Barriers and facilitators to skin cancer prevention among Hispanics: a qualitative study

Abstract

Background

In the past two decades, melanoma incidence among Hispanic people has risen greatly. This qualitative study explored Hispanic people’s perceived barriers and facilitators to skin cancer-related preventive behaviors.

Methods

Five focus groups among Hispanic people (2 in Spanish and 3 in English; n = 34; 11 Spanish-preferring and 23 English-preferring) were conducted, where participants discussed their perceptions and behaviors relating to skin cancer, sun protection, and skin self-examination. Additionally, healthcare providers (n = 9) and Hispanic community leaders (n = 6) were recruited for individual interviews to complement the results of focus groups. A thematic analysis was conducted on all transcripts.

Results

Perceived barriers to sun protection included: 1) Low levels of knowledge and awareness/misperception; 2) low perceived importance or not a priority, 3) economic issues or limited access, 4) downsides/concerns about engaging in sun protection behaviors, and 5) Hispanic cultural norms (e.g., machismo). Facilitators to sun protection included: 1) relevance/care for family, 2) negative consequences of sun exposure, and 3) Hispanic cultural norms (e.g., familismo). Barriers to skin examination included: 1) low levels of knowledge and awareness, 2) lack of insurance coverage or access, and 3) difficulty or discomfort associated with practicing skin self-examination. Facilitators to skin examination included: 1) relevance/previous experience and 2) having insurance coverage or access.

Conclusions

Future interventions should focus on individual, community, and system-level strategies to address misperceptions in the Hispanic community, increase knowledge and awareness, address perceptions of cultures regarding skin cancer preventive activities, and emphasize the importance or priority of health issues related to skin cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-024-20000-2.

Background

Skin cancer is the most common form of cancer in the United States (US). Melanoma, the deadliest form of skin cancer, is the fifth most common cancer in the US [1]. The National Cancer Institute Surveillance, Epidemiology, and End Results program projected that in 2023, there would be 97,610 new cases and 7,990 deaths from melanoma in the US [2]. Melanoma is more common among individuals of fair complexion and those who have been exposed to natural or artificial sunlight (such as tanning beds) over long periods of time [2]. Non-melanoma skin cancer has been on the rise in the United States, affecting approximately one in five individuals. Moreover, increasing prevalence is of concern among Hispanic and Asian ethnic groups [3, 4].

The Hispanic population is the fastest growing ethnic group in the US [5]. In the past two decades, melanoma incidence among Hispanic people rose by 20% [4]. Although the Hispanic population has lower incidence rates of both melanoma and non-melanoma skin cancers compared with non-Hispanic whites (NHW), the mortality rate of Hispanics is higher [4]. In general, compared with NHW, Hispanic people diagnosed with melanoma are younger (median age: Hispanics: 49 years; NHW: 58 years), have advanced stages of melanoma with thicker tumors during diagnosis (> 1.5 mm), and have worse 5-year melanoma-specific survival rates (for men, 5-year survival of 76.6% and 87.0%, respectively; for women, 88.3% and 92.3%) [6–9]. However, skin cancer is understudied among the Hispanic population [6]. Most US skin cancer-related public health efforts and prevention research have focused on the NHW population.

Mobile interventions offer several benefits for public health interventions, including among the Hispanic population. Firstly, mobile technology presents a promising solution to address health disparities, as supported by previous skin cancer prevention research that has shown success in promoting behavioral change through mobile interventions [10, 11]. Additionally, in 2019, 96% of Hispanics in the United States owned a cell phone, and 79% owned a smartphone, making mobile devices an accessible platform for reaching this population [12]. Furthermore, preliminary study findings indicated strong interest among Hispanics in participating in skin cancer interventions delivered via mobile platforms, with 71.8% expressing interest in using WhatsApp and 62.8% in receiving text messages [13, 14].

