Sun protective practices are a critical tool in preventing skin disorders such as melanoma, non-melanoma skin cancer, and actinic keratosis.1 The scientific literature suggests that racial/ethnic minority populations are less likely to engage in sun protective practices (i.e., use of sunscreen, wearing long sleeves, avoiding direct sunlight).2,3 Primary language spoken by an individual has been shown to impact health behaviors, healthcare access, and health outcomes.4 Despite the impact of language on general health behaviors, little is known of how primary language impacts sun protective practices. The current study uses data from the Behavioral Risk Factor Surveillance System (BRFSS) to evaluate the association between primary language spoken and sun protective practices.
The 2019 BRFSS collected survey information on health conditions, health behaviors, and use of preventative services from a nationally representative sample of Americans. In 2019, Wyoming and Maryland (n=18,873) included a module assessing sun protective practices. Respondents were asked, “When you go outside on a warm sunny day for more than one hour, how often do you protect yourself from the sun?”. The response options were organized into two categories, such that responses “Always” and “Most of the time” were categorized as “strong practices”, and response options “Sometimes”, “Rarely”, and “Never” were categorized as “risky practices”. The main study predictor was respondent primary language that was assessed by the survey language format used. Multivariate and univariate logistic regression models were fitted to predict sun protective practices. Unadjusted odds ratios (uOR) and adjusted odds ratios (aOR) were calculated with 95% CIs. All analyses were weighted and analyzed with survey sample weights to account for the complex sampling design.
Approximately 58.2% (n=10,987) of participants engaged in strong sun protective practices and 4.0% identify Spanish as their primary survey language (Table 1). The percentage of Spanish-speakers who engage in risky sun protective practices was significantly greater than Spanish-speakers who reported strong practices (5.3% vs. 2.7%;p<.001). Spanish-speakers in Maryland and Wyoming are almost two times more likely to engage in risky sun protective practices than English-speakers (uOR=1.99;[1.43–2.78]) (Table 2). This association held even after controlling for sociodemographic characteristics such as age, gender, race/ethnicity, income, and last doctor routine check-up, such that Spanish-speakers remain more likely than English-speakers to engage in risky sun protective practices (aOR=1.78;[1.12–2.84]).
Table 1.
Sun protective practices stratified by sociodemographic characteristics among 2019 Behavioral Risk Factor Surveillance System (BRFSS) participants in Wyoming and Maryland
| Characteristics | Total Sample n (%)† | Weighted Population | Strong Sun Protective Practices† n (%) | Risky Sun Protective Practices† n (%) | p-value |
|---|---|---|---|---|---|
| Row Total | 18,873 (100.0) | 4,275,245 | 10,987 (58.2) | 7,886 (41.8) | <.001 |
| Survey Language | |||||
| English | 18,624 (96.0) | 4,104,710 | 10,883 (97.3) | 7,741 (94.7) | |
| Spanish | 249 (4.0) | 170,534 | 104 (2.7) | 145 (5.3) | |
| Age Group | <.001 | ||||
| 18–29 years old | 1,260 (18.4) | 773,074 | 541 (14.5) | 719 (22.5) | |
| 30–39 years old | 1,508 (16.7) | 704,818 | 789 (15.6) | 719 (17.9) | |
| 40–49 years old | 1,954 (15.1) | 633,673 | 1,115 (14.7) | 839 (15.4) | |
| 50–59 years old | 3,390 (18.7) | 785,350 | 2,004 (20.2) | 1,386 (17.0) | |
| 60 and older | 10,416 (31.2) | 1,312,109 | 6,323 (34.9) | 4,093 (27.1) | |
| Gender | <.001 | ||||
| Male | 8,264 (48.2) | 2,058,905 | 4,362 (41.7) | 3,902 (55.2) | |
| Female | 10,609 (51.8) | 2,216,340 | 6,625 (58.3) | 3,984 (44.8) | |
| Race/Ethnicity | <.001 | ||||
| White, Non-Hispanic | 14,355 (56.7) | 2,422,221 | 8,865 (64.2) | 5,490 (48.5) | |
| Black, Non-Hispanic | 2,895 (26.4) | 1,129,669 | 1,316 (20.7) | 1,579 (32.6) | |
| Asian, Non-Hispanic | 293 (5.7) | 241,854 | 143 (5.5) | 150 (5.9) | |
| American Indian/Alaskan Native, Non-Hispanic | 121 (0.5) | 22,259 | 59 (0.6) | 62 (0.5) | |
| Hispanic/Latinx | 718 (8.8) | 377,466 | 351 (7.3) | 367 (10.4) | |
| Other | 491 (1.9) | 81,774 | 253 (1.8) | 238 (2.0) | |
| Income | <.001 | ||||
| Less than $15,000 | 922 (5.9) | 210,270 | 488 (4.8) | 434 (7.0) | |
| $15,000 to less than $25,000 | 1,963 (11.8) | 422,239 | 1,057 (10.8) | 906 (12.9) | |
| $25,000 to less than $35,000 | 1,306 (6.6) | 234,618 | 736 (6.0) | 570 (7.1) | |
| $35,000 to less than $50,000 | 1,926 (11.2) | 399,321 | 1,067 (10.0) | 859 (12.4) | |
| $50,000 to less than $75,000 | 2,528 (14.3) | 512,732 | 1,502 (14.4) | 1,026 (14.2) | |
| $75,000 or more | 7,097 (50.3) | 1,801,745 | 4,337 (53.9) | 2,760 (46.6) | |
| Last Doctor Routine Check-Up | <.001 | ||||
| Within the past year | 15521 (79.1) | 3,345,105 | 9,250 (81.8) | 6,271 (76.2) | |
| Within the past 2 years | 1620 (10.8) | 457,131 | 882 (9.9) | 738 (11.8) | |
| Within the past 5 years | 795 (5.9) | 249,776 | 411 (4.9) | 384 (7.0) | |
| 5 or more years ago | 690 (3.7) | 157,170 | 326 (3.1) | 364 (4.4) | |
| Never | 79 (0.4) | 18,348 | 34 (0.3) | 45 (0.6) | |
Column percentage (differences in subtotal due to item nonresponse or missing values in sample.)
