|Year : 2019 | Volume
| Issue : 2 | Page : 94-99
Assessment of knowledge and attitude towards sun exposure and photoprotection measures among Indian patients attending dermatology clinic
Vivek Kumar Dey
Department of Dermatology, People's College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India
|Date of Web Publication||16-Dec-2019|
Dr. Vivek Kumar Dey
Department of Dermatology, People's College of Medical Sciences and Research Centre, Bhopal - 462 037, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: Many skin diseases are known to be either initiated or aggravated by excessive ultraviolet (UV) exposure. High cumulative levels of UV radiation may lead to tanning, burning, photoaging, photoallergic and phototoxic reactions, immunosuppression, and even skin cancers. Many international studies have found that the level of knowledge, attitudes, and practices of the general public toward sun exposure and sun protection measures is good in the Western countries, especially in countries with high incidence of skin cancers compared to Asian countries and Middle East. In India, the incidence of skin cancer is not very high, but UV exposure has definitely increased in the past few decades. Little is known about the knowledge and attitude of Indians toward sun exposure and sun protection due to the paucity of research in this arena. Aims and Objectives: This study was aimed at exploring the knowledge and attitudes of Indians toward sun exposure and sun protection measures. Materials and Methods: A cross-sectional survey was conducted using a predesigned questionnaire related to the knowledge, behavior, and attitudes toward sun exposure and sun protection of the participants visiting a dermatology outpatient clinic for various dermatological problems. Results: total of 324 patients were studied. Participants were divided into five age groups of equal number of male and female participants. Mean age was 37.7 ± 13.15. Overall awareness and knowledge was poor and only 14% were using regular sunscreen. Females had better knowledge and attitude toward sun exposure and protection. The most commonly used sun protection measure was avoiding sun during peak hours of the day. Conclusion: The level of knowledge regarding sun exposure hazards was very low among the study population, and sun prevention behaviors were also very poor. Regular use of sunscreen was practiced only by a small fraction of our population. Knowledge of sun exposure and photoprotection was better in urban, young participants, female gender, and also positively associated with higher education and socioeconomic status. Participants from urban background, females, and middle-aged participants had better attitude toward photoprotection.
Keywords: Skin cancer, sun protection factor, sunscreens, ultraviolet radiation
|How to cite this article:|
Dey VK. Assessment of knowledge and attitude towards sun exposure and photoprotection measures among Indian patients attending dermatology clinic. Indian J Drugs Dermatol 2019;5:94-9
|How to cite this URL:|
Dey VK. Assessment of knowledge and attitude towards sun exposure and photoprotection measures among Indian patients attending dermatology clinic. Indian J Drugs Dermatol [serial online] 2019 [cited 2022 Aug 17];5:94-9. Available from: https://www.ijdd.in/text.asp?2019/5/2/94/272956
| Introduction|| |
Solar ultraviolet (UV) radiation has a great impact on human life. Centuries back ancient Greeks and Romans worshipped Apollo as sun god and god of light and were known for bringing sickness as well as cure. Even today, a similar scientific recognition and consensus are that exposure to UV radiation via sunlight has important public health implications in the form of both beneficial and deleterious effects.
Exposure to large quantities of UV radiation has increased greatly in the past few decades due to the thinning of protective ozone layer, increased outdoor activities, and increased usage of devices emitting UV radiation.
Although there is no trend showing total ozone depletion over India, an ozone depletion trend is noticed in the upper layers of the stratosphere. Since India already receives high doses of UV-B radiation, effects of ozone layer depletion could be far more disastrous.,
Many skin diseases are known to be either initiated or aggravated by excessive UV exposure. High cumulative levels of UV radiation may cause damage to the skin cells and may lead to tanning, burning, photoallergic or phototoxic reactions, pigmentary changes, photoaging, and even immunosuppression and skin cancers., All these deleterious effects of UV radiation have increased the need for photoprotection. Avoiding sun exposure during peak hours of the day, seeking shade, wearing protective clothing, wide-brimmed hats and sunglasses, and using sunscreen are the most suitable types of sun protection behaviors which have great potential to block UV radiation, delaying the photoaging process, and reducing the risk of skin cancer.,,, The incidence of all varieties of skin cancers is thought to be lower in Indians as compared to the Western population due to the protective effects of melanin. The death rate in India due to skin cancers is 0.18/0.43 (per 100,000 populations) which is one of the lowest, compared to Western countries like the United Kingdom (2.93), USA (2.85), and Canada (2.56) with the highest incidence in New Zealand (/7.17) and Australia (6.04). Although national surveys and cross-country data in India are unavailable, there are indirect indications from several smaller studies that nonmelanoma skin cancers may be on the rise in India.,, Many international studies have been conducted to assess the knowledge, awareness, behavior, and attitude of the public toward sun exposure and its deleterious effect.,,, However, during our extensive online literature search, we found that there is a paucity of any such Indian study, and therefore, we conducted this study.
