Abstract
Background:
Latine and underserved populations experience worse skin cancer outcomes and limited access to dermatologic care. Linguistically tailored interventions are essential for improving sun protection behaviors and skin self-examinations. Few studies have evaluated community-based interventions and skin cancer beliefs tailored to underserved Spanish- and Punjabi-speaking populations in the United States.
Objective:
To evaluate the effectiveness of a community-based skin cancer educational intervention in underserved Latine Spanish-speaking and Asian Punjabi-speaking communities.
Methods:
We implemented a 3-part, in-person intervention between April and August 2024 at University of California, Davis-affiliated student-run clinics. Participants completed pre- and postintervention surveys assessing demographics, skin cancer knowledge, beliefs, and self-examination confidence. The intervention used American Academy of Dermatology materials, delivered in English, Spanish, and Punjabi, supported by trained bilingual medical and undergraduate student volunteers.
Results:
Thirty-two adults (56% Latine, 44% Asian; 81% women, 84% aged ≥40 years) participated. Significant improvements were observed in skin cancer knowledge, including understanding of the ABCDE rule (6–90%, P < .001), and self-examination confidence (19–63%, P < .001). However, changes in beliefs, particularly regarding biopsies and skin cancer misconceptions, were limited. Key structural barriers identified included high costs, lack of insurance, and referral access, disproportionately affecting Latine participants.
Limitations:
This study is limited by variability in educational delivery and a small, older sample population, limiting generalizability.
Conclusion:
An in-person, linguistically tailored, community-based education can significantly improve skin cancer awareness and self-examination confidence among underserved Spanish- and Punjabi-speaking populations. Shifting deeper health beliefs may require more sustained and targeted interventions. Future efforts should expand community-driven, language-concordant interventions and explore long-term impacts on behavior and beliefs.
Keywords: educational intervention, health disparities, language concordance, Latine health, skin cancer prevention, skin of color
What is known about this subject in regard to women and their families?
In many Latine communities, women often bear the primary responsibility for managing their families’ healthcare, making crucial decisions about their well-being and that of their families. This pivotal role emphasizes the importance of educating women on health issues like skin cancer prevention and early detection.
Despite this, there is a notable lack of skin cancer educational resources specifically tailored to meet the needs of Spanish- and Punjabi-speaking women, particularly those in low-resource settings.
What is new from this article as messages for women and their families?
This study presents an in-person linguistically tailored, community-based educational intervention aimed at enhancing skin cancer awareness and self-examination confidence among underserved Spanish-speaking Latine and Punjabi-speaking Asian populations in the United States.
Primarily impacting women aged 40 and older, many of whom have household incomes under $40,000 per year, the intervention highlights the effectiveness of targeted health education in these communities.
This study also reveals the need for a deeper exploration of certain health beliefs, particularly those related to biopsies and misconceptions about skin cancer, that could hinder early detection and prevention efforts.
Introduction
Skin cancer represents a persistent public health challenge, particularly in underserved communities where access to dermatology care and sun protection education is often limited.1,2 Disparities are especially pronounced among patients of color, who frequently present with worse skin cancer outcomes, including more advanced stages of melanoma at diagnosis and lower survival rates.3–5 For instance, Latine individuals have a 2.4-fold increased likelihood of being diagnosed with stage III melanoma and are 3.64 times more likely to have distant metastasis compared with non-Hispanic White groups.6 Additionally, Latine Hispanic men in California have been found to present with significantly thicker primary tumors.6 Notably, Latine and Black patients are disproportionately more likely to present with squamous cell carcinomas (SCCs) at later stages in anatomically sensitive areas, contributing to worse outcomes.7 Furthermore, SCC-specific mortality rates are higher among Latine and Black men compared with their White male counterparts. Similarly, dermatofibrosarcoma protuberans incidence rates are doubled in Black individuals compared with White individuals, and they are 1.8 times more likely to present with large tumors and face a 1.7 times higher risk of all-cause mortality.7
Barriers such as limited access to dermatological care, lack of insurance, geographic barriers, and the shortage of racially and linguistically concordant providers hinder timely diagnosis and treatment.7 Moreover, public health campaigns and prevention strategies have historically centered on lighter-skinned populations, contributing to lower awareness of skin cancer risk among communities of color.8 Latine communities, in particular, may be less likely to perform skin self-examinations due to low perceived susceptibility, misinformation, and access barriers.6 These patterns underscore the urgent need for inclusive education, culturally tailored interventions, and a more diverse dermatology workforce to address inequities in detection, treatment, and outcomes.