Skin cancer is preventable with sun protection behaviors like wearing sunscreen with high sun protection factor (SPF), wide brimmed hats, sunglasses, protective clothing; staying out of the sun at peak midday hours; avoiding tanning, etc. However, studies have identified that there are differences in sun-protective behaviors among individuals by race and ethnicity with the magnitude of some of these differences increasing [15]. Similarly, although more than half of all new primary melanomas are self-detected [16, 17], few Hispanic individuals check their skin for skin cancer. Early detection of skin cancer through skin examination can also improve skin cancer outcomes. Therefore, early detection by skin self-exam has the potential to reduce melanoma morbidity and mortality, and thus reduce the burden of melanoma among Hispanics in the U.S. [18].

A systematic review on the trends in primary skin cancer prevention among the Hispanic population identified the need for improvements in primary skin cancer prevention practiced by Hispanics in the U.S. [19]. The studies targeting skin cancer prevention efforts among Hispanic people in the US are limited, and the review suggested that future research and interventions should consider diversity in socio-cultural backgrounds, levels of acculturation, and occupational differences within the U.S. Hispanic population. Several studies have investigated the impact of educational interventions on sun protection and skin self-examination among Hispanic people [20, 21]. However, these interventions were one-time events consisting of relatively short sessions with limited short-term effects. Furthermore, their designs either did not incorporate a comprehensive array of factors that could potentially be effective in influencing behavioral changes related to skin cancer among Hispanic people, or they did not asses both skin self-examination and awareness of skin cancer risk [20, 21]. Future studies should address a more comprehensive set of correlates that may be potentially associated with skin cancer outcomes of Hispanic people. Given the dearth of literature surrounding this important topic among Hispanic people, this study aimed to explore the facilitators and barriers related to the skin cancer preventive behaviors (including sun protection and skin examination) among Hispanic people to inform the development of a mobile health intervention with potential for cost-effective dissemination.

Methods

This study aimed to assess the factors that impact skin cancer prevention and self-screening among Hispanic people. The present study had a qualitative research design using focus group and key informant interviews. There were five focus groups conducted among Hispanics living in New Jersey and 15 key informant interviews among community leaders, medical practitioners, and health professionals working with the local Hispanic population [22].

Recruitment and data collection

Participants for this study were selected using convenience and snowball sampling. Specifically, focus group participants were recruited through social media and local community organizations for Hispanic populations, while key informant interviewees were recruited by contacting medical providers and offices, community organizations, and local hospital networks. Participant eligibility screening and consent were completed by telephone and email. Interviews and focus groups were conducted in English or Spanish, depending on participants’ language preferences. During the focus groups/interviews, the protocol and consent forms were read again to potential participants, and their voluntary consent to participate in the study was obtained. Upon receiving informed consent, focus groups/interviews took place over Zoom and lasted between 1 and 2 h. Data were coded from transcriptions of audio/visual recordings. However, the participants were not required to turn their cameras on.

Interview guides for both focus groups and key informant interviews were developed for this study and included questions about the following three domains: 1) knowledge about skin cancer in the Hispanic population, 2) engagement in skin cancer preventive behaviors (sun protection and skin self-examination), and 3) overall social media use. After discussing these topics, participants were asked questions about the use of social media for health education among the Hispanic population and suggestions about social media intervention design (reported elsewhere). Two research team members were present at each interview, one to conduct the interviews and the other to take notes. Focus group participants were compensated with $50 electronic gift cards, and key informant interview participants were compensated with $70 electronic gift cards.

Data analysis

Focus groups and key informant interviews were audio recorded and transcribed using Zoom’s auto-transcription feature; focus groups conducted in Spanish were transcribed and translated by a professional transcription and translation company. Final transcripts were reviewed by team members for accuracy. The interview transcripts were then reviewed and prepared for thematic analysis using ATLAS.ti data management software. A code book for analysis was developed based on emerging themes summarized by the team to analyze the interview transcripts. A team of four researchers individually coded each interview. There was a second analysis of the coded interviews to identify any potential gaps in the coding and attain consensus in the results. A master file with the coded interviews was developed using ATLAS.ti software, and a report was generated to identify memos and themes related to barriers and facilitators of skin cancer prevention among Hispanic people.