Aims and objective
In this study, we aimed at performing a clinic-based survey of the level of knowledge and attitudes regarding sun exposure and sun protection among Indians and also assessed the influencing factors such as age, gender, educational level, and socioeconomic status.
| Materials and Methods|| |
This cross-sectional study was carried out between March 01, 2017 and June 30, 2017 at a dermatology outpatient clinic in Bhopal, India, after prior approval from the institutional ethical committee. Three hundred and twenty-four participants, in the age group of 16–60 years, who visited the clinic for different dermatological problems, and willing to participate in the study, were offered predesigned and pretested questionnaires in the waiting room to fill in. The participants were divided into five age groups with equal number of males and females in each group. Participants were selected by convenience sampling method. When a responder refused to participate, the next one was asked to and so forth till the required number of participants was completed in that age group.
Participants were informed about the purpose of the study and its methodology and also helped in filling up the questionnaire by trained assistants as and when needed. The questionnaire was self-designed and developed at the clinic through relevant literature search.,,, Pilot testing was done in 15 participants to calculate approximate time to complete it, clarity of questions, and scope for further improvement and modification based on the feedback. These questionnaires were excluded from the final analysis. The final questionnaire consisted of three sections A, B, and C. Section A consisted of seven demographic questions including age, gender, education, income, occupation, and residence. Socioeconomic status was assessed by using modified B.G. Prasad classification with current consumer price index on December 2014. Section B comprised questions related to participant's knowledge of benefits and harmful effects of sunlight, source of information, preferred method of sun protection, and required sun protection factor (SPF). All questions were in multiple-choice formats with one or more correct answers. Section C had 12 questions to assess the attitude of respondents toward the use of sunscreen. The attitude scale comprised five-point Likert type items ranging from strongly agree to strongly disagree. Knowledge was evaluated using the total scores of knowledge questions, with 1 point for each correct response and 0 for each incorrect answer. As there were eight responses possible in the knowledge section, maximum possible score was 8 if all responses are correct and minimum was 0. Attitude toward sunscreen use was measured by summing the scores on attitude items for each question. Each item was scored 5 points for the most positive (favorable to sunscreen) and 1 point for the most negative attitude. With a total of 12 questions, the possible total attitude score ranged from 12 to 60.
Knowledge was categorized as good (score 6–8), average (score 3–5), and poor (score 0–2) for assessment. Similarly, attitude was categorized as positive (score 46–60), neutral (score-31–45), and negative (12–30). Data were presented as frequency (%) or mean ± standard deviation. Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, U.S.A) for Windows, version 19.0 software.
| Results|| |
Out of 350 participants who were offered the questionnaire, 324 accepted to participate in the study, corresponding to 93% response rate. Patients were divided into five groups of 10 years age interval. There was an equal gender split into all age groups for easy comparison between gender and age groups. There was a diverse range of age of the participants ranging from 16 to up to 60 years (mean 37.7 ± 13.15). Sociodemographic details are given in [Table 1].
Majority of the participants (70%) were aware that sunlight is important for Vitamin D synthesis. However, knowledge about the healing power and psychological effect of sunlight (includes mood elevation and antidepressant effects) was less among the participants, 12% and 17%, respectively. The level of knowledge and awareness among participants regarding sun exposure is shown in [Table 2].
