The primary objective of this study was to assess whether racial/ethnic groups differed in knowledge of skin health and self-perceived risk of skin cancer in a low SES community. With respect to participants’ knowledge of sun protection, relative to Whites, Latinos held a stronger belief that sunscreen is important for health, understood that sun rays are the most important cause of skin cancer, and were more likely to say it is not worth getting sunburned to be tan. Nonetheless, they rarely used sunscreen and were less confident in their skin cancer knowledge. This outlines a significant discrepancy between sun protection beliefs and knowledge/behaviors: an important area for future research. Further study is needed to assess if the lack of sunscreen use is related to cost or is beyond knowing the best preventative practices.
In terms of skin cancer risk, Whites did not have the highest self-perceived risk. Latinos tended to be more concerned that they would get skin cancer than Whites. Surprisingly, we also found that more Asian and Eastern Indian/Pakistani respondents perceived a lower than average risk for skin cancers compared to White respondents. This suggests that previous research concluding that African American populations have a lower perceived risk of getting skin cancer may not be generalized to other racial/ethnic groups.,, Studying each race/ethnicity separately is likely best practice, as other factors such as belief systems, SES, knowledge, and cultural values may come into play. Additionally, evidence for Whites having greater knowledge of skin care and sun protection and increased self-perceived risk of skin cancer was not clear in our study but it may reflect that our population was entirely restricted to those of a lower SES and therefore harbor different beliefs than the White population at large.
The data generally supported our hypotheses that ethnicities differ in their knowledge of sun protection and self-perceived risk of skin cancer. Trends from other racial/ethnic comparisons,, supported our hypotheses. These trends are unsurprising, for the majority of the public education efforts have focused on lighter-skinned races and ethnicities., Even if sunscreen awareness is high, deficits in skin care and sun protection knowledge exist. A survey of individuals attending health seminars in New Jersey observed similar results. Most participants understood the benefits of sunscreen use, but their knowledge of sun protection was incomplete, leading to low compliance. Another interventional study achieved increased knowledge and perceived risk of skin cancer but lacked behavior change in adolescents. This discrepancy between attitudes, knowledge and behavior may also be prevalent in our study population.
There may be barriers preventing this community from applying their knowledge to behavior. For example, cost may be a barrier to purchasing sunscreen or other sun protective measures., However, only 7.5% of our participants reported price as a major factor in purchasing sunscreen and there may be other factors limiting sunscreen use requiring further study. This could inform future public health initiatives, as one may initially think supplying communities directly with sunscreen or funds to purchase sun protection items may improve adherence; however, our data and others point to other factors at play.
Low sunburn frequency may also discourage sunscreen use. For instance, children with darker pigmentation may receive less parental encouragement to use sun protection compared to their fairer counterparts., Our sample had low skin sensitivity to UV radiation (91.5% type III or higher), so sunscreen use may be rare. ,, More simply, sunscreen is often seen as unnecessary without sunburns and with low perceived risk of skin cancer (optimistic bias)., Nevertheless, our findings indicate a need to better understand why there is a discrepancy between knowledge and behavior in this population.
Most participants reported that they did not go to a dermatologist or know how to find one, especially in Asian and Latino groups. Considering the changing demographics of the US and the quickly growing minority populations, issues with minority access to dermatology among those with lower SES must be addressed, as individuals with darker skin are less likely to be aware of skin cancer and sun exposure risks and early detection strategies.,,,, These disparities may explain decreased survival rates observed among minorities due to more advanced stages at presentation. Increasing awareness through culturally appropriate health education to promote prevention, screening, early diagnosis, and treatment is key. ,,,
To improve validity, data collection occurred during the spring to account for seasonal biases, which is known to influence self-reported sun protection behaviors. Survey administration aimed for cultural competence with translators who addressed literacy and clarification needs. Aligning research staff to sample population is known to improve participation rates. Subsequently, we achieved a response rate of 86.4%.
There were several limitations. While diverse, the overall sample size was limited, especially in the African/African American and Native American populations. This was attributed to the closure of the clinic targeting Sacramento’s African American community during survey administration. A larger sample size could improve the significance of observed trends. Additionally, this cross-sectional data cannot establish temporality between skin care beliefs and behaviors. This self-reported data is also susceptible to social desirability bias., Finally, only a minority of participants were White and were from a lower SES; qualifying for free primary care. We utilized the White population as our reference group, but it is possible that our sample has a different view on health risks compared to other surveys utilizing White populations with higher SES. Nevertheless, our surveys were analyzed as a comparison, and our comparisons are valid when restricted to a lower SES population. Therefore, this study may not be generalizable to the greater US population, especially those in areas with less sunlight or without free clinics or among those of higher SES.
Lastly, the assumption that race correlates with self-reported skin type may be invalid for some participants. This is because race correlates poorly with self-reported skin phototype and objective measures., The Fitzpatrick scale likely also has limited applications for skin of color, as it was originally developed for light-skinned populations.,
The data presented identified several key aspects of skin care knowledge and behavior with potential targets of future improvement. Markedly, the Latino population reported the lowest confidence in skin cancer knowledge, had the greatest concern for skin cancer risk, yet had low sunscreen use. Therefore, the Latino community may be a motivated population for change. A similar study examining sun protection behaviors among patients utilizing a free clinic came to the same conclusion. Another comparable study identified lower income Spanish-speaking patients as an ideal population for promoting skin protection awareness.