Results

A total of 34 Hispanic people participated in 5 focus groups (3 groups were conducted in English and 2 in Spanish). The participants’ ages ranged from 18 to 73 years, and there was an equal distribution of male and female participants (n = 17). Average household income was below $25,000, and 32.3% of participants had less than a college degree. Of the Hispanic participants, 67.6% preferred English as their language of communication, while the rest preferred Spanish (Table 1). In addition to the focus groups, there were 15 individual key informant interviews (Table 2), which included 6 community leaders (community outreach coordinators, church leaders, and leaders from other local community organizations) and 9 healthcare providers (dermatologists, social workers, nurses, and oncologists) serving the Hispanic population. All focus group participants and 78.6% of individual interview participants reported being of Hispanic heritage.

Table 1.

Demographics of focus group participants

Variable	N (%)
Age	18 – 73a (mean=33.44)
Gender
Female	17 (50%)
Male	17 (50%)
Average Household Income
Below $25,000	10 (29.4%)
Education
Less than college degree	11 (32.4%)
College or above	23 (67.6%)
Language
English	23 (67.6%)
Spanish	11 (32.4%)

^aAge range of study participants

Table 2.

Demographics of individual participants

Stakeholders	Mean (SD)	N	Ethnicity
Age	43 (22.6)	15
Gender
Female		13
Male		2
Role
Dermatologist		1	Hispanic
Oncologist		1	NHW
Nurse		4	NHW = 2, Hispanic = 2
Licensed social worker		1	Hispanic
Clinical coordinator		2	Hispanic
Community leaders (organization/church leaders)		6	Hispanic

Data from focus groups and key informant interviews were grouped into themes to better understand the barriers and facilitators to different types of skin cancer preventive behaviors among Hispanic people (Table 3). Data revealed a range of barriers to and facilitators of skin cancer prevention, sun protection, and skin examination behaviors at both personal and structural levels.

Table 3.

Themes of barriers and facilitators

Behaviors	Facilitators	Barriers
Sun protection	Theme 1: Relevance/care for family Theme 2: Negative consequences of sun exposure Theme 3: Hispanic cultural norms	Theme 1: Low levels of knowledge and awareness/misperception Theme 2: Low perceived importance or not a priority Theme 3: Economic issues or limited access Theme 4: Downsides/concerns of engaging in sun protection behaviors Theme 5: Hispanic cultural norms
Skin examination	Theme 1: Relevance/previous experience Theme 2: Having insurance coverage or access	Theme 1: Low levels of knowledge and awareness Theme 2: Lack of insurance coverage or access Theme 3: Difficulty or discomfort associated with practicing skin self-examination

Barriers to sun protection behaviors

A thematic analysis of the interviews highlights possible barriers to sun protection behaviors among Hispanic people, identifying several key themes. First, participants perceived low levels of knowledge and awareness, with misconceptions about skin cancer and sun protection. Second, skin cancer was not considered a priority in daily life, as other concerns took precedence. Third, economic barriers were also mentioned, with sunscreen costs being a hindrance. Fourth, concerns about engaging in sun protection behaviors included the difficulty of finding suitable sunscreen products and the downsides of certain ingredients. Lastly, participants highlighted cultural norms influencing sun protection practices. Overall, these findings underscore the multifaceted nature of barriers within the Hispanic population and highlight the need for targeted interventions addressing knowledge gaps, economic constraints, and cultural influences.

Theme 1: low levels of knowledge and awareness/misperception

In general, participants perceived that the Hispanic population generally had low levels of knowledge and awareness regarding skin cancer and/or sun protections behaviors. For example, the participants stated that the Hispanic community generally would not know about statistics on skin cancer or effective sun protection behaviors. In addition, the participants felt that Hispanic people tended to have misperceptions regarding skin cancer and sun protection (e.g., people with dark skin can’t get skin cancer). These are best exemplified by the following quotes:

• “Sometimes people think if their skin is a little darker. They’re not as much risk.”

