SUMMARY
Background/Purpose
Rates of melanoma are rising in Hispanics in the United States. Excessive sun exposure in childhood increases the risk of melanoma in adulthood, and little is known about the factors motivating sun protection behaviors among Hispanic youth.
Methods
Correlates of sun protection were examined among Hispanic children residing in Los Angeles, California (N = 1891). Associations between multiple constructs (psychosocial, familial, and cultural) and sun protection outcomes (use of sunscreen, protective clothing, and shade seeking/sun avoidance) were examined.
Results
Family variables were associated with more frequent sun protection among Hispanic children across outcomes, as were perceived peer norms, perceived self-efficacy, and fewer sun protection barriers. Skin cancer risk factors such as lighter skin and sunburn experience, and level of acculturation were not associated with greater sun protection.
Conclusion
Family sun protection habits are instrumental to Hispanic children’s sun safe behaviors, and interventions that engage the family may be most effective. Increasing risk communication to high-risk subgroups of Hispanic children (those with lighter, more sun reactive skin) is important when developing intervention strategies. However, there is overlap between Hispanic children’s sun protection correlates and those observed among non-Hispanic white children, suggesting that interventions to improve sun protection may generalize across cultural contexts.
Keywords: adolescent, children, hispanics, melanoma, skin cancer
Incidence of melanoma has been increasing globally over the past 30 years (1). While fair-skinned, non-Hispanic white (NHW) populations are at greatest risk of the disease, incidence of invasive melanoma is rising among Hispanics in the United States (2, 3) who experience more advanced disease at diagnosis and poorer outcomes than NHWs (4, 5). Substantial increases in the U.S. Hispanic population over the next decades will necessitate greater public health focus to curb rising melanoma rates and reduce disease disparities for this rapidly growing ethnic group (6).
Exposure to ultraviolet radiation (UVR) is the major environmental risk factor for both melanoma and nonmelanoma skin cancer (7, 8). Primary prevention, achieved by reduction of excessive UVR exposure through sun protection behaviors, is recommended to reduce risk of skin cancer. Because high UVR exposure and sunburn in childhood are associated with increased risk of melanoma in adulthood (7, 8), primary prevention interventions appropriately target children.
The majority of sun safety interventions targeted to children, however, have been conducted among white populations, both in the United States and globally, although recent interventions have targeted more diverse populations who are traditionally underserved by sun protection messaging (9). Despite an emerging recognition of the need to extend sun protection education to individuals with skin of color (10), data remain sparse regarding the factors motivating sun protection behaviors among non-white children in general, and in the U.S. context, among Hispanic youth.
Among white children, knowledge of sun protection concepts (11, 12), positive attitudes toward sun protection (13), perceived self-efficacy to use sun protection (11, 14), fewer barriers to use of sun protection (14), perceived peer norms (15–17), parental normative influence (18, 19, 20), and perceived risk (21, 22) have been found to be associated with greater sun protection, including both reduced UVR exposure (e.g. duration of time in the sun) and the practice of UVR protective behaviors (such as use of sunscreen and protective clothing) while exposed to sun. In the few studies examining sun protection among Hispanic youth, Hispanic teenagers have been found to practice less sun protection and possess less knowledge and awareness of skin cancer than their white peers (23, 24). In earlier research conducted by the authors of this study, sun protection behaviors of Hispanic children were found to be heterogeneous, although the majority practiced low and inconsistent sun protection, with use of sunscreen particularly infrequent (25). In addition, Hispanic parents of adolescents receive less physician sun protection counseling than NHW parents, and Hispanic mothers have significantly lower skin cancer and sun protection knowledge than NHW mothers (26). Despite emerging research, few studies have examined the psychosocial factors associated with sun protection among Hispanic children, and the lack of such information impedes development of interventions and health messaging targeted to this population.
To contribute to the emerging knowledge regarding sun protection behaviors among U.S. Hispanic, we examined correlates of sun protection behaviors among Hispanic elementary schoolchildren residing in Los Angeles County, a region with high levels of UVR as well as high rates of skin cancer (27). Our study aimed to explore the demographic, psychosocial, cultural, and familial factors related to sun protection in this group. Because studies have suggested that sun protection behaviors have distinct motivators and barriers (28), three sun protection outcomes were separately assessed: use of sunscreen, use of sun protective clothing (long sleeves and long pants), and shade seeking/peak hour sun avoidance. We focused on the self-reported sun protection behaviors associated with reduced risk of skin cancer rather than on measures of sun exposure such as duration of time outdoors, as children’s outdoor routines may not be under their control during school days.
