Ashley Roberts February 2, 2010

1. Summer Sunburn and Sun Exposure Among US Youths Ages 11 to 18: National Prevalence and Associated Factors Ashley Roberts February 2, 2010

2. Objective • To gather national, population-based data on sun exposure and protection behaviors among US youths ages 11 to 18 to measure the extent and patterns of sun exposure and establish baselines for continuedobservation • Ultraviolet radiation (UVR) from sun exposure is the number 1 modifiable risk factor for skin cancer, including melanoma.

3. Method • The American Cancer Society (ACS) did a nationwide survey based on random digit dialing in 48 states (excluding Alaska and Hawaii) • During July through October (1998) • Population based sample of 1,192 youth ages 11 to 18

4. Survey • Sunburn was defined as “any reddening of the skin that lasts at least 12 hours, received either from being out in the sun or from using a tanning bed or sunlamp.” • “Did you get a sunburn during the past weekend? Was the sunburn painful?” • “Have you had a sunburn this summer? • If yes, “how many times were you sunburned during this summer?” • “What were you doing when you received your most serious sunburn this summer?”

5. Sun Sensitivity Index • Physical characteristics • skin type • susceptibility to sunburn, • ability to tan • the natural color of the skin, and • natural hair color. • Categorized youth into high, medium, and low levels of physical susceptibility to sun exposure.

6. Sun Exposure • The total average of hours per week spent outdoors • “On average during this summer, about how many hours per week did you spend outdoors between 10 am and 4 pm on weekdays only?” • “On average during this summer, about how many hours per week did you spend outdoors between 10 am and 4 pm on weekends?”

7. Sun Exposure • Activities performed outdoors during the weekdays and weekend • up to four activities were coded for each respondent • activities were coded into five groups • participating / watching outdoor recreational activities, • sunbathing • working outside for pay • water sports • socializing

8. Sun Protection Behaviors • “When outside on a very sunny day during the summer for more than 1 hour” • Rank use of sunscreen lotion on a 5-point Likert scale response format ranging from never to always. • At least one summer sunburn • “Did you do anything to protect yourself from the sun before you received your most serious sunburn this summer?”

9. Sun Protection Behaviors • “What did you do to protect yourself from the sun?” • Up to 3 answers were coded per respondent • wore long-sleeve shirt and/or pants • wore a baseball cap • wore a hat with 2+ inch brim • wore sunscreen with 15+ SPF • stayed in the shade

10. Attitude Connections Related to Sun Protection • Factor Analysis • Benefits (Chronbachα = 0.58) • “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” • High score = benefits of sun protection more desirable

11. Attitude Connections Related to Sun Protection • Barriers (Chronbachα = 0.69) • “I feel healthy when I have a nice tan” • “I look better when I have a tan” • Low score = tan less desirable • Categorized Groups • High • Medium-high • Medium-low • Low

12. Statistical Analyses • SUDAAN • Standard errors and 95% CI • X2 tests with α = 0.01 • Univariate logistic regression analyses • association between factors of interest and each outcome • Multivariate logistic regression analyses • adjusted prevalence odds ratios (aPOR) and 95% CI for the covariates

13. Results • Overall response rate of 57.7% • 72% reported having had at least 1 summer sunburn. • 30% reported at least 3, and 12% reported at least 5 sunburns. • 1 in 5 spent on average more than 32 total hours outdoors. • Approximately 62 % were participating in or watching sports.

14. Results • Before receiving their most serious summer sunburn, 39% of youths reported having applied SPF 15+ sunscreen. • Factors associated with increased odds of sunburn • Greater sun sensitivity, white race, age younger than 16 years, • more hours spent outdoors, and high desirability of a tan.

15. Discussion • There is a need for better education and awareness of proper use of these lotions • Programs would be designed to reduce sunburn and increase sun protection behaviors • Shape social norms to reduce the desirability of a tan and to increase the perceived benefits of protection. • Incorporating sun safety interventions into other school based health interventions

16. Strengths • Use of validation and reliability assessment • Defined objects of interests • Collected data in enough detail to identify variables desired • Likert scale • Factor anaylsis – construct validity • Chronbachα in 0 to 1 range • Face validity of Objective • Content validity

17. Strengths • Criterion validity • Accounted for habitual behavior • Reflected different geographical regions • Reflected different ethnic groups • Internal consistency

18. Weaknesses • Memory • Recall bias • Self-reporting • False information

19. Improvements • Surveys distributed during months of peak sun exposure (summer break) • Observation of youth at a popular location from 10am to 4pm

20. Source • Davis, K. J., Cokkinides, V. E., Weinstock, M. A., O'Connell, M. C., & Wingo, P. A. (2002). Summer sunburn and sun exposure among US youths ages 11 to 18: National prevalence and associated factors. Pediatrics, 110(1 Pt 1), 27-35. DOI: 10.1542/peds.110.1.27