  (Interview 3, community outreach director, female, Hispanic)

• “I use aloe vera, natural things, lemon juice, and things like that but I don’t use any product on my face, only a moisturizer that my daughter gives me for my face, but it doesn’t have sunscreen.” (Spanish Focus group 2).

Theme 2: low perceived importance or not a priority

Many participants mentioned that skin cancer or sun protection behaviors were not really a priority in their daily lives. They reported that other concerns, such as managing living expenses, often took precedence over health prevention measures. Furthermore, participants mentioned that potential health problems typically garnered their attention only when they or their family members actually experienced them, rather than focusing on preventive actions. Moreover, using sunscreen was not a part of their daily skin care routine.

• “I think it is a topic that is less talked about or less known. We don’t pay much attention to it, or we don’t use things to protect ourselves, they don’t exist in our daily lives.” (Spanish Focus Group 2).

• “I think it (skin cancer among Hispanics) is important, but it’s not always front and center. I think, more front and center is the day-to-day survival, which is paying the rent, you know, making enough money to make ends meet.” (Interview 5, local organization leader, male, NHW).

Theme 3: economic issues or limited access

Some of our participants reported that they might have economic barriers that prevent them from engaging in sun protection behaviors. For example, sunscreen may be expensive for this population. This economic barrier highlights the need for more affordable sun protection options and better education on cost-effective methods to help prevent skin cancer.

• “I think part of it might be the cost of some lotions because these are most of all these lotions are imported. They are more expensive. So, I guess that’s a commodity that not everyone can access. And I do think that plays into the usage of it. ” (Interview 2, clinical coordinator, female, Hispanic)

• “I feel like the exposure that happens to the sun is inadvertently because a lot of them are doing outdoor activities work in the outdoor setting. They walk they don’t have access to you know, they don’t have a car. So they’re just constantly being exposed. ” (Interview 9, nurse, female, Hispanic)

Theme 4: downsides/concerns of engaging in sun protection behaviors

Some of the concerns that participants expressed regarding engaging in sun protection behaviors include not knowing the specific ingredients of products or difficulty finding a good product/sunscreen that is suitable for each individual, e.g. depending on oily/dry skin type, makeup, reapplication. These factors can make the process of selecting and consistently using sun protection products more complex and difficult.

• “I know one of the things that make it hard is when you go to buy some of these products. A lot of them have ingredients that are not healthy like they’re actually carcinogenic. They cause cancer, basically the ingredients inside the actual thing that’s supposed to prevent cancer causes cancer. So, then you try and go for the more holistic stuff that’s natural, and those tend to be quite pricey when you’re trying to get the healthy like sunscreen, as opposed to the one with all these dioxide and titanium and cancer causing because recently they also just pulled one of the one of the sunscreen was pulled in for causing cancers. I think it was Sun Boat. I think that was the brand. I don’t know if you saw it on the news.” (Focus Group 1)

• “I try and get as much sun as I can. No SPF, no hiding, and also we tend my family tends to be low on vitamin D, and a lot of people their medical doesn’t cover vitamin D, so they would never know they’re vitamin D deficient because that’s not something our insurance typically covers. So, I know there was actually a study saying that we need more vitamin D and that sunscreen is not good because we’re not getting enough of the vitamin D.” (Focus Group 1)

• ”You know I don’t really like to wear it, because I still haven’t found one that doesn’t turn me some pale shade of what ghostly white on my face.” (Focus Group 5)

• ”I have to make sure it works with the makeup I’m wearing on top of it and reapplying. It is also very difficult, if you’re also wearing. And another issue is, I have very oily skin, and I have the opposite problem.” (Focus Group 5)

Theme 5: Hispanic cultural norms

Hispanic participants mentioned their unique cultures and values might play an important role in impacting an individual’s sun protection behaviors. Moreover, using sunscreen or actively engaging in sun protection was not a common practice to some in the population while growing up. Many participants also mentioned the tanning cultures existing in the Hispanic population. Each of these practices may help to explain the current barriers to engaging in sun protection behaviors.

