What do young people think about dangers of sunbathing, skin cancer and sunbeds? A questionnaire survey among young Italians.

Monfrecola G.*, Fabbrocini G.**, Posteraro G.*, Pini D.*

* Dept of Dermatology- University of Naples "Federico II"- Italy

** Dept of Biol and Pathol Cell and Mol- University of Naples "Federico II"- Italy

Abstract

Background: Previous experience in Australia and Sweden showed that public education programms produced substantial changes in people’s thoughts, attitude and perceptions on melanoma, non-melanoma skin cancer, sunlight, sunbeds and suntanning. In order to organize effective prevention campaigns, more must be learned about sunbathing habits in Italian children and adolescents are. Purpose: The aim of our study is to get a better understanding of the knowledge that young people of Southern European Country have about sun risk. .

Methods:764 young people ranging from 16 to 22 years old (mean age: 19.3 1.2) answered a questionnaire in order to detect young people’s thoughs on sunbathing, skin cancer and sunbeds.

Results: Our study suggests that young people are very aware of the risks associated with sunbathing but they continue to expose themselves without taking any precautions. Conclusion:This suggests that : a)the majority of young italians reasonably well-informed but they did not observe any preventative measures; b) one efficient measure could be the promotion of the idea that a untanned body is more aesthetically pleasing than a tanned one; c) a crucial point in the programming of any future safety measures in suntan centers involves rigorous and regular controls.

Key-words: sunbathing- sunbeds-skin cancer-survey-Mediterranean population

Introduction

Clinical and experimental studies showed that chronic and prolonged sun-exposure has a crucial role in the pathogenesis of epithelial skin cancer while intermittent and indiscriminate sun exposure has a somewhat controversial role in the pathogenesis and progression of melanoma. Many reports noted that sunburn at an early age can be considered a risk factor of cutaneous malignant melanoma particularly in sensitive skin types. 1

Artificial ultraviolet (UV) exposure (sunbeds) is a controversial risk factor for skin tumours and in particularly for cutaneous melanoma. The effect is slightly stronger for lentigo maligna and for lesions on the face, head, neck and arms. The risk is greater and more significant for both sexes in the domestic use of sunbeds/sunlamps, increasing with different melanoma presentation sites. Infact concerning this aspect only lesions of the trunk are significantly associated with sunbed/sunlamp use.2,3,4,5

Many authors stress the importance of prevention in reducing sunburn risk . Previous experiences in Australia and Sweden showed that public education programms produced substantial changes in in people’s knowledge, attitude and perceptions of melanoma, non-melanoma skin cancer, sunlight, sunbeds and suntanning. 6

An increased rate of incidence of melanoma has been recording in Italy over the last decades, with 9-13 cases of melanoma /100.000 persons with an annual rate of increase of 3-7% of cases. For this reason the Italian Government intends to run an information program and public health campaign. In order to organize an effective prevention campaign, more must be learned about sunbathing habits of Italian children and adolescents. The aim of our study is to get a better understanding of the knowledge level of young people of Southern European Country have about sun risk. This study aimed at finding out the reasons why adolescents in the Mediterranean area expose themselves to the sun, or to artificial ultraviolet sources and whether they are conscious of the negative adverse effects of ultraviolet rays.


Materials and Methods

Study area and study population

Our study was carried out in Naples city. Naples (2 million inhabitants) is located in the South of Italy at a a latitude of 45 .

764 young people ranging from 16 to 21 years of age (average age: 19.3 1.2) were selected by stratified random sampling by age of students from 10 different high schools (last year of frequency) and from the Faculty of Medicine, University of Naples "Federico II" (first year of frequency) .

Questionnaire design

We submitted a questionnaire with 28 questions to detect what young people think about sunbathing, skin cancer and sunbeds.

We excluded people affected by sunrelated skin pathologies in order to avoid information bias.

The questionnaire consisted of 28 questions which registered information on age, sex, self-assessed skin type, sunbed use, sunbathing and sunscreen use, knowledge about possible risk of sunexposure or sunbed use, skin reaction to sunbed use, social behaviour on suntanning, skin cancer and sunbeds. (Tab. 1)

Classification of skin type was based on the Fitzpatrick classification. 7

Referring to sunbed use:0-3vs >= 4x30 min sunbed sessions during the previous 12 months was chosen as a cut-off for non-use/use. In order to anticipate recall bias, data on sunbed use were asked for only the previous 12 months.

Referring to sunscreen: sunscreen use during the previous 2 years was used as a cut-off for use/non-use.

Collection and analysis of data

Data were collected from November 1996 through February 1997 by two dermatologists. Students were only allowed to ask if a question was unclear. No student refused to respond. Eight questionnaires were excluded due to unusable answers, resulting in 756 questionnaires available for evaluation.

Data collected were analysed by BMDP software version 1993. Univariate descriptive analysis was performed and cross-tables were performed by Chi-square test to evaluate statistically significative association.

 

RESULTS

Sunbathing

Our results showed that people prefer to be tanned. Infact 44.65% of those interviewed felt that a tan was aesthetically more pleasant.
No difference in opinion was observed between males and females.