Understanding the association between sun exposure and skin hyperpigmentation was reported in 87% of the respondents. Although sunburn is much less common than suntan in Indian skin types, 85% reported that sun exposure can cause sunburn, whereas only 38% were aware of the association between sun exposure and tanning of skin. This is probably due to misunderstanding of these two terms in general population. Fifty-five percent were aware of the relationship between sun exposure and skin cancer, and only 32% had knowledge that sun exposure is also responsible for skin aging. Although electronic media such as TV and internet were the most common sources of information regarding sun exposure and protection as reported by 92% and 40% of respondents, respectively, patients who were prescribed sunscreen by the doctors had much better knowledge. Magazines, journals, family, and friends served as other sources of information. Twenty-eight percent participants had never heard about sunscreen. Sixty-five percent had no idea about SPF. Others believed that higher the SPF, better the protection. [Figure 1] elucidates the sun protection behavior of participants. Overall, the protection level was found to be low in the study population, in 33% respondents the most commonly adopted method of sun protection was avoiding going out in the sun, whereas 26% implemented sun protection by wearing light protective clothes, 28% by wearing sunglasses, and 16% by using an umbrella. Female seemed to be more aware about regular sun protection. Fifty-eight percent participants reported that they did not use sunscreen at all, while only 14% reported regular use of sunscreen during outdoor activities [Figure 2].
Overall good knowledge about effects of sun exposure was seen in 16.6% participants only, 36.4% had average knowledge and 46.9% had poor knowledge. Young participants (16–35 years), higher educated participants, and student had better knowledge (P < 0.001). Higher level of knowledge was also associated with higher socioeconomic status and urban background (P < 0.001), and also with female gender (P = 0.001). Details are shown in [Table 3].
|Table 3: Knowledge about sunlight, stratified by age, gender, education level, occupation, socioeconomic status, and background (rural/urban) in 324 responders|
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Attitude toward sunscreen use was better in younger age group (P = 0.001), higher socioeconomic status (P = 0.005), and participants from urban background (P = 0.004), but no statistically significant difference was seen in different educational levels, occupations, and genders [Table 4].
|Table 4: Attitude toward sun protection stratified by age, gender, education level, occupation, socioeconomic status, and background (rural/urban) in 233 responders|
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| Discussion|| |
There has been a significant increase in the incidence of skin cancer worldwide over the last few decades. The risk of developing skin cancer is directly related to lifetime cumulative sun exposure. It is estimated that 80% of sun damage occurs before the age of 18 years. Although till now the prevalence of skin cancer is low in India, overall UV exposure has greatly increased in the past few years. To prevent the incidence of skin cancers from forging ahead in the near future, it is important for the general public to understand the association of UV exposure with skin diseases and cancers and hence adopting sun protection measures.
Little is known about the public awareness and behaviors regarding sun exposure and protection measures among Indians. In our research, we assessed the awareness about the benefits and dangers of sun exposure. It was found that the only well-known beneficial effect of sun exposure was its effect on Vitamin D synthesis. The most widely recognized and correctly answered adverse effect of exposure to sun proved to be hyperpigmentation and sunburn. Surprisingly, the least accurately understood deleterious effect of sunlight was its effect on aging of the skin.
In this study, the most commonly adopted method for avoiding the harmful effects of the sun exposure was found to be avoiding going outside in between 10.00 am and 4.00 pm by 28% of men and 40% of women. We believe that this may be because of selection bias, as 230 participants were students, homemakers, or office workers who generally stay indoors during daytime. Kaymak et al. found a similar conclusion in schoolchildren. A Greek study found the use of sunglasses as the most common sun protection measure in Mediterranean inhabitants (83.4%), while wearing protective clothing was not as much popular among them (57.8%). We too had a similar finding, wherein wearing a hat was the least adopted method of sun protection among women (4%), and using an umbrella was least preferred by men (5%). We believe that along with the lack of knowledge, social, and cultural barriers are also responsible behind this ignorant behavior toward sun protection.
In many international studies, the knowledge about sun exposure, its relation with skin cancers, and measure of sun protection was quiet high, and sun-protective cream was the most commonly used form of protection. This is generally seen more commonly in communities with a higher incidence of skin cancer. However, in our study, we found that the understanding of hazardous effects of excessive sun exposure is very low.