Culturally and linguistically tailored interventions are essential for improving sun protection behaviors and skin self-examinations, particularly in Hispanic communities where there is a recognized need for translated and culturally appropriate awareness campaigns.9,10 Community-based educational interventions offer a promising approach to reach these vulnerable populations in familiar and trusted settings. While numerous skin cancer prevention programs exist, only a few studies have explored the impact of such interventions on skin cancer awareness, self-examination confidence, and skin cancer beliefs in linguistically diverse, underserved populations, particularly among Spanish-speaking Latine communities and Punjabi-speaking Asian communities in the United States.11–13 This study aimed to evaluate the effectiveness of an in-person, community-based educational intervention designed to increase skin cancer awareness, improve confidence in self-skin examination, and explore skin cancer beliefs in underserved Latine and Asian populations, including Spanish- and Punjabi-speaking individuals.
Materials and methods
We conducted a 3-part, in-person, quasi-experimental pre- and post-educational intervention based on a prior sun safety educational intervention design established as an effective public health education intervention to promote the prevention of skin cancer in underserved communities.11 Between April and August 2024, free skin cancer education using American Academy of Dermatology materials was provided at community skin cancer screenings and educational events at Knights Landing One Health Center, as well as at a local Sikh Temple in California supported by Bhagat Puran Singh Health Initiative and Shifa Community Clinic; all University of California, Davis affiliated free student-run clinics serving largely underinsured Latine and Punjabi communities. At Knights Landing One Health Center, participants were recruited during free skin cancer screening and community health events. At Bhagat Puran Singh Health Initiative and Shifa Community Clinic, participants were approached during routine health screenings. In both settings, participants represented a mix of those seeking dermatologic care and those engaged for general community health.
Pre- and postintervention data on demographics, risk awareness, and self-examination confidence were collected. The surveys were administered and collected using Qualtrics software, an online survey tool, Version August 2024, Copyright 2024 Qualtrics.26. We used Studio R Version 2022.12.0 + 353 for descriptive statistics and analyzed categorical survey data using χ2 tests for independence and Fisher’s exact tests to evaluate differences between pre- and postintervention responses. This study was approved by the UC Davis Institutional Review Board #2030488-2.
This study was guided by both the Health Belief Model (HBM) and Social Cognitive Theory (SCT). HBM informed the design of the intervention by addressing participants’ perceived susceptibility to and severity of skin cancer, as well as perceived benefits of and barriers to skin self-examination.14,15 Social Cognitive Theory further supported the intervention through its emphasis on observational learning and self-efficacy.16–18 By using bilingual medical and undergraduate student volunteers as peer educators, the intervention aimed to enhance participants’ confidence in performing self-examinations and to model positive health behaviors within a culturally and linguistically concordant setting.
Study instruments
Before the educational intervention, participants completed a 52-question survey available in English, Spanish, and Punjabi (Supplementary Material 1, https://links.lww.com/IJWD/A79). It was divided into 5 sections: demographics, perceived barriers and solutions, skin cancer beliefs, skin cancer knowledge, and sun protection and surveillance. Sections 1–3 (demographics, perceived barriers and solutions, and skin cancer beliefs) consisted of questions developed by our research team, incorporating perceived barriers and solutions questions from prior interventions.11 Section 4 (skin cancer knowledge) included an adapted version of the validated Skin Examination Questionnaire, a tool previously utilized in underserved communities.11–13,19,20 Section 5 (sun protection and surveillance) was based on a validated sun protection and surveillance behavior questionnaire used to evaluate the effects of prevention programs across diverse populations.21,22 For participants who required assistance with literacy, medical, and undergraduate students were available to help administer the surveys.
Educational intervention
Following survey completion, participants received a 15-minute educational intervention, delivered by trained medical and undergraduate students. The intervention involved group sessions of 3 to 5 participants, during which American Academy of Dermatology webpages and videos were used to deliver sun safety education. One-to-one sessions were also provided, with patient preference and volunteer availability. The educational modules covered key topics such as the importance of sun protection, the proper selection and application of sunscreen, identification of common skin cancer risk factors, the ABCDE rule for melanoma surveillance (asymmetry, border irregularity, color, diameter, and evolving), steps for conducting self-skin examinations, and skin cancer in skin of color (Supplementary Material 2, https://links.lww.com/IJWD/A80). The educational materials were available in English and Spanish; however, given the diverse linguistic background of participants at the local Sikh temple, English materials were also used, with interpretation provided by native Punjabi-speaking undergraduates for those who required assistance. Immediately following the educational intervention, participants completed sections 3–5 of the original survey (31 questions) again to assess changes in their confidence and knowledge related to skin cancer beliefs, sun protection, and surveillance. After completing the postintervention survey, a gift card, sunscreen, and hats were provided. Within both the Latine and Asian groups, participants received materials either in their native language, in English with interpretation, and/or in English directly. Given that variability was present within each group, we analyzed all Latine participants together and all Asian participants together to assess the overall feasibility and impact of culturally and linguistically tailored education.
