentation.⁷ Other factors might include suboptimal early-detection practices, inadequate knowledge about and awareness of skin cancer, low perceptions of skin cancer risk, heightened fear of a cancer diagnosis, and living in a community with low educational attainment.8, 9, 10, 11, 12

Exposure to solar ultraviolet radiation (UVR) is a well-established primary risk factor for nonmelanoma skin cancer and melanoma in whites.13, 14, 15 There is an association between UVR and basal cell carcinoma in African Americans; that is, 89% of these tumors develop on sun-exposed skin.16, 17, 18, 19 In contrast, squamous cell carcinoma and melanoma typically present on unexposed skin in African Americans.6, 16, 17, 20, 21, 22 Only a few studies have examined the association between UVR exposure and melanoma among African Americans and whites. One²³ found that UV index and latitude were related to melanoma incidence in African-American men, but another²⁴ found this association only for white men and women. Irrespective of the strength of the relationship between UVR exposure and skin cancer among African Americans versus whites, reducing UVR exposure (to potentially reduce skin cancer risk) among all Americans is an objective of Healthy People 2010.25, 26 Specifically, the Healthy People 2010 objective is to increase the percentage of people who engage in at least one sun-protective behavior, including sun avoidance, wearing protective clothing (e.g., sunglasses and wide-brim hat), and using sunscreen with a sun-protection factor (SPF) of at least 15 during midday sun exposure.25, 26, 27 These behaviors are efficacious in reducing UVR exposure.28, 29, 30

Six studies8, 31, 32, 33, 34, 35 have examined such behaviors among African Americans, with three31, 32, 34 of these involving nonclinical participants. Unfortunately, the African-American samples in these studies were small and/or nonrepresentative, and hence findings from the studies are tentative. Thus, the purpose of this study was to acquire basic data on sun-protection behaviors among African Americans by assessing those behaviors in a random, statewide sample to inform cancer-prevention interventions.

Section snippets

Participants

A random, statewide sample (N=2187) of African-American adult residents of California aged 18–95 years (mean age=43.5 years) participated; 93% had a high-school education or higher, and 57.7% were women. Characteristics of the sample are shown in Table 1.

Method

Community-based sampling methods were used.36, 37, 38, 39, 40 Community-based sampling is a three-stage, random-probability household-sampling procedure often used in population studies36, 37, 39, 40 of African Americans and Latinos to ensure

Prevalence and Correlates of Sun-Protection Behaviors

Prevalence of sun-protection behaviors is shown in Table 1. About 31% (n=667) of the sample reported always engaging in at least one sun-protection behavior. Each sun-protection behavior outcome was analyzed separately. The five response categories were collapsed into these three: never, sometimes/half of the time/often, and always for the regression analyses. Multivariate multinomial logistic regression analyses were used to explore relationships between each sun-protection behavior and

Discussion

This study confirms prior findings of low levels of sun-protection behaviors among African Americans relative to current recommendations.1, 25, 26 The results also reveal significant predictors of sun-protection behaviors among African Americans and highlight areas for tailored interventions.

Low prevalence of sunscreen use among this sample is comparable to national statistics for African Americans found in studies from 1992 and 1998.31, 34 These findings may be attributed to African Americans'