Psychosocial correlates included knowledge of sun protection concepts, perceived risk for UVR-related consequences, perceived self-efficacy to use sun protection, perceived peer norms for sun protection, and perceived barriers to sun protection. Family correlates included perceived parental monitoring of child’s sun protection, availability of sunscreen in the home, and family communication about sun protection.
The primary cultural factor examined was acculturation. Acculturation, the process by which a cultural group is brought into contact with and adopts the beliefs and behaviors of another culture (29–31), has been associated with differential patterns of sun protection in Hispanics: Higher levels of acculturation to United States culture have been associated with greater use of sunscreen among Hispanic adults, but also with risk behaviors such as sunbathing and indoor tanning (32, 33). By contrast, lower U.S. acculturation among Hispanics has been associated with greater use of sun protective clothing as well as shade seeking (32, 33). However, as these studies have been conducted among Hispanic adults, the influence of acculturation on the sun protective practices of Hispanic children has not been well characterized.
Extrapolating from the literature on NHWs and findings regarding psychosocial predictors of sun protection among Hispanic adults, we anticipated that higher levels of psychosocial and familial variables would be positively associated with sun protection outcomes. We additionally hypothesized that higher levels of U.S. acculturation would be positively associated with sunscreen use, but negatively associated with the three other sun protection outcomes.
METHODS
Sample and measures
Baseline data from SunSmart, a skin cancer prevention intervention conducted from 2013 to 2015 during spring semesters to promote sun safe behaviors among fourth-grade and fifth-grade children from 11 public elementary schools in Los Angeles County, were used in this cross-sectional analysis. All students in 4th and 5th classes were eligible for the intervention activities, and no students refused to participate in the schools recruited. Only students who self-reported as Hispanic or Latino were retained for the present analysis (N = 2003), comprising 70% of the total sample (N = 2856). All questionnaires were self-reported and completed by children during regular classroom time. Because acculturation was measured at posttest of the intervention, analysis was restricted to students who completed pretest and posttest (N = 1891). No significant differences were found between students who completed pretest only and those who completed both pre- and posttest on all of the demographic and sun protection items.
Outcomes
Sunscreen use
Three items that assessed the use of sunscreen at school, outside of school, and general sunscreen frequency on a 4-point Likert-type scale (1 = Never; 4 = Often) were averaged into a single variable (Cronbach’s α = 0.72) (34).
Use of long sleeves and long pants
Four items that assessed the use of long sleeves and long pants at school and outside of school on a 4-point Likert-type scale (1 = Never; 4 = Often) were averaged into a single summary variable (Cronbach’s α = 0.74) (34).
Shade seeking/peak hour sun avoidance
Four items that assessed shade-seeking behaviors and peak hour sun avoidance (e.g. around lunchtime) at school and outside of school on a 4-point Likert-type scale (1 = Never; 4 = Often) were averaged into a single summary variable (Cronbach’s α = 0.54). These items were combined as they loaded together onto a single factor with a cutoff of 0.30 in factor analysis, the threshold due to generally low factor loadings in the sample.
Correlates
Correlates were selected for their theoretical relevance to child sun protection:
Psychosocial correlates
Knowledge of sun protection concepts:
Students’ knowledge of sun protection concepts (e.g. proper use of sunscreen, whether having a tan is healthy) was assessed with nine questions. Response options included ‘true’, ‘false’, and ‘I don’t know’. Correct responses were summed into a single summary variable. The response ‘I don’t know’ was coded as an incorrect response.
Barriers to use of sunscreen:
Barriers to sunscreen were assessed with four Likert-type items rated on a scale of 1–4 that asked children whether a particular statement was true for them (e.g. ‘Sunscreen is messy to use’) (35). Response options ranged from ‘untrue’ to ‘true’. The items were averaged into a single summary variable (Cronbach’s α = 0.52).