Results
Demographic characteristics
Thirty-two community members identifying as Latine (18, 56.0%) or Asian (14, 44.0%) participated, primarily aged ≥40 years (27, 84.0%), female (21, 81.0%), with Fitzpatrick skin type III (12, 38.0%), and incomes under $40,000 per year (11, 35.0%) (Table 1). In the Latine group, a larger proportion preferred Spanish (72%), and in the Asian group, (50%) preferred Punjabi. Two individuals were not able to complete the postintervention survey due to work-related time constraints.
Table 1.
Demographic characteristics of participants among total study population, Latine and Asian groups
| Demographics (N, %) | Total (N = 32) | Latine (n = 18) | Asian (n = 14) |
|---|---|---|---|
| Age | |||
| 18-30 | 1, 3.0% | 1, 6.0% | 0, 0.0% |
| 31-40 | 4, 13.0% | 2, 11.0% | 2, 14.0% |
| 41-50 | 9, 28.0% | 4, 22.0% | 5, 36.0% |
| 51-60 | 9, 28.0% | 5, 28.0% | 4, 29.0% |
| 61+ | 9, 28.0% | 6, 33.0% | 3, 21.0% |
| Gender | |||
| Female | 26, 81.0% | 16, 89.0% | 10, 71.0% |
| Male | 6, 19.0% | 2, 11.0% | 4, 29.0% |
| Preferred language | |||
| English | 12, 38.0% | 5, 28.0% | 7, 50.0% |
| Spanish | 13, 41.0% | 13, 72.0% | 0, 0.0% |
| Punjabi | 7, 22.0% | 0, 0.0% | 7, 50.0% |
| Health insurance | |||
| Private | 19, 59.0% | 6, 33.0% | 13, 93.0% |
| Medicaid | 7, 22.0% | 6, 33.0% | 1, 7.0% |
| Uninsured | 4, 13.0% | 4, 22.0% | 0, 0.0% |
| Not disclosed | 2, 6.0% | 2, 11.0% | 0, 0.0% |
| Annual income | |||
| Less than 20k | 6, 19.0% | 6, 33.0% | 0, 0.0% |
| Less than 40k | 5, 16.0% | 3, 17.0% | 2, 14.0% |
| Less than 60k | 3, 9.0% | 1, 6.0% | 2, 14.0% |
| Less than 80k | 4, 13.0% | 1, 6.0% | 3, 21.0% |
| Less than 100k | 2, 6.0% | 1, 6.0% | 1, 7.0% |
| More than 100k | 3, 9.0% | 0, 0.0% | 3, 21.0% |
| Not disclosed | 9, 28.0% | 6, 33.0% | 3, 21.0% |
| Self-reported Fitzpatrick skin type | |||
| Type I | 4, 13.0% | 3, 17.0% | 1, 7.0% |
| Type II | 10, 31.0% | 5, 28.0% | 5, 36.0% |
| Type III | 12, 38.0% | 7, 39.0% | 5, 26.0% |
| Type IV | 5, 16.0% | 2, 11.0% | 3, 21.0% |
| Type V | 1, 3.0% | 1, 6.0% | 0, 0.0% |
| Type VI | 0, 0.0% | 0, 0.0% | 0, 0.0% |
| Where do you work or spend most of your day | |||
| Outside | 7, 22.0% | 4, 22.0% | 3, 21.0% |
| Indoors with no windows | 5, 16.0% | 2, 11.0% | 3, 21.0% |
| Indoors with windows | 18, 56.0% | 12, 67.0% | 6, 43.0% |
| Not disclosed | 2, 6.0% | 0, 0.0% | 2, 14.0% |
Perceived barriers and solutions
Responses from our perceived barriers and solutions surveys (Table 2) showed a high interest in learning about skin cancer (59%) and how to examine for it (41%). Key barriers to dermatology care included a lack of insurance (16%), high costs (22%), and a lack of knowledge about skin cancer (41%). Cost was a particular concern for Latine participants (39%). Language barriers were more prevalent among Asian participants (14%). Participants suggested several solutions to increase dermatology access, including free health education events (31%), improving insurance coverage (16%), and better referral assistance (6%).
Table 2.