Table 2.
Unadjusted and adjusted odds of reporting risky sun protective behaviors among 2019 Behavioral Risk Factor Surveillance System (BRFSS) participants in Wyoming and Maryland
| Characteristics | Unadjusted Odds Ratio | Adjusted Odds Ratio |
|---|---|---|
| Survey Language (ref = English) | ||
| Spanish | 1.99 [1.43–2.78] | 1.78 [1.12–2.84] |
| Age Group (ref = 60 and older) | ||
| 18–29 years old | 2.01 [1.71–2.35] | 1.75 [1.45–2.12] |
| 30–39 years old | 1.48 [1.27–1.71] | 1.32 [1.12–1.56] |
| 40–49 years old | 1.35 [1.17–1.54] | 1.25 [1.07–1.46] |
| 50–59 years old | 1.08 [0.97–1.21] | 1.12 [0.99–1.27] |
| Gender (ref = Female) | ||
| Male | 1.72 [1.57–1.89] | 1.80 [1.62–2.00] |
| Race/Ethnicity (ref = White, Non-Hispanic) | ||
| Black, Non-Hispanic | 2.09 [1.86–2.34] | 2.12 [1.86–2.41] |
| Asian, Non-Hispanic | 1.42 [1.07–1.90] | 1.58 [1.15–2.18] |
| American Indian/Alaskan Native, Non-Hispanic | 1.15 [0.68–1.94] | 1.05 [0.57–1.95] |
| Hispanic/Latinx | 1.89 [1.53–2.32] | 1.32 [1.00–1.74] |
| Other | 1.50 [1.17–1.91] | 1.52 [1.15–2.00] |
| Income (ref = $75,000 or more) | ||
| Less than $15,000 | 1.69 [1.35–2.13] | 1.38 [1.09–1.76] |
| $15,000 to less than $25,000 | 1.39 [1.17–1.64] | 1.25 [1.04–1.50] |
| $25,000 to less than $35,000 | 1.38 [1.13–1.69] | 1.29 [1.05–1.60] |
| $35,000 to less than $50,000 | 1.44 [1.22–1.70] | 1.41 [1.19–1.68] |
| $50,000 to less than $75,000 | 1.15 [0.99–1.33] | 1.13 [0.97–1.32] |
| Last Doctor Routine Check-Up (ref = Within the Past Year) | ||
| Within the past 2 years | 1.29 [1.10–1.52] | 1.26 [1.04–1.51] |
| Within the past 5 years | 1.52 [1.22–1.88] | 1.34 [1.06–1.69] |
| 5 or more years ago | 1.55 [1.22–1.96] | 1.36 [1.04–1.79] |
| Never | 2.02 [1.01–4.02] | 1.03 [0.42–2.48] |
Given Hispanics/Latinx had lower odds of engaging in risky sun protective practices than Spanish-speakers while controlling for confounders, it is possible that risk is more closely correlated to language spoken rather than racial/ethnic background. This may suggest that limited English proficiency plays a role in risky sun protective practices among Spanish-speakers. Poor health literacy has been associated with decreased access and utilization of healthcare services, decreased preventative practices, and poorer health outcomes, including increased hospitalization rates.5 Although further research is needed to understand the relationship between individuals who primarily speak Spanish and risky behaviors, healthcare providers should be attentive to primary language use and its relationship to sun protective practices. The findings of this pilot study may have implications for skin cancer risk in racial/ethnic minority groups.
Acknowledgements:
Funding/Support:
Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number P30CA240139.
Role of the Funder/Sponsor:
There was no funder/sponsor role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
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