Barriers to use of protective clothing:
Barriers to protective clothing were assessed with three Likert-type items rated on a scale of 1–4 that asked children whether a particular statement was true for them (e.g. ‘It is too hot to wear long sleeves when it is sunny outside’). Response options ranged from ‘untrue’ to ‘true’ (35). The items were averaged into a single summary variable (Cronbach’s α = 0.61).
Perceived peer norms:
Perceived peer norms (e.g. students’ perceptions of the frequency of their peers’ use of sun protection) were assessed with four Likert-type items rated on a 1–4 scale (35). The items were averaged into a single summary variable (Cronbach’s α = 0.35).
Perceived risk:
Perceived risk of long-term consequences from sun overexposure was assessed with two Likert-type items rated on a 1–4 scale. The items were averaged into a single summary variable (Spearman’s ρ = 0.46).
Perceived self-efficacy:
Perceived self-efficacy to use sun protection was assessed with five Likert-type items rated on a 1–4 scale (1 = I’m sure I can’t; 4 = I’m sure I can) (35). The items were averaged into a summary variable (Cronbach’s α = 0.44).
Family and cultural correlates
Perceived parental monitoring of child sun protection:
Perceived parental monitoring of child sun protection was measured with three Likert-type items rated on a 1–4 scale (1 = never; 4 = often). Items assessed parent’s request that the child use sunscreen, protective clothing, and hats when outdoors on a sunny days. The items were averaged into a summary variable, with higher scores representing greater protective behaviors (Cronbach’s α = 0.48).
Availability of sunscreen in the home:
Availability of sunscreen in the home was measured with a single item with responses including ‘yes/maybe/no’. The item was dichotomized as 1 = ‘yes’ vs. 0 = ‘maybe/no’.
Family communication regarding sunscreen/protective clothing:
Family communication regarding sunscreen and protective clothing was measured with two single items asking if the participant had spoken to their family about sunscreen or protective clothing (long sleeves, long pants, hats) within the two weeks prior to the survey; possible responses were ‘yes/no’ (Spearman’s ρ = 0.47).
Acculturation:
Level of acculturation was measured with the Acculturation, Habits, and Interests Multicultural Scale for Adolescents (AHIMSA) scale (30). The AHIMSA scale is an 8-item scale measuring cultural preferences. The scale is multidimensional, with four response options representing four orientations of acculturation (assimilation, separation, integration, and marginalization): ‘the United States’, ‘the country my family is from’, ‘both’, and ‘neither’. For this study, the U.S. orientation scale (assimilation) was used. To score this scale, the number of times students responded to questions with ‘the United States’ was summed to generate a single score ranging from 0 to 8, with higher scores reflecting higher levels of assimilation to U.S. norms (Cronbach’s α = 0.78).
Additional covariates included gender, skin phototype, and ever experienced sunburned (yes/no). Skin type was assessed with a five-level item adapted the Fitzpatrick skin phototype scale (36); children were provided with a simple visual image that featured the range of skin tones corresponding to verbal descriptions to aid in skin type matching. Skin type ranged from 1 = very fair to 5 = very dark.
Statistical analysis
Descriptive statistics were used to characterize the sample. Cronbach’s alpha were calculated for items presumed to indicate a single underlying construct (37). Intraclass correlations (ICCs) were calculated to assess potential clustering of observations nested in schools. Because of evidence of clustering (ICCs > 0.02), random intercepts for school were included in mixed effects regression models to control for within-school clustering. Bivariate regressions were first conducted between each independent variable and outcome. Variables with a univariate association of P < 0.10 were entered into multilevel multivariable regression models. The level of significance was set to alpha <0.05, and all analyses were performed in Stata (Version 12.1, StataCorp, College Station, TX, USA). Approval for the study was obtained by the University of Southern California Institutional Review Board.
RESULTS
Sample characteristics
Table 1 shows baseline socio-demographic characteristics of the sample. The proportion of boys and girls and 4th and 5th grader participating were roughly equal. The majority of children (64%) reported a skin phototype of ‘light brown’ or Fitzpatrick type 3.
Table 1.