Perceived barriers and solutions of among total study population, Latine and Asian groups
| Perceived barriers and solutions | Total (N = 32) | Latine (n = 18) | Asian (n = 14) |
|---|---|---|---|
| Reason for attending skin cancer education event | |||
| No access to dermatologist | 4, 13.0% | 3, 17.0% | 1, 7.0% |
| Concerning skin lesion | 3, 9.0% | 2, 11.0% | 1, 7.0% |
| Family history of skin cancer | 2, 6.0% | 2, 11.0% | 0, 0.0% |
| Would like to learn about skin cancer | 19, 59.0% | 9, 50.0% | 10, 71.0% |
| Would like to learn how to check skin for skin cancer | 13, 41.0% | 7, 39.0% | 6, 43.0% |
| Free opportunity for health care | 7, 22.0% | 4, 22.0% | 3, 21.0% |
| Othera | 2, 6.0% | 1, 6.0% | 1, 7.0% |
| Does not apply | 1, 3.0% | 1, 6.0% | 0, 0.0% |
| Perceived barriers to dermatology care | |||
| Lack of insurance | 5, 16.0% | 4, 22.0% | 1, 7.0% |
| Cost | 7, 22.0% | 7, 39.0% | 0, 0.0% |
| No primary care provider | 3, 9.0% | 3, 17.0% | 0, 0.0% |
| Difficult to obtain referral | 5, 16.0% | 4, 22.0% | 1, 7.0% |
| Lack of knowledge about skin cancer | 13, 41.0% | 8, 44.0% | 5, 36.0% |
| Language | 2, 6.0% | 0, 0.0% | 2, 14.0% |
| Transportation | 3, 9.0% | 2, 11.0% | 1, 7.0% |
| Does not apply | 13, 41.0% | 4, 22.0% | 9, 64.0% |
| Perceived solutions to increasing dermatology access | |||
| Free health education events/health fairs | 10, 31.0% | 6, 33.0% | 4, 29.0% |
| Primary care providers increasing awareness | 4, 13.0% | 2, 11.0% | 2, 14.0% |
| More help with referrals | 2, 6.0% | 1, 6.0% | 1, 7.0% |
| Lower cost or improve insurance coverage | 5, 16.0% | 3, 17.0% | 2, 14.0%1 |
| I do not know | 5, 16.0% | 2, 11.0% | 3, 21.0% |
| Not disclosed | 6, 19.0% | 4, 22.0% | 2, 14.0% |
| It is difficult to protect myself from the sun | |||
| Agree | 10, 31.0% | 6, 33.0% | 4, 29.0% |
| Disagree | 19, 59.0% | 11, 61.0% | 8, 57.0% |
| I do not know | 2, 6.0% | 1, 6.0% | 1, 7.0% |
| Does not apply | 1, 3.0% | 0, 0.00% | 1, 7.0% |
One attended because their friend brought them, and another attended because they were experiencing “skin issues.”
Skin cancer beliefs
The educational intervention led to some changes in participants’ skin cancer beliefs (Table 3), though many were not statistically significant. Recognition of risk factors such as increasing age (41–83%, P = .001), weakened immune system (31–60%, P = .04), and light skin, eyes, or hair (28–63%, P = .01) improved significantly. However, recognition of other risk factors, such as a history of blistering sunburns and a family history of skin cancer, did not significantly increase. Support for the importance of biopsies increased significantly (50–80%, P = 0.03); however, the belief that it is okay to undergo a biopsy procedure to detect skin cancer, interestingly, did not change significantly (53–50%, P value = 1). Other beliefs remained unchanged, notably, the belief that skin cancer is contagious.
Table 3.
Skin cancer beliefs, before and after skin cancer educational intervention
| Skin cancer beliefs | Preintervention (n = 32) | Postintervention (n = 30)a | P-valueb |
|---|---|---|---|
| What increases the risk of skin cancer?c | |||
| Ultraviolet radiation exposure from the sun, tanning beds, and occupational equipment | 27, 84.0% | 28, 93.0% | .39 |
| Family history of skin cancer and other genetic factors | 17, 53.0% | 21, 70.0% | .27 |
| Increasing age | 13, 41.0% | 25, 83.0% | .001 |
| A weakened immune system | 10, 31.0% | 18, 60.0% | .04 |
| History of blistering sunburns | 13, 41.0% | 20, 67.0% | .07 |
| Light skin, eyes, or hair | 9, 28.0% | 19, 63.0% | .01 |
| Diet | 4, 13.0% | 8, 27.0% | .21 |
| Does not apply | 3, 9.0% | 0, 0.0% | |
| Is skin cancer contagious? | .25 | ||
| Yes | 3, 9.0% | 5, 17.0% | |
| No | 23, 72.0% | 24, 80.0% | |
| I do not know | 5, 16.0% | 1, 3.0% | |
| Does not apply | 1, 3.0% | 0, 0.0% | |
| Is skin cancer dangerous? | .14 | ||
| Yes | 28, 88.0% | 30, 100.0% | |
| No | 2, 6.0% | 0, 0.0% | |
| I do not know | 2, 6.0% | 0, 0.0% | |
| It is important to diagnose skin cancer in a timely manner | .24 | ||
| Agree | 29, 91.0% | 30, 100.0% | |
| I do not know | 3, 9.0% | 0, 0.0% | |
| I know what a biopsy is | .32 | ||
| Yes | 24, 75.0% | 27, 90.0% | |
| No | 5, 16.0% | 2, 7.0% | |
| I do not know | 3, 9.0% | 1, 3.0% | |
| What are your thoughts about skin biopsies?c | |||
| It is not ok to do a biopsy, even if it’s to confirm skin cancer | 6, 19.0% | 1, 3.0% | .11 |
| Doing a biopsy is not important | 5, 16.0% | 2, 7.0% | .43 |
| Doing a biopsy is scary | 4, 13.0% | 0, 0.0% | .11 |
| Doing a biopsy is important | 16, 50.0% | 24, 80.0% | .03 |
| It is ok to do a biopsy to confirm skin cancer | 17, 53.0% | 15, 50.0% | 1 |
| Does not apply | 1, 3.0% | 1, 3.0% | |
| Protecting myself from skin cancer is important | .24 | ||
| Agree | 29, 91.0% | 30, 100.0% | |
| I do not know | 3, 9.0% | 0, 0.0% | |
Two participants did not complete the postintervention survey due to time limitations.