Obviously about 50% enjoyed sunbathing with a significant statistical difference between females and males. As expected, less sensitive skin types (photype III and IV) sunbathed more frequently than others; among females there is a prevalence of sunbathers in respect to males (p<0.00001; chi-square-test) Tab. 2). No difference was observed when we referred to the different ages of respondents.

Nevertheless more than half of young people interviewed sunbathed, about 50% declared that the sun has a harmful effect, with a prevalence among females.

Although females are more conscious of the sun they still sunbathed more than males.(Tab.3)

If we analyze these data correlating them with sunbathing yes/sunbathing no, we observe that there is no difference between the two categories of people. Therefore, the opinion does not influence behaviour.

These results are somewhat perplexing when we consider the following answers. 90% of young people interviewed were aware of the fact that the sun provokes cutaneous damage and more than 50% (of those interviewed) knew the type of skin damage caused.

The high cultural level of our sample could explain this high level of knowledge, but it is curious that they received almost all information from the mass media as seen by the results.

 

Sunscreen use

More than 60% of those interviewed applied sunscreens in order to avoid sunburn with a higher percentage of females than males. Females seem to be more prudent, they re-apply sunscreens once tanned in respect to males who, in 75% of cases, once tanned, do not continue the application.

Stratifying by phototype we observe that photypes I and II are in the habit of protecting themselves more and for a longer time than phototypes III and IV. A difference was registered among sex, females protect more themselves (Tab. 4)

Sunbeds

Our results showed that the use of sunlamps is independent of sex and skin type. Only 12.3% of our sample reported using them, usually, during the winter. In more than half of the cases they underwent one session a week.

Most people used sunlamps for aesthetic reasons .

Most people do not use sunlamps because they do not believe that a tan is an important aesthetic factor. Only 31.5% of people interviewed do not use sunbeds because they believe them to be dangerous.

As expected 77% of sunlamp users (12.3% of the whole sample) answered that they sunbathes with pleasure with respect to percentage of whole sample who sunbathes with pleasure equal to 50.6% in order to show that most of people who like to sunbathe in the summer, continues using sunlamp in the winter (sunlamp’s users).

Therefore sunbed users will, over the years, receive the highest cumulative dose of ultraviolet rays.

Sunrisk

In respect to the whole sample a lower percentage (30% vs 60%) of sunlamp users declared that the sun has a harmful effect. About 90% of them knew that ultraviolet lamps can provoke some skin damage specifically mentioning chronic damage and skin cancer.

Suntan centers and information source

Sunlamp users have strong faith in suntan centers. In 76% of cases they do not wish to purchase a personal sunlamp and they would not use sunbeds more frequently if they were free of charge.

Once again among sunbed users, the mass media is the main source of information. Surprisingly 23% suffered sunburn from sunbeds and only 60% of those who suspended sunlamp sessions.

 

DISCUSSION

Up to now, in Italy, few epidemiologic studies have been performed to identify young people’s knowledge on sunrisks and the beneficial effects of sun exposure, highlighting preventative measures for sunlamps users.

Whereas in Sweden, a lot of educational campaigns concerning sunbeds have been carried out to highlight recomending that individuals younger <16 years of age and those with sensitive skin types avoid their use.

Epidemiological studies concerning adolescents behaviour have been conducted in a lot of European countries such as Sweden and Scotland but the strong phenotypical difference between these countries and the Italy and the different enviromental and latitude conditions made the results not incomparable with our country. 8,9,10 The use of sunlamps and sunbeds seems to be strongly linked to socio-economic status with a positive gradient from the lowest to the highest socio-economic level and to skin type III and IV. 11

On the other hand the main aim of most epidemiological studies is to identify the relationship between human behaviour and the appearance of skin tumours in order to better define some aspects of the multifactorial photocarcinogenetic process while surveys which analyze knowledge on sun exposure and sunbed use are still uncommon. 12,13

The aim of our study was to better describe young people’s behaviour concerning sunexposure sun, sun risks, sunscreens and sunbeds use in order to optimize the subjects for future educational campaign.

This study was conducted on a randomly selected sample of adolescents from Naples in the South of Italy. It can thus be considered as being representative of that area However, before these results can be extrapolated to other places of the South of the Europe some particular aspects have to be considered. First, Naples is on the Mediterranean coast where the weather is warm and sunny, and sunbathing is a frequent pastime; inhabitants of regions with less favourable climatic conditions may have less opportunity for exposure. Secondly, Naples is a large city, and the behaviour of a rural population would probably be different. Third , unlike other countries, Italy has never organized a structured and prolonged information campaign on the hazards of sunlamp use.

Our study show that young people well know the risks for skin damage caused by sunexpose but almost half of them continue to sunbathe without precautions. This suggests that the majority was reasonably well-informed but do not observe preventative measures.There was a little bit difference between males and females. Infact, females paid more attention to preventative measures .