Demographic characteristics of sample at baseline (N = 1891)
| Mean age (SD) | 10.83 n | 0.69 % |
|---|---|---|
| Gender | ||
| Female | 997 | 52.72 |
| Male | 891 | 47.12 |
| Missing | 3 | 0.16 |
| Grade Level | ||
| 4th | 838 | 44.32 |
| 5th | 916 | 48.44 |
| Mixed 4th/5th | 137 | 7.24 |
| Skin phototype | ||
| Very fair | 14 | 0.74 |
| Fair | 348 | 18.40 |
| Light brown | 1214 | 64.20 |
| Dark brown | 292 | 15.44 |
| Very dark | 7 | 0.37 |
| Missing | 16 | 0.85 |
Sunscreen use
Table 2 shows the results of the bivariate and multivariable analyses examining correlates of sunscreen use. In bivariate analyses, all variables except for barriers to protective clothing were significantly associated with sunscreen use. In the multivariable model, female gender remained significantly associated with sunscreen use. Barriers to sunscreen use and perceived peer norms of sun protection were the only psychosocial constructs significantly associated with sunscreen use in the adjusted model. All family-related variables except family discussion about sun protective clothing remained significantly associated with sunscreen use in the multivariable model.
Table 2.
Univariate and multivariable models of sunscreen use among Hispanic children (N = 1891)
| Bivariate associations b (SE) | Multivariable model b (SE) | |
|---|---|---|
| Girls (reference: boys) | 0.24 (0.04)*** | 0.12 (0.03)*** |
| Lighter skin phototype | 0.06 (0.03)* | 0.02 (0.03) |
| Ever sunburned (reference: never) | 0.07 (0.04)* | 0.02 (0.03) |
| Knowledge of sun protection‡ | 0.06 (0.01)*** | 0.02 (0.01) |
| Barriers to sunscreen use‡ | 0.27 (0.02)*** | 0.17 (0.02)*** |
| Barriers to protective clothing‡ | 0.02 (0.02) | – |
| Perceived norms‡ | 0.32 (0.03)*** | 0.15 (0.03)*** |
| Perceived self-efficacy‡ | 0.15 (0.03)*** | −0.01 (0.03) |
| Perceived risk‡ | 0.07 (0.02)*** | 0.01 (0.02) |
| Higher U.S. acculturation | −0.02 (0.01)** | −0.01 (0.01) |
| Parental monitoring of child sun protection‡ | 0.50 (0.02)*** | 0.32 (0.02)*** |
| Sunscreen available at home (reference: maybe/not available) | 0.59 (0.05)*** | 0.30 (0.04)*** |
| Family sunscreen discussion (reference: did not discuss) | 0.79 (0.05)*** | 0.44 (0.05)*** |
| Family clothing discussion (reference: did not discuss) | 0.48 (0.05)*** | 0.05 (0.05) |
| Intercept | 0.50 (0.12)*** |
Boldface indicates statistical significance (†P < 0.10; *P < 0.05, **P < 0.01, ***P < 0.001).
Higher scores denote protective responses.
Protective clothing
Table 3 shows the results of the bivariate and multilevel multivariable analyses examining correlates of sun protective clothing. In bivariate analyses, all variables except lighter skin phototype, perceived risk, and higher acculturation were associated with use of protective clothing. In the multivariable model, female gender was associated with use of protective clothing, and ever having a sunburn was negatively associated with sun protective clothing use. Fewer barriers to sun protective clothing, perceived norms of sun protection among peers, and perceived self-efficacy to use sun protection remained significantly associated with use of protective clothing in the multivariable model. Perceived parental monitoring and family discussion regarding protective clothing also remained significant in the multivariable model.
Table 3.
Univariate and multivariable models of protective clothing use among Hispanic children (N = 1891)
| Bivariate associations b (SE) | Multivariable model b (SE) | |
|---|---|---|
| Girls (reference: boys) | 0.18 (0.03)*** | 0.19 (0.03)*** |
| Lighter skin phototype | 0.01 (0.03) | – |
| Ever sunburned (reference: never) | −0.09 (0.04)** | −0.11 (0.03)** |
| Knowledge of sun protection‡ | 0.03 (0.01)** | 0.01 (0.01) |
| Barriers to sunscreen use‡ | 0.09 (0.02)*** | 0.03 (0.02) |
| Barriers to protective clothing‡ | 0.11 (0.02)*** | 0.09 (0.02)*** |
| Perceived norms‡ | 0.18 (0.03)*** | 0.09 (0.03)*** |
| Perceived self-efficacy‡ | 0.21 (0.03)*** | 0.13 (0.03)*** |
| Perceived risk‡ | 0.02 (0.02) | – |
| Higher U.S. acculturation | −0.01 (0.01) | – |
| Parental monitoring of child sun protection‡ | 0.25 (0.02)*** | 0.14 (0.03)*** |
| Sunscreen available at home (reference: maybe/not available) | 0.09 (0.05)* | −0.02 (0.05) |
| Family sunscreen discussion (reference: did not discuss) | 0.23 (0.05)*** | 0.01 (0.05) |
| Family clothing discussion (reference: did not discuss) | 0.37 (0.04)*** | 0.20 (0.05)*** |
| Intercept | 1.50 (0.13)*** |
Boldface indicates statistical significance (†P < 0.10; *P < 0.05, **P < 0.01, ***P < 0.001).