We analyzed categorical survey data using χ2 tests for independence and Fisher’s exact tests. The statistical significance for all tests was determined using a significance level of α = 0.05.
Evaluated as yes/no responses. The count on the table includes all yes responses.
Skin cancer knowledge
Significant improvements were observed in participants’ skin cancer knowledge following the intervention (Table 4). The proportion of individuals reporting high knowledge of skin cancer increased from 3 to 50% (P < .001), and awareness of the ABCDE rule for melanoma rose from 6 to 90% (P < .001). Participants’ confidence in performing self-skin examinations also improved, with those confident in examining their face, ears, hands, and feet increasing from 19 to 63% (P < .001). Regarding melanoma recognition, the proportion of participants confident in distinguishing melanoma from other moles increased from 0 to 43% (P < .001). Additionally, self-perceived risk for melanoma rose from 9 to 23% (P = .01).
Table 4.
Responses to adapted skin examination questionnaire among total study population before and after skin cancer educational intervention
| Skin cancer knowledge (N, %) | Preintervention (n = 32) | Postintervention (n = 30)a | P valueb |
|---|---|---|---|
| How much do you know about skin cancer? | |||
| A lot | 1, 3.0% | 15, 50.0% | <.001 |
| Somewhat | 22, 69.0% | 12, 40.0% | |
| Not at all | 9, 28.0% | 3, 10.0% | |
| If you answered, “a lot or somewhat,” where did you learn? | .003 | ||
| Work | 3, 13.0% | 2, 7.0% | |
| School | 3, 13.0% | 1, 4.0% | |
| Health care provider | 5, 22.0% | 1, 4.0% | |
| Previous health education event | 6, 26.0% | 11, 41.0% | |
| Health education event today | 4, 17.0% | 17, 63.0% | |
| A friend or family member | 6, 26.0% | 1, 4.0% | |
| Other | 2, 9.0% | 1, 4.0% | |
| Does not apply | 4, 17.0% | 1, 4.0% | |
| If you answered, “not at all,” why do you think that is? | .63 | ||
| No one ever taught me | 8, 89.0% | 2, 67.0% | |
| It is difficult to understand/remember | 1, 11.0% | 0, 0.0% | |
| I do not have access to health care | 1, 11.0% | 0, 0.0% | |
| I have not seen information about it on the news or social media | 3, 33.0% | 0, 0.0% | |
| Does not apply | 1, 11.0% | 1, 33.0% | |
| I know what the ABCDE rule is and what each letter stands for | <.001 | ||
| Yes | 2, 6.0% | 27, 90.0% | |
| No | 19, 59.0% | 1, 3.0% | |
| I do not know | 10, 31.0% | 2, 7.0% | |
| Does not apply | 1, 3.0% | 0, 0.0% | |
| I am at risk for developing melanoma | .01 | ||
| Yes | 3, 9.0% | 7, 23.0% | |
| No | 8, 25.0% | 16, 53.0% | |
| I do not know | 20, 63.0% | 7, 23.0% | |
| Does not apply | 1, 3.0% | 0, 0.0% | |
| Has a doctor or any health care worker told you that you should examine your skin for skin cancer or melanoma? | .12 | ||
| Yes | 5, 16.0% | 11, 37.0% | |
| No | 26, 81.0% | 19, 63.0% | |
| Does not apply | 1, 3.0% | 0, 0.0% | |
| Has a doctor or health care worker taught you how to check your skin (perform self-skin examinations)? | <.001 | ||
| Yes | 2, 6.0% | 20, 67.0% | |
| No | 28, 88.0% | 10, 33.0% | |
| I do not know | 1, 3.0% | 0, 0.0% | |
| Does not apply | 1, 3.0% | 0, 0.0% | |
| How confident are you that you know the difference between melanoma and other types of moles? | <.001 | ||
| Not at all | 23, 72.0% | 1, 3.0% | |
| Somewhat | 9, 28.0% | 16, 53.0% | |
| Very confident | 0, 0.0% | 13, 43.0% | |
| How embarrassing is it to check your skin? | .67 | ||
| Not at all | 28, 88.0% | 27, 90.0% | |
| Somewhat | 4, 12.0% | 2, 7.0% | |
| Very embarrassing | 0, 0.0% | 0, 0.0% | |
| Does not apply | 0, 0.0% | 1, 3.0% | |
| How confident are you that you can examine the skin of your face, ears, hands, and feet for skin cancer? | <.001 | ||
| Not at all | 12, 38.0% | 2, 7.0% | |
| Somewhat | 14, 44.0% | 9, 30.0% | |
| Very confident | 6, 19.0% | 19, 63.0% | |
| If you examine your skin for skin cancer, do you consider any of the following? | .1 | ||
| Asymmetry | 10, 31.0% | 23, 77.0% | |
| Irregular borders | 13, 41.0% | 23, 77.0% | |
| Unusual colors | 17, 53.0% | 28, 93.0% | |
| Diameter: large size | 14, 44.0% | 23, 77.0% | |
| Evolution: changing over time | 15, 47.0% | 24, 80.0% | |
| Does not apply | 7, 22.0% | 1, 3.0% | |
Two participants did not complete the postintervention survey due to time limitations.