This level of knowledge is considered to be low compared to analogous studies carried out in western communities. For example, the linkage between skin cancer and sun exposure was made by around 90% of the study participants in Australia, 85% in Canada, 92% in the United States, and 92.5% in Malta, whereas only 55.5% in India in the present study. Women are generally more informed about skincare, sun protection, and skin cancer via the popular women's magazines and newspapers which can influence their sun protection behavior patterns, and this fact was confirmed both in our and in other studies. In our study, female participants demonstrated statistically significant higher knowledge levels and also better attitude toward sunscreen use than male participants (although statistically not significant). This finding has been reported by a good number of other studies as well.,,,,,,, To determine why males lag behind in sun protection knowledge and behaviors, further research is needed. Perhaps, sunscreen themselves are perceived as being feminine with feminine scents as suggested by Abroms et al.
As patient education efforts proved to increase the public understanding and awareness of the hazards of excessive sun exposure and the advantages of sunscreen use, our observations emphasize the need for education and awareness programs from primary school level. It is also important to educate the parents of young children about the dangers of excessive sun exposure so that they can initiate and inculcate preventive behaviors early in their children's lives. Correct method of using sunscreen should also be emphasized; otherwise, it may give a false sense of security during prolonged exposure in the sun resulting in more damage than protection as paradoxical increase in incidence of skin cancer has been reported due to sunscreen failure.,
Nevertheless, this study had methodological limitations. Because of a single study center and small sample size, results may not be representative of the residents of other geographic areas. India being a geographically diverse nation, to substantiate the results, this study has to be multicentric as residents of other areas may have different levels of exposure and knowledge, attitudes, and behaviors regarding sun exposure. Because patients who prescribed sunscreens by doctors for photosensitive and photoinduced dermatoses were also included in the study, this may be a source of bias as these individuals are more likely to be counseled regarding photoprotection. All questions were close-ended with only one option to choose, which may serve as another limitation as the responses might have been biased.
| Conclusion|| |
Several important findings emerged from our study. First, among the participants, the level of knowledge regarding sun exposure hazards was very low, and sun prevention behaviors were also very poor. Regular use of sunscreen was practiced only by a small fraction of our population.
Knowledge of sun exposure and photoprotection was better in young, urban participants, female gender, and also positively associated with higher education and socioeconomic status. Participants from urban background, females, and middle-aged participants had better attitude toward photoprotection.
As reported by our study, it is quite alarming to see the lack of knowledge and inadequate use of sunscreen by the general Indian population. It is time that the interest in this issue with regard to future studies and health education programs takes a center stage.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mead MN. Benefits of sunlight: A bright spot for human health. Environ Health Perspect 2008;116:A160-7.
Abarca JF, Casiccia CC. Skin cancer and ultraviolet-B radiation under the Antarctic ozone hole: Southern Chile, 1987-2000. Photodermatol Photoimmunol Photomed2002;18:29-302.
Sklar LR, Almutawa F, Lim HW, Hamzavi I. Effects of ultraviolet radiation, visible light, and infrared radiation on erythema and pigmentation: A review. Photochem Photobiol Sci 2013;12:54-64.
Sivasakthivel T, Siva Kumar Reddy KK. Ozone layer depletion and its effects: A review. Int J Environ Sci Dev 2011;2:30-7.
Armstrong BK, Kricker A. The epidemiology of UV induced skin cancer. J Photochem Photobiol B 2001;63:8-18.
Rai R, Shanmuga SC, Srinivas C. Update on photoprotection. Indian J Dermatol 2012;57:335-42.
] [Full text]
Rigel DS, Carucci JA. Malignant melanoma: Prevention, early detection, and treatment in the 21st
century. CA Cancer J Clin 2000;50:215-36.
Cottrell R, McClamroch L, Bernard AL. Melanoma knowledge and sun protection attitudes and behaviors among college students by gender and skin type. Am J Health Educ 2005;36:274-8.
Greaves M. Was skin cancer a selective force for black pigmentation in early hominin evolution? Proc Biol Sci 2014;281:20132955.
Panda S. Nonmelanoma skin cancer in India: Current scenario. Indian J Dermatol 2010;55:373-8.
] [Full text]
Khullar G, Saikia UN, De D, Radotra BD. Non-melanoma skin cancers: An Indian perspective. Indian J Dermatopathol Diagn Dermatol 2014;1:55-62. [Full text]
Adinarayan M, Krishnamurthy SP. Clinicopathological evaluation of non melanoma skin cancer. Indian J Dermatol 2011;56:670-2.
] [Full text]
AlGhamdi KM, AlAklabi AS, AlQahtani AZ. Knowledge, attitudes and practices of the general public toward sun exposure and protection: A national survey in Saudi Arabia. Saudi Pharm J 2016;24:652-7.