Higher scores denote protective responses.
Shade seeking/peak hour sun avoidance
Table 4 shows the results of the bivariate and multilevel multivariable analyses examining correlates of shade seeking and peak hour sun avoidance. In bivariate analyses, all variables except barriers to protective clothing were associated with shade seeking and sun avoidance; lighter skin phototype was marginally associated (P < 0.10). Higher U.S. acculturation was significantly negatively associated with shade seeking and sun avoidance. In the multivariable model, female gender remained positively associated with shade seeking and sun avoidance. Perceived norms, perceived self-efficacy, and perceived risk also remained associated in the multivariable model. Perceived parental monitoring and family discussion regarding sun protection clothing were the only significant family variables in the multivariable model.
Table 4.
Univariate and multivariable models of shade seeking/peak hour sun avoidance among Hispanic children (N = 1891)
| Bivariate associations b (SE) | Multivariable model b (SE) | |
|---|---|---|
| Girls (reference: boys) | 0.34 (0.03)*** | 0.30 (0.03)*** |
| Lighter skin phototype | 0.04 (0.02)† | 0.03 (0.02) |
| Ever sunburned (reference: never) | 0.03 (0.03) | – |
| Knowledge of sun protection‡ | 0.02 (0.01)* | −0.01 (0.01) |
| Barriers to sunscreen use‡ | 0.08 (0.02)*** | 0.02 (0.02) |
| Barriers to protective clothing‡ | −0.01 (0.02) | – |
| Perceived norms‡ | 0.26 (0.02)*** | 0.19 (0.02)*** |
| Perceived self-efficacy‡ | 0.15 (0.03)*** | 0.08 (0.02)** |
| Perceived risk‡ | 0.08 (0.01)*** | 0.04 (0.01)** |
| Higher U.S. acculturation | −0.02 (0.01)** | −0.01 (0.01) |
| Parental monitoring of child sun protection‡ | 0.26 (0.02)*** | 0.15 (0.02)*** |
| Sunscreen available at home (reference: maybe/not available) | 0.13 (0.04)** | −0.03 (0.04) |
| Family sunscreen discussion (reference: did not discuss) | 0.28 (0.04)*** | 0.07 (0.04) |
| Family clothing discussion (reference: did not discuss) | 0.28 (0.04)*** | 0.08 (0.04)* |
| Intercept | 1.11 (0.13)*** |
Boldface indicates statistical significance (†P < 0.10; *P < 0.05, **P < 0.01, ***P < 0.001).
Higher scores denote protective responses.
DISCUSSION
The present study examined correlates of sun protection behaviors in Hispanic children residing in Los Angeles County, a high UVR region with high rates of skin cancer. Family-related factors, including perceived sun protection monitoring of child by parent and family communication regarding sun protection, were consistently and strongly associated with greater sun protection across each outcome. While studies conducted among NHWs have demonstrated the importance of parental variables on children’s sun protection (19, 20), family influence may be particularly relevant for Hispanic children due to familism, a cultural value that describes the priority placed on the family as a unit within Hispanic culture (38).
In addition, sunscreen availability in the home was associated with greater frequency of child use. Promoting sunscreen to Hispanic parents may boost its application for children, a finding of importance as sunscreen use has been found to be low among Hispanics despite high sunburn rates (39). While at least one study has found limited accessibility to sunscreen in Hispanic neighborhoods in Chicago (40), a study conducted in Los Angeles found no significant differences in retail availability of sunscreen in Hispanic vs. non-Hispanic neighborhoods (41). Thus, culturally tailored strategies that focus on the entire family and that build self-efficacy to locate and effectively use sunscreen may improve sun protection among Hispanic children potentially more so than intervention approaches that target the child only.