• “This kind of machismo attitude comes into about using sun protection and taking care of yourself, I mean, I think that’s part of the reason why a lot of Latino men I know aren’t using masks when they’re dealing with a lot of dust. ” (Interview 7, nurse, female, NHW)

• “85% of my friends tan outdoors, especially when going to the beach. The tanning oil is probably more likely to be in our beach bag than sunscreen. And the reason being tanner is sexier. Let’s just put it that way.” (Focus Group 5)

• “I don’t know if it’s just my family that like just finds being darker to be more attractive.” (Focus Group 5)

Barriers to skin examination

A second category identified from the interviews was barriers to skin examination. Participants highlighted low levels of knowledge and awareness regarding how to conduct skin self-examinations and what to look for, including various aspects of skin changes. Limited insurance coverage or access to dermatologists posed a significant obstacle. Additionally, skin cancer detection examinations were often perceived as less urgent than other more immediate health concerns. Moreover, participants expressed difficulties and discomfort in practicing skin self-examination, particularly in hard-to-reach areas, and needing assistance from partners, family members, or healthcare professionals.

Theme 1: low levels of knowledge and awareness

Our participants indicated that the Hispanic community generally had low levels of knowledge/awareness in terms of how to do skin self-examination and what exactly to look for when conducting a skin self-examination (e.g., different types of lesions, size, shape, color, texture, skin changes over time, new growths, etc.).

• “They don’t know how to do it. Things like that right, I think, if the lesion is in an area where they can see they’ll pay more attention to it. I think that also plays into it, or also the oh, I’ve had that mole forever like it’s. I’ve always had it. So, it’s part of me.” (Interview 2, clinical coordinator, female, Hispanic)

• “There’s probably a lot of people in the Latino community who, you know, don’t see dermatologists, because maybe they have no history of melanoma or other skin cancers. They have no family history of it. They’re not aware they don’t notice anything on their body, so they only go, you know, if they notice something.” (Interview 12, oncologist, female, NHW)

Theme 2: lack of insurance coverage or access

Participants mentioned that a major barrier to having annual skin examinations done is the inability to visit the dermatologist due to lack of good insurance. Even if they do have primary care physicians, priority is given to immediate/serious health concerns rather than something preventative such as skin cancer screening.

• “Sometimes I think more the access to dermatologists that you know may be, you know, insurance reasons why they can’t be seen for surveillance on a regular basis. I mean, we tend to recommend.” (Interview 13, nurse, female, Hispanic)

• “And then what might be harder is getting to a dermatologist or a general practitioner to have them do the full body screen.” (Interview 3, community outreach director, female, Hispanic)

• “Another barrier is access to care. So a lot of the times they don’t have primary care physicians, and when they do go to see a provider, is because of something that they already have going on, is not necessarily for like preventative care, but more like, Oh, hey, comorbidity management. ” (Interview 9, nurse, female, Hispanic)

• “I think a lot of patients won’t go to the dermatologist because it’s not covered by their health insurance. Most of it is out of pocket and going to dermatology. Dermatologist is usually quite expensive. ” (Interview 2, clinical coordinator, female, Hispanic)

Theme 3: difficulty or discomfort associated with practicing skin self-examination

Participants expressed that it is difficult to perform skin self-examinations on oneself, particularly when trying to check areas of the body that are hard to see/reach, and would require the help of their partner, family member, or health care professional. In addition, people may have concerns or be reluctant to have skin exams.