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Melanoma-specific outcomes for Black patients are worse when compared to non-Hispanic white (NHW) patients. We sought to evaluate whether acral lentiginous melanoma, seen more commonly in Black patients, was associated with racial disparities in outcomes
The National Cancer Database was analyzed for major subtypes of stage I-IV melanoma diagnosed from 2004 to 2016. The association between Black race and (Siegel et al., Jan) 1 acral melanoma diagnosis and (Bradford et al., Apr) 2 receipt of major amputation for surgical management of melanoma was evaluated using multivariable logistic regression.
251,864 patients were included (1453 Black). Black patients had increased odds of acral melanoma (odds ratio [OR] = 27.6, 95% CI]: 24.4, 31.2) compared to NHW patients. Black patients still had higher odds ratios of major amputation across all stages after adjusting for acral histology and other potential confounders
Increased prevalence of acral melanoma in Black patients does not fully account for increased receipt of major amputation.
A characterization of sun protection attitudes and behaviors among children and adolescents in the United States
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This may be due to differences in tendency to sunburn, societal messaging, misinformation, or other social cultural norms. This agrees with the literature, which suggests those with more sun-sensitive or lighter skin, are more likely to use sun protection (Pichon et al., 2010a). Additionally, natural skin color may influence perceptions about skin cancer risk and subsequently impact sun protective behaviors.
Children and adolescents may be vulnerable to increased ultraviolet radiation exposure and greater risk for subsequent sun-related pathologies. This study examined the demographic, geographic, and phenotypic factors influencing sun exposure and protective behaviors among children and adolescents living in the United States. A cross-sectional survey on perceived sun exposure and protective behaviors was administered at three sports medicine clinics in California, Colorado, and Hawaii. Responses were measured with a 5-item frequency scale: Never, Rarely (25% of the time or less), Sometimes (50% of the time), Often (75% of the time or more), and Always. Sun protective behavior was examined using univariate and multivariate analyses. In total, 860 surveys were collected (52% female, 48% male; mean age 12.7 years). Females reported significantly greater frequency of using sunscreen (p = 0.001), staying in the shade or using an umbrella while in the sun (p = 0.004), and tanning (p < 0.001). Age was inversely associated with sunscreen use frequency (p < 0.001); the percentage of participants who reported always wearing sunscreen decreased as age increased. Participants in Hawaii reported using sunscreen less frequently than those in California and Colorado (p < 0.001). These results identify high-risk populations such as males, older adolescents, and Hawaii's youth who may not be practicing frequent sun protective behaviors. While it is important for youth to stay active, they must also be reminded to adopt protective behaviors while outdoors to prevent unnecessary sun damage and lower the risk of sun exposure complications.
Correlates of sun protection behaviors in racially and ethnically diverse U.S. adults
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Other studies have described several demographic factors associated with sun protection among minority groups (Buller et al., 2011; Coups et al., 2008; Coups et al., 2012; Coups et al., 2013; Andreeva et al., 2009; Ma et al., 2007; Pichon et al., 2005; Santmyire et al., 2001; Friedman et al., 1994; Pichon et al., 2010; Hall and Rogers, 1999). In prior work, gender, education and income have been associated with sunscreen use, but we did not find these associations across all groups (Coups et al., 2012; Coups et al., 2013; Andreeva et al., 2009; Pichon et al., 2005; Santmyire et al., 2001; Pichon et al., 2010). Females were more likely to use sunscreen across all groups except Asians and higher educational levels predicted use in Whites and Blacks only.
Although skin cancer incidence is highest among non-Hispanic Whites, minority populations are often diagnosed with more advanced stage disease and are more likely to experience poor outcomes. Fewer people of color do not practice primary prevention of skin cancer according to recommendations, but public health education and interventions to promote sun protection behaviors have consistently targeted non-Hispanic Whites. This study examines performance of sun protection behaviors in a multiethnic sample and whether demographic, lifestyle and psychosocial predictors of these behaviors differ by race and ethnicity. In this study, a probability-based sample of 1742 adults completed an online survey in 2015. Main outcomes of interest included sunscreen use, wearing a sleeved shirt, and seeking shade. We stratified the sample into racial/ethnic groups (White, Black, Hispanic, Asian) and investigated demographic, lifestyle and psychosocial correlates of these behaviors in each group. Differences in adjusted estimates from each behavior-specific model were tested across strata. Racial/ethnic groups were significantly different in regards to sunscreen use and wearing a sleeved shirt, but similarly engaged in seeking shade. Results from multivariate ordered logistic regression models for each behavior revealed important demographic, lifestyle and psychosocial predictors and the importance of some demographic correlates varied between racial/ethnic groups. This study provides insight into the practice and correlates of skin cancer prevention among a multiethnic sample. Our findings suggest that targeting public health education efforts and interventions to promote sun protection in minority populations may be a beneficial approach to addressing heightened skin cancer morbidity and mortality in these groups.
Skin cancer knowledge, awareness, beliefs and preventive behaviors among black and hispanic men and women
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Holman et al., 2018) While the etiology of skin cancer in blacks and Hispanics needs further exploration, negative effects of UVR on skin cancer risk among these groups exists (Lozano et al., 2012) and opportunities to engage in prevention behaviors should be leveraged. Poor engagement in sun protection behaviors (Manganello et al., 2016; Pichon et al., 2010a) among those who have traditionally been perceived at low risk for skin cancer due to their ethnic or racial background could be reflective of lower awareness. In 2014, The Surgeon General's Call to Action to Prevent Skin Cancer (US Department of Health and Human Services, 2014) described prevention strategies to protect Americans from overexposure to UVR from the sun and indoor tanning devices.
Black and Hispanic populations perceive their skin cancer risk to be low and are less likely to use sun protection strategies. We conducted formative research to understand knowledge, awareness, beliefs, and behaviors among these groups. In 2017, eighteen focus groups were conducted with black and Hispanic respondents(18–44 years) in four US cities. Groups were segmented by participant characteristics associated with elevated or lower risk for skin cancer, by race/ethnicity, gender, and age. A professional moderator followed a semi-structured discussion guide, and focus group transcripts were analyzed using conventional content analysis and NVIVO 11 Software. Most participants perceived themselves to be at low skin cancer risk due to their “darker skin tone” and/or “lack of family history.” Skin cancer signs and symptoms were more inconsistently reported by blacks than Hispanics. Few participants reported regular sun protection behaviors. Those who did used sunscreen, wore protective clothing, and had elevated risk based on sun sensitivity or UV exposure. While most participants recalled family discussions (as youth) about sunscreen and sun protection, the understood intent was to warn against “further skin darkening” or to “prevent aging,” not to reduce sun burns or skin cancer risk. Tanning bed use was low across all segments, especially among black respondents. Tailored skin cancer prevention campaigns need to address misperceptions about risks and benefits of skin cancer prevention behaviors among black and Hispanic populations. Families, peer groups, and healthcare providers need to be engaged in the creation of educational interventions and messaging efforts that target these populations.
Sun-protective behaviors in patients with cutaneous hyperpigmentation: A cross-sectional study
2017, Journal of the American Academy of Dermatology
Disorders of hyperpigmentation are seen commonly in clinical practice. Despite numerous studies investigating sun-protective habits among healthy persons, little is known about these behaviors within patient populations with hyperpigmentation disorders.
We sought to examine photo-protective behaviors and their associations in individuals with disorders of hyperpigmentation.
This cross-sectional study was conducted with 404 adults who complained of cutaneous hyperpigmentation.
About 67.5% reported using a product containing sunscreen, and 91% endorsed using one with a sun protection factor of 21 or higher. Among the participants, 48.5% were not sure if their sunscreen provided broad-spectrum protection, and only 7.6% reapplied every 2 hours. The odds of a patient with melasma using sunscreen were 6.7 times the odds of a patient with postinflammatory hyperpigmentation using sunscreen (P < .001). Additional predictors for sunscreen use were female sex (OR = 3.8, P = .0004) and disease duration of ≥1 year (OR = 2.1, P = .003). In a multivariate analysis, the odds ratio of sunscreen use among African Americans compared to whites was 0.31 (P = .008).
Limitations included recall bias, question misinterpretation, and reporter bias.
Patients diagnosed with postinflammatory hyperpigmentation, men, and those with disease duration <1 year reported lower sunscreen usage. These groups might benefit from increased counseling on sun-protective behaviors.
Photoprotection in specific populations: Children and people of color
2017, Journal of the American Academy of Dermatology
Improved education on appropriate photoprotection in children is vital. Photoprotection for these individuals should include seeking shade, the use of physical agents (clothing, hat, sunglasses), and application of sunscreens on exposed areas. Avoidance of the use of tanning beds is an important component of education for teenagers. Ultraviolet radiation exposure induces DNA damage and photoaging in all skin types, including people of color. The extent of such damage is inversely related to constitutive skin pigmentation. Therefore, personalized photoprotection recommendations concerning skin cancer risk factors, desired treatment outcomes, health needs (eg, vitamin D), and photoaging based on the needs and preferences of the patient are essential. It is clear that additional research is needed on optimal levels of protection against ultraviolet radiation for people of color.