Significant overlap was found between factors motivating improved sun protection among Hispanic children and correlates previously observed among NHW children. Female gender, for example, was significantly associated with greater sun protection across all sun protection outcomes, which has been observed among NHW children (42, 43). Psychosocial constructs such as fewer sun protection barriers, greater perceived peer norms, and greater perceived self-efficacy were significantly associated with greater sun protection in the present study, similar to prior studies among NHW samples (11, 14, 20). While more research is needed to examine the extent to which Hispanic children may benefit from a culturally tailored approach, these findings provide preliminary evidence that a broad approach to sun safety education might apply cross-culturally in school-based interventions delivered to ethnically diverse children.
In contrast to prior studies among NHW samples where lighter skin phototype and sunburn experience have been found to be predictors of greater sun protection (44, 45), neither attribute was strongly associated with greater protective behaviors save for a marginal association between lighter skin and shade seeking. Despite perceptions that Hispanics have darker pigmented skin conferring greater skin cancer protection, Hispanics have significant heterogeneity of skin phototype (46). It is thus concerning that greater skin cancer risk factors did not motivate greater sun protection behaviors in the present study, suggesting a lack of awareness about sun safety among Hispanic children who may be at greatest risk. Subsequently, it may be important to target high-risk subgroups among Hispanic children (e.g. lighter and more sun reactive skin) when developing sun protection risk communication and intervention strategies.
Although an important variable in several other studies regarding sun protection among Hispanics (32, 33), acculturation was not significantly associated with any of the sun protection outcomes in the present study in multivariate models. As prior studies that have found differences in sun protection by level of acculturation have been conducted exclusively among Hispanic adults, the effects of acculturation might differ for children. Moreover, as acculturation is a dynamic and often family-centered process, its influence on child sun protection may be more effectively examined within a familial and generational context and assessed over time.
Limitations and strengths of the research
The use of cross-sectional data limited causal inference, as only associations among variables can be asserted. Self-reported measures of sun protection, though the only feasible method for capturing data in the present study, may not accurately represent children’s actual usage. However, studies have suggested that self-reported sun protection behaviors provide sufficiently valid reports compared to objective data (47). In addition, well-validated measures for sun protection among Hispanic children are not available and some of the outcomes had relatively low Cronbach’s alphas, indicating potential unreliability in responses.
In this study, ‘Hispanic’ is considered a uniform category; however, Hispanic ethnic origin is heterogeneous, with varying subgroups, and recent studies have indicated that sun protection may differ by Hispanic subpopulation (33). Due to demographic data for Los Angeles, the assumption is that the majority of students who self-reported as ‘Hispanic/Latino’ in the sample were Mexican-American based on available census data (~75% of Hispanics in LA County are Mexican-American) (48). However, further research is needed to examine potential differences in children’s sun protection among Hispanic subgroups.
Despite these limitations, strengths of the study include a large sample of Hispanic children representative of the school-based population in a high UVR region, a unique sample that is understudied population in sun protection. In addition, the utilization of previously validated core questionnaire items and inclusion of several domains and constructs is a unique strength of the study.
In conclusion, while the importance of family factors has been found in prior sun protection studies in NHW children, the social structure of Hispanic culture which prioritizes family ties may necessitate a family-centered approach to sun protection for this population. However, our study also indicates significant overlap in key correlates of sun protection between Hispanic children and NHWs. With the rapid growth of the Hispanic population in the United States, broad approaches to sun protection delivered to multiethnic audiences will undoubtedly be required, and several psychosocial constructs may generalize across cultural contexts to be scalable into sun safety health promotion for diverse youth audiences. Future research should continue to investigate the extent to which culturally tailored strategies are needed to improve child sun protection among this at-risk population.
ACKNOWLEDGEMENTS
This work was supported by the National Cancer Institute and the National Institute of Child Health and Human Development under grant R01CA158407. The authors are indebted to all of the schools and children participating in the SunSmart study.
Footnotes
Conflicts of interest: The authors of this study declare no conflict of interest.
Financial disclosures: No financial disclosures were reported by the authors of this study.
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