In respect to other countries such as Sweden the percentage of sunbed users in our sample is lower (12.36% vs 57% ). This difference may be linked to different enviromental conditions between the two countries.

The comparison between our study and that of Boldeman showed many similarities of behaviour for example in both studies a lower attention to photoprotection between phototypes III and IV respect to phototypes I and II was observed.

Whereas significative differences concerning reasons for sunexposure were present : for example in Sweden a lot of people use sunbeds to mask certain skin pathologies such as acne and seborrhea while in our sample most of respondents (95%) sunbathe to sun and to sunbeds because they believe them to be more attractive. 14

Our results show that Italy focused lower attention to the application of legislative and preventive devices of suntan centers. Our study, infact, showes that in some cases sunlamp centers do not respect the safety devices. More than 70% of people interviewed did not receive any information from the staff concerning the avoidance of such unpleasant effects as sunburn and only 38.5% wore protective glasses..

Our results suggests that future educational campaigns have to be improved and have to induce suntan centers to respect safety devices.

The sunrisk, infact, is well-known among adolescents but the behaviour is unchanged;

Maybe it’s not useful give more information about risk but it could be more efficacious to promote the idea that untanned people are more attractive than tanned ones;

More control respect to the tanning centers following European legislation about kind of sun lamps, safety measures, kind of training for the operator in the tanning centers.In Italy, infact, the breaking of these photoprotective rules is a crucial point in the programming of any future safety measures concerning sunlamp use.

 

REFERENCES

1. Elwood JM, Gallagher RP, Davisson J. Hill GB. Sunburn, suntan and risk of cutaneous malignant melanoma, the Western Canada Melanoma Study. Br J Cancer 1985;51:543-9

2. Autier P, Joarlette M, Lejeune F et al. Cutaneous malignant melanoma and exposure to sunlamps and sunbeds: a descriptive study in Belgium. Melanoma Res 1991; 1: 69-74

3. Walter SD, Marret LD, From L et al. The association of cutaneous malignant melanoma with the use of sunbeds and sunlamps. Am J Epidemiol 1990; 131:232-43

4. Westerdal K, Olsson H, Masback A. et al. Use of sunbeds or sunlamps and malignant melanoma in Southern Sweden. Am J Epidemiol 1994; 140:691-699

5. Swerdlow AJ, Weinstock MA. Do tanning lamps cause melanoma? An epidemiologic assessment. I Am Acad Dermatol 1998; 38(1):89-98

6. Marks R. Melanoma prevention: is it possible to change a population’s behavior in the sun? Pigment Cell Res 1994 ; 7(2):104-106

7. Fitzpatrick TB. The validity and praticalitity of sun rective skin types I trough VI. Arch Dermatol 1988; 124:869-871

8. C. Boldeman, H.Beitner, B.Jansson, B.Nilsson and H.Ullen. Sunbed use in relation to phenotype, erythema, sunscreen use and skin diseases. A questionnaire servey among Swedish adolescents. British Journal of Dermatology 1996; 135:712-716

9. Victoria B, Mawn BA and Alan B.Fleischer, Jr. MD Winston-Salem, North Carolina. A survey of attitudes, beliefs, and behavior regarding tanning bed use, sunbathing, and sunscreen use. Jurnal of the American Academy of Dermatology. December 1993; 29 (6):959-962

10. Grob JJ, Guglielmina C, Gouvernet J et al. Study of sunbathing habits in children and adolescents: application to the prevention of melanoma. Dermatology 1993; 186:94-98

11. Mawn VB, Fleischer AB Jr., A survey of attitudes, beliefs, and behavior regarding tanning bed use, sunbathing, and sunscreen use. J Am Acad Dermatol 1993; 29: 959-962

12. Westerdahl J, Olsson H, Masback A et al. Is the use of sunscreens a risk factor for malignant melanoma? Melanoma Res 1995; 5:59-65

13. Rivers JK, Norris DG, Murphy GM et al. UVA-sunbeds: tanning, photoprotection, acute adverse effects and immunological changes Br J Dermatol 1989; 120:767-777

14. B. Fiala, M.Kopp and V.Gunther. Why do young women use sunbeds? A comparative psychological study. British Journal of Dermatology 1997; 137: 950-954

 

Skintype

Yes

No

I n=21

33.3

66.7

II n=88

39.1

60.9

III n=353

43.1

56.9

IV n=294

53.1

47.9

SEX YES NO
MALES n=319 38.3% 61.7%
FEMALES n=433 54.8% 45.2%

 

 

 

 

Tab. 3

 

 

Male n=319

Female n=433

Is healty for skin

32.5

20.8

It isn’t healty for skin

50.0

60.2

It is indifferent

17.5

19.0

 

 

 

 

Tab. 4

Do you use some sunscreens during first sunexposures?

Skintype

Yes n=530

No n=226

I

68.7

31.3

II

90.8

9.2

III

73.3

26.7

IV

68.7

31.3

p= n.s.

According to sex.....

Sex

Yes n=530

No n=226

MALES

40.8%

59.2%

FEMALES

55.3%

44.7%

p<0.0005