Original Research
Knowledge and attitudes to sun exposure among adolescents in Korinthos, Greece
Citation: Saridi M, Pappa V, Kyriazis I, Toska A, Giolis A, Liachapoulou A, Skliros E, Birbas K. Knowledge and attitudes to sun exposure among adolescents in Korinthos, Greece. Rural and Remote Health 9 (online), 2009: 1162. Available from: http://www.rrh.org.au
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ABSTRACT
Introduction: Extended sun exposure may lead to serious health problems, and evidence of this is in the increase in skin cancer and malignant melanoma worldwide. Extended sun exposure during childhood or adolescence increases the probability of skin cancer in adulthood. The aim of the study was to identify and examine the knowledge, attitude, behaviour and beliefs of Greek adolescents (high school students) related to sun exposure and its adverse effects on health. The majority of participants (89.7%) were of Greek nationality.
Methods: The study took place in 5 schools in the prefecture of Korinthos, and 816 of the total 925 students aged 15–18 years participated. The questionnaire was pilot tested and assessed for validity and reliability, both of which were adequate (Cronbach’s α = 0.70 and rs = 0.78); SPSS 13.0 software was used for analysis.
Results: Only 37.9% of participants knew that melanoma was a type of skin cancer; 50% said they did not know what melanoma was. Regarding behavior, 35.5% reported that during the last summer they went to the beach on 20 to 50 occasions, and only 50% reported that they wore a sunhat or stayed in the shade. The frequency of sunscreen use was alarmingly low, with the majority of the adolescents unfamiliar with its proper use, and 50% not using a sunscreen with sufficient sun protection factor. Television was an important source of information about protection from sun exposure, while the family was the most important provider of advice.
Conclusions: Participants’ knowledge of sun exposure was insufficient and they reported risky behaviours in the summer months. Despite health promotion and community education programs focusing on sun smart strategies, these young people still associated suntans with beauty. Health promotion and education programs need to challenge such beliefs. However, as a sole approach to health promotion, teaching protective measures and appropriate ways for youth to protect themselves against the harmful effects of sunbathing may be insufficient to reduce the epidemic of skin cancer.
Key words: attitudes of teenagers, Greece, melanoma, sun protection, sun protection factor.
ARTICLE
Introduction
Extended sun exposure may lead to serious health problems, and evidence of this is in the increase in skin cancer and malignant melanoma worldwide1. Ultraviolet radiation (UVR) is responsible for ocular damage (cataract formation), skin disorders (dermatopathy, premature skin aging) and several types of skin cancer, of which melanoma is the most dangerous2. Contributing to these health risks is the depletion of the protective ozone shield due to climate change3,4.
It is well-established that extended sun exposure during childhood or adolescence increases the probability of skin cancer in adulthood. Furthermore, 50–80% of the total amount of UVR is accumulated during these periods, although the mechanism for this phenomenon is unclear5-8.
In countries such as Australia, New Zealand and the USA the incidence of melanoma and other skin cancers (such as basal cell and squamous cell carcinoma) is increasing rapidly, as is the mortality rate attributed to melanoma9-12. In Greece, documentation from the Euromelanoma prevention campaign has shown the incidence of skin cancer to be increasing, although the incidence is not as high as in other northern European countries13-22.
The aim of this study was to identify and examine the knowledge and attitudes of Greek adolescents (high school students) regarding sun exposure and its adverse effects on health.
Methods
Sample
This study was conducted in 5 high schools in Korinthos Prefecture, Greece (Table 1). This prefecture was selected because it has close and direct access to the beach (within 2 min from the centre of Korinthos). Korinthos contains several semi-urban towns/villages, and because students living in those areas attend high schools in Korinthos, this also provided a representative rural sample. Question 4 on the questionnaire concerned place of residence (town or village; Appendix I).
Table 1: Name, location and number of students for schools selected in Korinthos prefecture
The study included the whole adolescent (15–18 years) population of the selected schools (n = 925). The timing of the researcher’s school visits was based on the each school’s grade schedule.
Ethics approval and consent
The research protocol was approved by the the Educational Institute and the Ministry of Education. The director of the Secondary Education Authority of Korinthos and the principals of the selected schools were informed of the study procedures.