We analyzed categorical survey data using χ2 tests for independence and Fisher’s exact tests. The statistical significance for all tests was determined using a significance level of α = 0.05.
Sun protection and surveillance behavior
Responses to the Sun Protection and Surveillance Behavior Questionnaire (Table 5) reveal key characteristics in sun protection behaviors among our Latine and Asian participants. On average, participants reported varying levels of sun exposure between 10 a.m. and 4 p.m., with Latine participants (61%) spending longer times (>3+ hours daily) outdoors than Asian participants (21%). Regarding sunburns, 56% of participants reported no sunburns in the past year. In terms of sun protection, 28% of participants never wore sunscreen, with Latine participants (33%) reporting higher nonuse compared with Asian participants (21%). Most participants reported wearing shirts with sleeves that cover their shoulders “always” (38%) or “sometimes” (25%), with Latine participants showing more consistent behavior. For hats, 28% of participants wore them “always,” and 22% never wore them, with a higher percentage of Asian participants wearing hats “often” (50%) compared with Latine participants (11%). Only 22% of participants had a full skin check by a healthcare professional. Additionally, a few participants (6%) reported self-examining their skin, and most (94%) did not report conducting a skin cancer check in the last 12 months.
Table 5.
Baseline responses to the validated, sun protection, and surveillance behavior questionnaire among total study population, Latine, and Asian groups
| Sun protection and surveillance behavior questionnaire (N, %) | Total (N = 32) | Latine (n = 18) | Asian (n = 14) |
|---|---|---|---|
| In the summer, on average, how many hours are you outside per day between 10 a.m.-4 p.m. on weekend days (Saturday & Sunday) | |||
| 30 minutes or less | 7, 22% | 1, 6% | 6, 43% |
| 31 minutes-1 hour | 6, 19% | 2, 11% | 4, 29% |
| 2 hours | 5, 16% | 4, 22% | 1, 7% |
| 3 hours | 3, 9% | 2, 11% | 1, 7% |
| 4 hours | 5, 16% | 5, 28% | 0, 0 % |
| 5 hours | 2, 6% | 2, 11% | 0, 0% |
| 6 hours | 4, 13% | 2, 11% | 2, 14% |
| In the past 12 months, how many times did you have a red or painful sunburn that lasted more than 1 day? | |||
| 0 | 18, 56% | 9, 50% | 9, 64% |
| 1 | 4, 13% | 3, 17% | 1, 7% |
| 2 | 2, 6% | 2, 11% | 0, 0% |
| 3 | 1, 3% | 1, 6% | 0, 0% |
| 4 | 1, 3% | 1, 6% | 0, 0% |
| 5 or more | 3, 9% | 0, 0% | 3, 21% |
| Does not apply | 3, 9% | 2, 11% | 1, 7% |
| How often do you wear sunscreen? | |||
| Never | 9, 28% | 6, 33% | 3, 21% |
| Rarely | 4, 12% | 2, 11% | 2, 14% |
| Sometimes | 6, 19% | 4, 22% | 2, 14% |
| Often | 6, 19% | 3, 17% | 3, 21% |
| Always | 7, 22% | 3, 17% | 4, 29% |
| How often do you wear a shirt with sleeves that cover your shoulders? | |||
| Never | 2, 6% | 1, 6% | 1, 7% |
| Rarely | 4, 12% | 3, 17% | 1, 7% |
| Sometimes | 8, 25% | 4, 22% | 4, 29% |
| Often | 6, 19% | 1, 6% | 5, 36% |
| Always | 12, 38% | 9, 50% | 3, 21% |
| How often do you wear a hat? | |||
| Never | 7, 22% | 4, 22% | 3, 21% |
| Rarely | 3, 9% | 3, 17% | 0, 0% |
| Sometimes | 4, 12% | 3, 17% | 1, 7% |
| Often | 9, 28% | 2, 11% | 7, 50% |
| Always | 9, 28% | 6, 33% | 3, 21% |
| How often do you stay in the shade or under an umbrella? | |||
| Never | 0, 0% | 0, 0% | 0, 0% |
| Rarely | 6, 19% | 4, 22% | 2, 14% |
| Sometimes | 7, 22% | 3, 17% | 4, 29% |
| Often | 13, 41% | 7, 39% | 6, 43% |
| Always | 6, 19% | 4, 22% | 2, 14% |
| How often do you wear sunglasses? | |||
| Never | 9, 28% | 5, 28% | 4, 29% |
| Rarely | 3, 9% | 1, 6% | 2, 14% |
| Sometimes | 5, 16% | 2, 11% | 3, 21% |
| Often | 6, 19% | 3, 17% | 3, 21% |
| Always | 9, 28% | 7, 39% | 2, 14% |
| How often do you spend time in the sun to get a tan? | |||
| Never | 28, 88% | 16, 89% | 12, 86% |
| Rarely | 2, 6% | 0, 0% | 2, 14% |
| Sometimes | 2, 6% | 2, 11% | 0, 0% |
| Often | 0, 0% | 0, 0% | 0, 0% |
| Always | 0, 0% | 0, 0% | 0, 0% |
| What is the color of your untanned skin? | |||
| Fair | 12, 38% | 7, 39% | 5, 36% |
| Olive | 2, 6% | 1, 6% | 1, 7% |
| Light brown | 12, 38% | 6, 33% | 6, 43% |
| Dark brown | 6, 19% | 4, 22% | 2, 14% |
| Have you ever had your skin checked for skin cancer from head to toe by a health professional? | |||
| Yes | 7, 22% | 4, 22% | 3, 21% |