• “Check the spots that they can’t see like sometimes, even with a mirror, can be hard to see.” (Interview 3, community outreach director, female, Hispanic)

• “I think what would make it hard is depending on the location of the skin, right, so if it’s at the back of the leg like pieces that they you don’t have easy access to that, you know, if there may be someone who may be overweight, so may not have as much mobility and looking at certain locations that might impact them. Also, someone you know, who might have those limitations may not feel as motivated to look, because, you know, they’re just trying to get by with their day-to-day activities, that that might be just an additional task that they don’t really have the energy for. ” (Interview 9, nurse, female, Hispanic)

• “Some people might not be comfortable disrobing and getting that kind of exam.” (Interview 3, community outreach director, female, Hispanic)

Facilitators to sun protection behaviors

Themes identified in this domain regarding facilitators to sun protection behaviors pertained to multiple contextual levels. The relevance and care for family members affected by skin cancer or related issues play a crucial role in participants’ awareness of and commitment to sun protection measures. Family experiences, such as a relative’s struggle with skin cancer, serve as motivators for adopting sun protection habits. Further, the fear of negative consequences associated with sun exposure, including aging, sunburns, photosensitivity, and certain medical conditions, serve as strong motivation for individuals to engage in protective behaviors. Preventing premature aging and avoiding discomfort are key motivators. In addition, cultural norms influence perceptions of attractiveness based on skin color, impacting sun protection practices. The desire for lighter skin, driven by prejudice, shapes some individuals’ choices to use sunscreen and adopt protective measures; whereas, the desire for darker skin motivates tanning behavior.

Theme 1: relevance/care for family

If the participants had family members who had skin cancer or experienced skin problems, they reported knowing more about and paying more attention to skin cancer, sun protection, and skin examination. (e.g., sunscreen for children and parents).

• “Well, when it’s their turn or when someone in the family is affected.” (Interview 11, church leader, male, Hispanic)

• My dad died of cancer, so I have to check myself constantly; I do it with my boyfriend or with my sister, with whoever, tell them if you have a spot, check if it is normal or if it is growing. So, when I go to my friends who are doctors, I ask them if that is normal or if I should have a more thorough check-up. (Spanish Focus Group 2)

• “We have a very personal family case that is not mine, you can tell him, that he is her brother. My brother also worked for a long time outside and maintenance on buildings and things like that, and he has permanently cancerous cells in his head. So, since he lives in Florida and has the boat and goes to the sea, then he has already made a great culture out of it. Why? Because every time he goes to the doctor, he suffers, because it always has to be done burns on the head to remove all those cells. So, he has shared it with other people in the family, because we are so white, we turn red. And I know he does it with the rest family for that, because we really have the experience. It has become a habit.” (Interview 11, church leader, male, Hispanic)

Theme 2: negative consequences of sun exposure

To avoid certain unwanted consequences, such as worry and fear of aging, getting sunburns, photosensitivity, having certain medical conditions was another theme.

• “And that’s how I sell it. I sell it as, you know, we don’t want wrinkles. ” (Interview 3, community outreach director, female, Hispanic)

• “If someone is susceptible to burning. They might want to cover up so that they don’t burn, because that can be uncomfortable. ” (Interview 3, community outreach director, female, Hispanic)

• “I hear comments like discoloration of the skin of reasons why to protect themselves from the sun. ” (Interview 9, nurse, female, Hispanic)

• “So, I have a reason as well for migraines. And also for people on certain medications to avoid the sun.” (Focus Group 1)

Theme 3: Hispanic cultural norms

Perceptions related to which type of skin color would be more attractive significantly impact sun protection behaviors.