Consent forms were distributed to each student and their parents. The parents’ response rate was 96.5% (n = 901) while that of the students was 95.89% (n = 864). Students or parents who did not sign the consent form, students who did not agree to participate and those who were absent on the day of the study were excluded from the sample.
Questionnaire
A questionnaire was used to evaluate adolescents’ attitudes, knowledge and beliefs about sun exposure and its impact on human health (Appendix I). The questionnaire used was modified with permission from one used in a similar study conducted by La Bat et al23 in 2005. The original questionnaire had 15 questions, 2 of which about artificial tanning were excluded in the present study. Ten questions were added concerning demographic data and personal characteristics, as were 15 questions about the risks of UVR and disorders caused by it. Finally, 7 questions were added to examine the students’ knowledge of protective measures. All additional questions were based on a question-and-answer format WHO questionnaire: this involved questions 11–23 and 41–47 (about knowledge of sun exposure) and questions 24–40 (attitudes)24-27.
The final questionnaire was piloted with 30 same-age adolescents who did not attend the schools in the study. Analysis of the pilot data revealed unclear answers to the knowledge questions, so these were converted to multiple choice questions (numbers 12, 13, 15, 18, 19, 23, 30, 32, 33 and 37 in the appendix questionnaire), with some choices being intentionally misleading to ensure maximum reliability. The revised questionnaires were pilot tested by the same students and there was no difficulty found in collecting or processing the data. To test for internal consistency and reliability, Cronbach’s α was used and found to be 0.76, establishing the reliability (>0.70) of the questionnaire.
The questionnaire also required mole counting and mapping (questions 7 & 8; Appendix I). A body sketch was provided on the questionnaire to allow students to map the position of their moles. In addition, the researcher was present while students completed their questionnaires and available to any student who needed help.
Statistical analysis
For statistical analysis SPSS software v13.0 (SPSS; Chicago, IL, USA; www.spss.com) was used. In the two-sided test p <0.05 was considered significant. Due to the multiple comparisons, Bonferroni correction was used to avoid a type 1 error, thus setting α to 0.05/k (k = number of comparisons). In addition, a χ2 test was used to examine the correlation of variables (eg students’ knowledge of the risks of sun exposure correlated to their demographics). The mean value and standard deviation described students’ total knowledge score. The Kolmogorov-Smirnov test was used to determine whether the total score fell into a normal distribution (p = 0.052). To compare students’ total knowledge scores as a quantitative variable among three or more groups, analysis of variance (ANOVA) was used, while Student’s t-test was employed for the comparison of students’ knowledge between two groups.
Results
There were slightly more males than females (53.1% and 46.9%, respectively) in the study population, and the majority of participants were of Greek nationality (89.7%) (Table 2).
Counting and mapping the moles revealed that more than 25% of the adolescents reported 10 or more moles and these were usually located on the upper extremities and the front of the torso (Table 3), sites where melanoma presents in highest incidence.
The main source of adolescents’ information about sun exposure was family (79.8%), followed by television (68.2%), then magazines, school, doctors and friends. Of the participants 37.9% knew that melanoma was a type of skin cancer; however, 50% said they did not know what a melanoma was (Table 4).
Table 2: Demographic data of the participants
Table 3: Mean body distribution of moles
Table 4: Participants’ basic knowledge of melanoma and ultraviolet radiation (UVR)
The adolescents reported risky summer behavior with 35.5% reporting that they went to the beach on 20-50 occasions last summer, and 43% more than 50 times.
Few of the students (36%) reported going to the beach after 16.00 hours (the safest option for sun exposure). In contrast, the majority of the students (55%) went to the beach between 10.00 and 16.00.
The results show that using a hat and staying in the shade were not popular behaviors because these strategies were reported by only 50% of the participants. Furthermore, only 50% of the participants reported using sunscreen with sufficient sun protection factor (SPF; Fig1). Concerning the incidence of sunburn, 55.6% had been sunburned at least once, while 17.3% had experienced sunburn with blisters (questions examining the incidence of sunburn are numbers 36, 37 and 38). Of the sample, 44.4% had suffered no sunburn during the last summer.