| No | 25, 78% | 14, 78% | 11, 79% |
| In the last 12 months, have you or a partner examined your entire body, including your back, for skin cancer? | |||
| Yes | 2, 6% | 1, 6% | 1, 7% |
| No | 30, 94% | 17, 94% | 13, 93% |
Discussion
The findings from this study suggest that the skin cancer educational intervention was highly effective in improving participants’ knowledge and self-examination confidence related to skin cancer. Significant increases were observed in participants’ understanding of the ABCDE rule for melanoma and their confidence in performing self-skin examinations and recognizing melanoma from other types of skin cancers. These outcomes are consistent with previous studies demonstrating that in-person educational interventions in underserved communities can increase both knowledge of melanoma warning signs and self-efficacy in health-related behaviors.11–13 The substantial rise in participants’ understanding of melanoma signs, particularly the ABCDE rule, is especially noteworthy, as early detection is crucial for improving melanoma prognosis.23 This study is particularly unique as providing an in-person intervention in 2 languages, Spanish and Punjabi, which, to our knowledge, has not been done before. Prior in-person and online Spanish interventions were successful,11,12,24 with a systematic review highlighting the ongoing need to develop and disseminate more Spanish dermatology resources to educate patients about sun safety and skin cancer.25
When comparing participants’ skin cancer beliefs before and after the intervention, we found that most changes were not statistically significant. Although there were increases in the recognition of risk factors, these changes were less pronounced and not significant compared with increases observed in knowledge and self-examination confidence. This pattern mirrors the knowledge-attitude gap, a discrepancy between the individual’s knowledge and attitudes or behaviors towards addressing the health issue, in the HBM.26 This suggests that, while the intervention was effective in conveying factual information, it may not have sufficiently addressed underlying beliefs or attitudes toward skin cancer prevention and diagnosis held by these communities. For example, while the belief that doing a biopsy is important increased, the belief that it is okay to undergo a biopsy procedure to detect skin cancer unfortunately decreased. This suggests that despite an increase in knowledge about the importance of skin cancer diagnosis, participants may still harbor reservations about undergoing biopsy procedures, a finding that has been highlighted in the literature.27 This aligns with research indicating that attitudes toward medical procedures can be more resistant to change than knowledge alone.28 Future material may therefore place added emphasis on countering beliefs such as contagiousness and the role of skin biopsies in sun protection material among underserved Latine/Asian communities. Further studies could explore the underlying reasons for biopsy hesitancy in these populations. Addressing these concerns may contribute to improved screening and early detection outcomes in underserved racial and ethnic minoritized populations with histories of worse skin cancer outcomes.
The perceived barriers to dermatology care revealed different challenges across racial/ethnic groups. Cost emerged as a major barrier for Latine participants compared with Asian participants, suggesting that financial constraints disproportionately limit Latine individuals’ access to dermatological services, as has been found in prior studies.29 Additionally, a greater number of Latine participants reported lacking insurance, emphasizing the critical role of socioeconomic factors in hindering healthcare access. The difficulty in obtaining referrals, reported by Latine participants, points to systemic barriers that further restrict specialized care access and exacerbate existing disparities.30,31 Previous research has similarly identified low levels of knowledge and awareness, insurance coverage, and limited access as major obstacles to skin cancer prevention behaviors among Latine patients.2,9,10,32,33 This supports the importance of systemic changes to reduce healthcare disparities and improve dermatology access for underserved groups.