• “I would say, there is a cultural bias, at least there is in my family, unfortunately, to tend to favor, get them to find lighter skin to be more attractive. And so, I do know that they are sell people to make on the work, put on sunscreen specifically, so that their skin does not tan is very fair skin. But in her case, she just doesn’t go out into the sun. And she does go out, she actually carries an umbrella with her specifically, not for rain, but just to protect her from direct sunlight.” (Focus Group 1)

Facilitators to skin examination

Key themes related to facilitators to skin examination emphasized roles of personal experiences and healthcare access in encouraging regular skin self-examinations among Hispanic people. Participants indicated the importance of relevance and previous experience, noting that individuals with certain skin conditions or a history of skin cancer are more likely to engage in regular self-skin examinations. This heightened awareness and proactive approach stem from personal experiences, such as the removal of moles or skin cancer diagnoses in the past. Moreover, access to coverage, particularly through good insurance, was identified as a facilitator. Participants with reliable insurance reported being able to undergo annual full-body professional skin examinations with dermatologists, reinforcing the significance of accessible healthcare resources in promoting skin examination practices.

Theme 1: relevance/previous experience

Participants mentioned that people who have certain skin conditions (e.g. moles) or have had skin cancer in the past are more likely to perform self-skin examinations on a regular basis.

• “My sister is very fair, so I’m actually darker than her, … and so she’s had to have moles removed and be more on top of it. So again, maybe because it’s something that they’re more conscious of. There’s more proactivity to get something done where, as somebody who maybe doesn’t have a lot of marks on their skin, they might not think to get a skin check. ” (Interview 3, community outreach director, female, Hispanic)

• “People like myself ,who have had skin cancer, are more likely to be thinking about it. And a lot of people who maybe tan easily have a perception.” (Interview 7)

Theme 2: having insurance coverage or access

Participants mentioned that having access to good insurance enables them to have a full-body professional skin exam done by a dermatologist once a year.

• “I tend to have a lot of moles all over my body, and they recommend it that from my specific case that I do an annual mole check with a dermatologist. But again, I have a really good insurance. And so, for me, it wasn’t a big deal to schedule an annual check with a specialist specifically just for this.” (Focus Group 1)

• “Sometimes I think more the access to dermatologists that you know may be, you know, insurance reasons why they can’t be seen for surveillance on a regular basis.” (Interview 13, nurse, female, Hispanic)

Discussion

The current study provides insight into barriers and facilitators to sun protection and skin examination behaviors among Hispanic people integrating perspectives from both Hispanic community members and other key informant including community leaders and health care providers for Hispanic people. Hispanic participants in our sample were relatively diverse in their socio-cultural backgrounds and levels of acculturation and shared narratives that indicated low prioritization and knowledge regarding skin cancer and related preventive behaviors. Additionally, this population shared specific barriers and facilitators to both sun protection and skin examination behaviors, adding to existing literature by illustrating personal, community, and structural level factors that impact skin cancer prevention among Hispanic people in the US. Our findings have direct implications for researchers, community health advocates who promote skin cancer preventive behaviors, and clinicians who engage in skin cancer prevention efforts among Hispanic people.

Our findings highlighted the low knowledge and awareness of skin cancer, sun protection, and skin examination among Hispanic people, which are consistent with previous studies regarding Hispanic people and sun protection [23–26]. For example, we found that Hispanic people’s engagement in different sun protection behaviors (e.g., wearing wide-brimmed hat, wearing sunglasses) was low [24, 25]. A study among Black and Hispanic individuals found that only a small number of participants mentioned consistently engaging in sun protection behaviors [5]. Another recent study focused on Hispanic people in Florida and Puerto Rico also revealed relatively low levels of sun-protective behavior among U.S. Hispanic people and low levels of worry and concern about skin cancer [23].

Additional factors that emerged in our interviews included misperceptions/concerns about skin cancer and sun protection, as well as discomfort in engaging in skin self-examination. Lunsford and colleagues (2018) also mentioned that the majority of their Black and Hispanic participants believed their risk of skin cancer to be low, attributing it to their “darker skin tone” and/or the “absence of family history” [5]. Future interventions should address these barriers by increasing the skin cancer knowledge and awareness, perceptions about health priority, and addressing concerns among Hispanics regarding skin cancer, sun protection, and skin examination.