When asked about their suntan beliefs, participants stated that they tanned for beauty reasons (67.7%) and for style and ‘coolness’ (41.9%). However, a large proportion (85.9%) indicated that they used sunscreen because they thought this would protect their health. The primary source of encouragement to use of sunscreen was family (70.8%), followed by doctors (38.4%), with television, magazines and school being unimportant.
Figure 1: Students’ reported use of sunscreen during the last summer.
Total knowledge and attitude
In order to examine students’ sun exposure total knowledge level, a score was created by adding all correct answers to the 16 questions that assessed knowledge. The scores ranged from 0 (no knowledge) to 16 (excellent knowledge). The mean study population score was 7.7 (SD = 2.2) and the range was 1 to 14 (Fig2).
Likewise, in order to examine students’ sun exposure total attitude a score was created by adding all correct answers to the 16 questions relating to attitude. The scores ranged from 0 (not a responsible attitude at all) to 16 (excellent attitude) (Fig3).
The students’ knowledge was correlated with their attitude and the correlation coefficient was r = 0.26, p <0.001, indicating a positive correlation between knowledge and having a responsible attitude to sun exposure (Fig4).
Figure 2: Students' total knowledge of sun exposure.
Figure 3: Students' total attitude to sun exposure.
Figure 4: Correlation of students’ knowledge about and attitude to sun exposure.
Discussion
The results of this study show that knowledge about melanoma and UVR is very poor among teenagers in the area studied. Risky behaviors, such as going to the beach between 10.00 and 16.00 (the dangerous time period for exposure to high UVR) without sunscreen were commonplace. This is of concern.
It is also of concern that the majority of participating adolescents believed that having a tan was a sign of health. The mean values for the reported body site of moles revealed that these were located on the upper extremities (mean 1.9, SD = 2.4), followed by the front of the torso (mean 1.8, SD = 2.0), and the back of the torso (mean 1.6, SD = 2.4) – all locations reported to be of high incidence for melanoma20,28,29. In total, 43% of the students also reported from 5 to 30 moles on their body; the number of moles on an individual is one of the risk factors for the development of a malignant melanoma28,29. However, apart from the Euromelanoma16 campaign studies, there are no studies about the number and sites of moles on children and adolescents.
Of even greater concern is that 77.8% of the present study participants reported that they do not visit a doctor to have their moles checked, nor do 62.7% self-examine their moles for changes in size, shape or color as is advised by the ABCD rule (a simple self-examination procedure)5,30,31 (Table 5). Because moles may develop into melanoma or indicate an increased risk for melanoma, it is important that people know the difference between melanoma and an ordinary mole.
Table 5: The self-examination ABCD rule for melanoma
The results of this study are comparable to those worldwide, many of which focus on adolescents22,23,31-50. Of interest in the demographic data and personal characteristics of the population, males and females were more or less equally represented, and over 80% were of Greek nationality, so the participants were not in a high risk group in terms of skin phototype (IV, V, VI). Because of the country’s geographic location and climate, typical Greek phototypes are III, IV, V15,16, similar to those of the study population. In other studies, the prevalent skin phototypes of adolescent populations were I, II, III (ie fairer than the present study participants), as would be expected in Australia, New Zealand, USA and Sweden where the geographic location results into different phototypes16-19,51-53.
In accordance with the results of similar studies, the present findings show that family and television are the main sources of information, although the percentages vary (Fig5)22,23,31,34-36,52,53. However, the teenagers from Korinthos seem to be at a disadvantage as far as knowledge of melanoma is concerned. While only 37.9% of the participants reported knowing what a melanoma was, in the aforementioned countries the percentage of those with this knowledge was much higher (New Zealand54 75%, Australia36 66%, and USA49 80%; Fig6).
Much of Greece, and especially the area where the present study was conducted, is located close to the coast. So it was not surprising that the participants reported going to the beach frequently each summer and spend a lot of time exposed to the sun. Among the participants 40% used sunscreen several times or always, and 80.8% of these used SPF >15 sunscreen. However, these adolescents do not use enough sunscreen when compared to those in other countries (eg Israel, Australia, USA)41,42,47 (Fig7).