Our findings revealed differences in sun protection behaviors between Latine and Asian participants. Latine participants reported higher sun exposure and less frequent sunscreen use compared with their Asian counterparts. However, both groups faced similar challenges in adopting consistent sun protection practices, such as infrequent use of hats and a low rate of self-skin examinations. We found a much lower rate (6%) of self-skin examinations within our patient population, compared with previously reported rates of 17.6% among Hispanic adults residing in 5 southern and western states, and 16% among minority groups in a dermatology clinic of a New York public hospital.32,34 Our results align with prior research, which has shown that sun-protective behaviors like wearing long-sleeved shirts and hats are often underutilized in the Latine community.10 Both Latine and Asian groups expressed a strong preference for community-based solutions, such as free health education events and health fairs. These types of interventions have been shown to be effective in bridging gaps in healthcare access.35 Additionally, participants highlighted the need for better referral assistance and improved insurance coverage, signaling the need for structural reforms to enhance healthcare access for these populations. Overall, our findings support the value of community-based initiatives and underscore the need for increased awareness of sun protection and skin cancer prevention.
Limitations
The study had several limitations, including a small sample size that may not represent the broader Latine and Asian populations, limiting generalizability. Most participants were over 40, potentially limiting the applicability of results to younger demographics. Reliance on self-reported data introduces the potential of recall bias and social desirability biases. Additionally, half of the intervention pre- and post-survey utilized nonvalidated questions, which impact the reliability and generalizability of the findings. Furthermore, there was variability in the educational delivery methods across populations, which may have influenced engagement and comprehension. Lastly, the 45-minute intervention, including pre- and post-surveys, may have discouraged participation due to time constraints. Streamlining the sessions to include only the 10 to 15-minute skin cancer education portion may improve participation engagement in future encounters.
Conclusion
This pilot study demonstrates the feasibility of delivering culturally and linguistically tailored, community-based skin cancer education to underserved Spanish-speaking Latine and Punjabi-speaking Asian communities, using a combination of native-language materials and interpreted English materials. Our combined analysis showed that this intervention can significantly improve skin cancer awareness and self-examination confidence among these patient populations, particularly women, primarily aged ≥40 years, with incomes under $40,000 per year. Notably, participants showed substantial gains in knowledge of melanoma warning signs, particularly the ABCDE rule, and reported increased confidence in performing self-skin examinations. These outcomes highlight the importance of accessible, language-concordant health education delivered in trusted community settings. However, the intervention had a limited impact on shifting certain beliefs, such as hesitancy around biopsies, suggesting that deeper attitudes may require more sustained engagement. While knowledge improved, changing health-related behaviors and beliefs likely depends on continued community involvement and culturally sensitive messaging. The study also revealed ongoing structural barriers to dermatologic care, including cost, lack of insurance, and limited access to referrals, with Latine participants disproportionately affected. These findings underscore the need for both educational and systemic approaches to reducing disparities in skin cancer outcomes. Looking ahead, future efforts should continue leveraging trusted community settings, provide linguistically and culturally appropriate materials, and directly address cultural beliefs and misconceptions. Additionally, future research should focus on conducting larger studies that analyze these populations separately to better understand the effectiveness of language-specific educational approaches. Long-term follow-up research is also needed to assess whether improvements in knowledge translate into sustained behavioral change over time.
Conflicts of interest
None.
Funding
MES-A and AAO were supported by the CeraVe and the National Association of Free and Charitable Clinics, Sun Safety Grant Program.
Study approval
This study was reviewed and approved by the University of California, Davis Institutional Review Board and classified as exempt under protocol #2030488-2.
Author contributions
MES-A: Participated in research design, writing of the paper, and performance of the research, and data analysis. JCZJ: Participated in research design, writing of the paper, and performance of the research. YL: Participated in performance of the research, writing of the paper, contributed analytic tools, and participated in data analysis. EM: Participated in research design. AAO: Participated in research design, writing of the paper, and performance of the research.
Patient consent
Informed, written consent was received from all individuals who participated in the intervention, as presented in the manuscript.
Data availability
As per institutional policies and ethical considerations, data from this study cannot be shared and is not publicly available. However, aggregate data and summary findings may be available upon request to the corresponding author, subject to approval.
Supplementary data
Supplementary material associated with this article can be found at https://links.lww.com/IJWD/A79 and https://links.lww.com/IJWD/A80.
Acknowledgements
We thank Knights Landing One Health Center, Bhagat Puran Singh Health Initiative and Shifa Community Clinic undergraduate and medical students who helped implement the intervention.
Supplementary Material
Footnotes
Published online 11 December 2025
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
As per institutional policies and ethical considerations, data from this study cannot be shared and is not publicly available. However, aggregate data and summary findings may be available upon request to the corresponding author, subject to approval.