There were also themes signaling the need to incorporate systems-level factors in future intervention efforts. Some of the interpersonal and system-level barriers include economic factors (e.g., can’t afford sunscreen, Ultraviolet (UV) exposure, no car to get to work) and limited insurance coverage for skin checks by health care providers. Moreover, Hispanic culture can play an important role in preventing Hispanic individuals from engaging in optimal sun protection or skin examination behaviors [27, 28]. Providing access to sunscreen, improved health insurance, and combating the misperceptions rooted in one’s cultures and values may help promote skin cancer-related preventive behaviors.

Our study also identified fewer, but still important, facilitators to sun protection and skin examinations, including perceived personal relevance, previous experiences with skin cancer, care for family, and good insurance. Interestingly, various Hispanic cultures’ views of attractive skin tones, fear of consequences of photo-aging, getting sunburns, photosensitivity, and having certain skin characteristics and conditions such as numerous moles also seemed to promote sun protection behaviors (such as using an umbrella and sunscreen). The findings regarding fear of consequences of photo-aging and to maintain an attractive skin tone (lighter) are consistent with a previous study, which indicated that most participants’ intent of using sunscreen was aiming to discourage “further skin darkening” or to “prevent aging,” rather than the reduction of sunburns or the risk of skin cancer [5]. Insurance was also mentioned as a significant facilitator by both our focus group and our individual interview participants, which has been reported to effectively boost regular skin checks by a dermatologist [27].

Strengths and limitations

The present study has several strengths, particularly including multiple perspectives from both Hispanic community members and key informants, such as healthcare providers and community leaders. This comprehensive approach allows for a richer understanding of the diverse viewpoints within the Hispanic community. However, the study also has limitations of qualitative methods in general. With a small sample size (N = 34), the findings may not be representative of the broader Hispanic population. Additionally, the majority of participants possessing a college education or higher suggests a potential bias towards more educated individuals, which may not reflect the experiences of those with different educational backgrounds. The use of snowball sampling further introduces sample bias, as participants are more likely to recruit individuals with similar characteristics. Moreover, the focus group methodology could have influenced individual responses due to group dynamics, whereby participants’ views may have been swayed by the opinions of others in the group. These limitations highlight the need for caution in generalizing the results and suggest that future research should aim for larger, more diverse samples and consider alternative sampling methods to mitigate these biases.

Conclusions

Hispanic people’s knowledge and awareness of skin cancer, sun protection, and skin examination behaviors were generally low, and they tended to have misperceptions of skin cancer-related issues. This study noted important barriers and facilitators to Hispanic people’s sun protection and skin examination behaviors. Future interventions should focus on individual, community, and system-level strategies to address Hispanic people’s misperceptions, increase knowledge and awareness, address culturally-based perspectives regarding skin cancer preventive activities, and emphasize the importance or priority of health issues related to skin cancer. Public health implications of our findings are that these facilitators and barriers should be considered and potentially incorporated in the development and implementation of effective skin cancer related health interventions for Hispanic populations.

Abbreviations

NHW

Non-Hispanic whites

UV

Ultraviolet

US

United States

Authors’ contributions

The study was conceptualized by Z.N., C.J.H., Y.M.R., S.L.M., S.V.H., and F.P. The main manuscript text was written primarily by Z.N.. Z.N., Y.M.R., J.B., and A.S. participated in interview facilitation and data coding. Z.N., J.B., and A.S. worked on qualitative data analysis. All authors reviewed and revised the manuscript.

Funding

This work was supported by National Institute on Minority Health and Health Disparities (K99MD016435/R00MD016435)​​ and New Jersey Commission on Cancer Research (COCR22PPR007).

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

All procedures were conducted in accordance with the ethical standards of the Declaration of Helsinki. This study was approved by the Rutgers Institutional Review Board (IRB) at Rutgers University (Pro2022000533, Pro2021001562). Participants in this study received consent form before the interview and all of them gave their oral consent before participating in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.