Figure 5: Television as the main source of information about melanoma, according to country.
Figure 6: Knowledge of what melanoma is, according to country.
Figure 7: Frequency of sunscreen use, according to country.
Likewise, the use of hat and sunglasses was disappointingly low (39% and 25.5%, respectively), which is similar to other studies22,34,35,43. The majority of the students (60.2%) reported staying in the sun for more than 1 hour in order to tan. Young people worldwide are likely to stay in the sun for extended periods, especially those aged 13-19 years55. Because it has been shown that adolescents have the lowest probability for change in behavior55,56, educational efforts should focus mainly on younger students42.
With regard to sunburn, while 29.9% of the participants reported having sunburn at least once during the last summer, and 26% had been sunburned more than once, 44.4% stated they had never been sunburned. In 3 similar US studies16,44,45, sunburn percentages were very high (92%, 83% and 72%, respectively). In New Zealand53,55, 35% reported having been sunburnt at least once, while only 23% had never been sunburnt. In Australia34, 68% reported having been sunburnt last summer. These results are similar to the sunburn incidence reported in studies from Lithuania43 (40.6%), Chile57 (38%), Italy25 and France48 (46%) (Fig8).
Figure 8: Sunburn incidence, according to country.
The majority of the present participants reported that they wished to tan for beauty reasons (67.7%), or for style and ‘coolness’ (41.9%). In US studies49,50 32% of participating American students considered tanning to be healthy. Teenage girls in Australia were of a similar opinion35,36. Moreover, in studies of adolescents in Malta27 and the USA57, 45.5% and 52% of the participants, respectively, considered tanned skin to be healthier. While those results agree with a study conducted in Norway39, in Turkey24, while 86% of the adolescents considered tanned skin to be more attractive, 50% stated that this was not a healthy strategy.
A review of the literature shows that great efforts are being made in some countries (such as Australia, New Zealand and USA) to assess adolescents’ knowledge, attitudes and perceptions of UVR, and to implement education programs. There are many such campaigns, for instance the Ministry of Health and The New Zealand Cancer Control Trust 200257, the Sun-smart America Curriculum 200451, The Transtheoretical Model 2003 in Sweden39, Slip, Slop, Slap (Slip on a shirt, Slop on sunscreen and Slap on a hat) 1980 and Sunny Days, Healthy Ways, 2005 in the USA12,45,49, the Australian Sun-smart58 (2000) and Euromelanoma (2003) in Europe16,19. The main goal of these campaigns, as is consistent with WHO27 and CDC59 guidelines, is to raise awareness of the risks of extended sun exposure, and to educate the public about protective measures.
Crucial to improving health education about the risks of sun exposure in Greece, will be the devising of a new approach to educational campaigns with reference to the international literature, and also upgrading the approach used in schools.
Limitations
A larger sample size and country-wide adolescent participation would provide more data about the knowledge and attitudes of teenagers to UVR. The interview of other groups (eg younger students, parents and teachers) would allow the comparison of their beliefs with those of teenagers.
The moles were not counted by a health professional and the number recorded were according to the student’s memory. While there were a number of strategies employed to compensate (the presence of the researcher while the students completed their questionnaires, and the body diagram provided for accurate marking of mole location), nevertheless this is a serious limitation to the study.
Conclusion
The sun exposure knowledge of the Greek adolescents studied was insufficient and they reported risky behaviors in the summer months. As a sole approach to health promotion, teaching protective measures and appropriate ways for youth to protect themselves against the harmful effects of sunbathing may be insufficient to reduce the epidemic of skin cancer. Despite health promotion and community education programs focusing on sun-smart strategies, some young people in Greece still associate suntans with beauty. Such beliefs must be challenged by health promotion and education programs.
Acknowledgement
The authors thank Professor C Lionis for his useful comments and suggestions.
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Appendix I: Participant questionnaire
© Maria Saridi, Vasiliki Pappa, Ioannis Kyriazis, Aikaterini Toska, Anastasios Giolis, Alexandra Liachapoulou, Eystathios Skliros, Konstantinos Birbas 2009 A licence to publish this material has been given to Deakin University, http://www.rrh.org.au
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