Goulart JM, Wang SQ. Knowledge, motivation, and behavior patterns of the general public towards sun protection. Photochem Photobiol Sci 2010;9:432-8.
Johnson K, Davy L, Boyett T, Weathers L, Roetzheim RG. Sun protection practices for children: Knowledge, attitudes, and parent behaviors. Arch Pediatr Adolesc Med 2001;155:891-6.
Garbutcheon-Singh KB, Dixit S, Lee A, Brown P, Smith SD. Assessment of attitudes towards sun-protective behaviour in Australians: A cross-sectional study. Australas J Dermatol 2016;57:102-7.
Situm M, Vurnek Zivković M, Dediol I, Zeljko Penavić J, Simić D. Knowledge and attitudes towards sun protection in Croatia. Coll Antropol 2010;34 Suppl 1:141-6.
Ramezanpour A, Niksirat A, Rad SG. Knowledge, attitude and behavior (practice) toward sunscreen use among hospital personnel in comparison with laypeople in Zanjan, Iran. World Appl Sci J 2013;22:683-9.
Cheng S, Lian S, Hao Y, Kang N, Li S, Nie Y, et al.
Sun-exposure knowledge and protection behavior in a North Chinese population: A questionnaire-based study. Photodermatol Photoimmunol Photomed 2010;26:177-81.
Mangal A, Kumar V, Panesar S, Talwar R, Raut D, Singh S, et al.
Updated BG Prasad socioeconomic classification, 2014: A commentary. Indian J Public Health 2015;59:42-4.
] [Full text]
Wesson KM, Silverberg NB. Sun protection education in the United States: What we know and what needs to be taught. Cutis 2003;71:71-4, 77.
Kaymak Y, Tekbaş OF, Işıl S. Knowledge, attitudes and behaviours of university students related to sun protection. Turk Derm 2007;41:81-5.
Nikolaou V, Stratigos AJ, Antoniou C, Sypsa V, Avgerinou G, Danopoulou I, et al.
Sun exposure behavior and protection practices in a mediterranean population: A questionnaire-based study. Photodermatol Photoimmunol Photomed 2009;25:132-7.
Aquilina S, Gauci AA, Ellul M, Scerri L. Sun awareness in Maltese secondary school students. J Eur Acad Dermatol Venereol 2004;18:670-5.
Al Robaee AA. Awareness to sun exposure and use of sunscreen by the general population. Bosn J Basic Med Sci 2010;10:314-8.
Paul C, Tzelepis F, Walsh RA, Girgis A, King L, McKenzie J, et al.
Has the investment in public cancer education delivered observable changes in knowledge over the past 10 years? Cancer 2003;97:2931-9.
Thieden E, Philipsen PA, Heydenreich J, Wulf HC. UV radiation exposure related to age, sex, occupation, and sun behavior based on time-stamped personal dosimeter readings. Arch Dermatol 2004;140:197-203.
Mermelstein RJ, Riesenberg LA. Changing knowledge and attitudes about skin cancer risk factors in adolescents. Health Psychol 1992;11:371-6.
Banks BA, Silverman RA, Schwartz RH, Tunnessen WW Jr. Attitudes of teenagers toward sun exposure and sunscreen use. Pediatrics 1992;89:40-2.
Robinson JK, Rademaker AW, Sylvester JA, Cook B. Summer sun exposure: Knowledge, attitudes, and behaviors of Midwest adolescents. Prev Med 1997;26:364-72.
Abroms L, Jorgensen CM, Southwell BG, Geller AC, Emmons KM. Gender differences in young adults' beliefs about sunscreen use. Health Educ Behav 2003;30:29-43.
Walkosz B, Voeks J, Andersen P, Scott M, Buller D, Cutter G, et al.
Randomized trial on sun safety education at ski and snowboard schools in Western North America. Pediatr Dermatol 2007;24:222-9.
Wright MW, Wright ST, Wagner RF. Mechanisms of sunscreen failure. J Am Acad Dermatol 2001;44:781-4.
Stanton WR, Janda M, Baade PD, Anderson P. Primary prevention of skin cancer: A review of sun protection in Australia and internationally. Health Promot Int 2004;19:369-78.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]