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Research articleSun-Protection Behaviors Among African Americans

Background

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Participants

Method

Prevalence and Correlates of Sun-Protection Behaviors

Discussion

J Am Acad Dermatol

J Am Acad Dermatol

Nurs Outlook

Prev Med

Dermatol Clin

J Am Acad Dermatol

J Invest Dermatol

J Photochem Photobiol B

Am J Prev Med

Ann Epidemiol

Prev Med

J Am Acad Dermatol

Prev Med

Am J Prev Med

Prev Med

Cancer facts & figure 2009

Melanoma in African-Americans: trends in biological behavior and clinical characteristics over two decades

J Surg Oncol

Malignant melanoma in African Americans

Cutis

Malignant melanoma in black American and white American populationsA comparative review

JAMA

Mutation analysis of the EGFR-NRAS-BRAF pathway in melanomas from black Africans and other subgroups of cutaneous melanoma

Melanoma Res

Early detection of skin cancer: racial/ethnic differences in behaviors and attitudes

J Cancer Educ

Survey of knowledge of and awareness about melanoma—U.S., 1995

MMWR Morb Mortal Wkly Rep

Demographic predictors of melanoma stage at diagnosis

Arch Fam Med

Recent developments in melanoma epidemiology, 1993

Melanoma Res

Epidemiology of melanoma and nonmelanoma skin cancer—the role of sunlight

Adv Exp Med Biol

An overview of skin cancersIncidence and causation

Cancer Suppl

Skin cancer in African Americans

Cancer

Association of surface ultraviolet B radiation levels with melanoma and nonmelanoma skin cancer in U.S. blacks

Cancer Epidemiol Biomarkers Prev

Basal cell carcinoma in blacks: a report of 15 cases

Ann Plast Surg

Acral lentiginous melanoma: incidence and survival patterns in the U.S., 1986–2005

Arch Dermatol

Skin cancer in black patients

Cancer

Research article
Sun-Protection Behaviors Among African Americans