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ABSTRACT: The incidence of skin cancer is increasing throughout the world. If detected early, skin cancer is readily treated and cured. It is important to recognize and assess lesions so that treatment can be initiated. It is also important for individuals to be aware of and practice measures to prevent the development of skin cancer. The purpose of this study was to examine the knowledge and beliefs regarding skin cancer and preventative measures. A questionnaire based on the Health Belief Model was developed to measure these perceptions. Overall reliability of the questionnaire was acceptable (Chronbach's [alpha] = .87). Four components (susceptibility, motivation, awareness, and seriousness) were measured and compared. Three of the factors had similar means, which ranged from 3.6 to 3.8. The fourth factor (susceptibility) had a much lower mean of 2.9, which suggests that, although participants were aware of the seriousness of skin cancer, they do not necessarily believe they are at risk. Responses to other questions point to an awareness of the seriousness of melanoma and the effects of UVA and UVB rays. Other statements indicate a need for further teaching regarding use of sunscreen, recognition of changes in moles, and use of tanning beds.
The incidence of skin cancer is increasing in the United States and throughout the world. The Skin Cancer Foundation (2009) estimates that 20% of Americans will develop skin cancer, whereas the World Health Organization (2009, 2010) estimates that 33% of cancer cases worldwide will be some form of skin cancer. Common types of skin cancer include basal cell, squamous cell, and melanoma. Melanoma is considered the most serious type of cancer because of its systemic involvement.
If detected in early stages, skin cancer is readily treated and cured. It is, therefore, extremely important to recognize and assess lesions so that treatment can be initiated. It is equally important for individuals to be aware of and practice measures to prevent the development of skin cancer. The Skin Cancer Foundation, the American Academy of Dermatology, and the American Cancer Society recommend monthly self-assessment as a routine part of early detection and provide printed and online materials that demonstrate effective exams. These organizations further recommend a regular skin assessment by a dermatology healthcare provider.
Many practices that are protective against the development of skin cancer have been identified. These practices are noted in Table 1. Healthcare practitioners are challenged not only with teaching individuals about these protective measures but also with enhancing individual's belief in the importance of practicing these measures. Central to instilling a commitment to preventive health practices is understanding why individuals value or do not value specific health behaviors.
The authors were interested in developing a screening tool to assess individuals' attitudes toward health behaviors regarding skin cancer prevention. It is believed that such an instrument would be helpful for health practitioners when developing effective educational efforts. This study primarily sought to establish the psychometric properties of the screening tool developed by the authors in Phase 1 of this project. The Health Belief Model (HBM) was used as the conceptual framework in instrument development. Themes that emerged from the Phase 1 study were consistent with the constructs from the HBM. A more in-depth explanation of the HBM and its extensive use in healthcare research is presented in the report of the Phase 1 study (Shelestak & Lindow, 2009).
In addition to establishing the psychometric properties, the instrument was used to address the following questions:
1. Are individuals aware of the risk factors associated with the development of skin cancer?
2. Are individuals knowledgeable about health behaviors identified to decrease or prevent skin cancer?
3. Are individuals informed about the role of skin self-assessment in the early detection of skin cancer?
It is hoped that by developing an understanding of a person's attitudes and beliefs, it will be possible to institute teaching and other measures, which will encourage individuals to "buy into" and value the preventive health practices related to skin cancer.
The review of literature addresses attitudes and beliefs toward skin cancer and preventive practices. This review also notes factors and practices that contribute to the increased prevalence of skin cancer.
Few studies, which specifically explore an individual's beliefs and attitudes toward skin cancer and skin cancer prevention practices, were found. In a qualitative study to determine an individual's awareness of skin self-assessment as an early detection tool for skin cancer, Shelestak and Lindow (2009) found that most respondents believed that skin cancer was a serious condition but was not viewed as a concern unless it had personally affected them. Most respondents did not view skin assessment as a valued health behavior. None of the respondents mentioned skin self-assessment as a preventive measure against skin cancer. In a study of young adult beliefs about ultraviolet (UV) protection behaviors, Linton and Jones (2009) found that the UV protection beliefs within the sample population were generally favorable and that the participants had adequate knowledge of the risks of UV exposure.
The harmful effects of UV rays have been well documented (Baron, Kirkland, & Domingo, 2008; Environmental Protection Agency, 2010). UV radiation may be natural (from the sun) or artificial (such as from tanning booths). The American Cancer Society, Skin Cancer Foundation, American Academy of Dermatology (2008a), and Center for Disease Control recommend the use of protection measures to minimize harmful UV effects.
Frequent use of tanning booths exposes users to significantly more UV radiation than sun exposure (http://www.skincancer.org/skin-cancer-facts). The National Council on Skin Cancer Prevention (2011) states that exposure to UV radiation, whether from sun or tanning booths, is harmful and notes that international cancer experts have designated tanning booths as a top cancer risk. It has also been reported that "tanorexia," an obsession and/or addiction to tanning, is occurring more frequently (Kravitz, 2010).
Meyer et al. (2007) reported that a survey of persons who had been treated for skin cancer revealed that these persons were aware of the cancer risks of sunlight. Most respondents took sun protective measures such as wearing protective clothing, suggesting that after the diagnosis of skin cancer persons are more likely to follow protective behaviors.
The American Cancer Society (2009) has long identified fair skin as a significant risk factor for skin cancer development. Researchers are now focusing on skin cancer awareness in people of color. Bradford (2009) notes that, whereas skin cancer is less common in people of color, it is often associated with increased morbidity and mortality. Bradford cites delay in diagnosing the lesions and socioeconomic factors resulting in inadequate healthcare as factors in these poorer outcomes. In a study to determine sun protection behaviors among African Americans, Pinchon, Corral, Landrine, Mayer, and Norman (2010) found that only 31% of respondents participated in at least one sun protection behavior, with the use of sunscreen being the least prevalent behavior. The authors recommend interventions tailored specifically to this population. Torrens and Swan (2009) cited an increasing rate of melanoma in minority ethnicities, especially Asians and Hispanics, and in persons in lower socioeconomic groups. The author notes that more educational materials specifically tailored to these populations need to be formulated to aid in educational efforts within these groups.
In a study examining the obstacles to skin cancer examinations and prevention counseling among primary care physicians, Geller et al. (2004) found that 59% of physicians examine the skin of persons with high risk for developing melanoma and 68% of physicians provide prevention counseling for this high-risk population. The study further found that physicians using multiple information sources for cancer education were more likely to screen and examine patients regarding skin cancer detection and prevention. These physicians preferred easy-to-use materials such as posters, brochures, and newsletters.
This was a descriptive study designed to measure a person's perceptions of the following: susceptibility for developing skin cancer, seriousness of skin cancer, and practices to prevent or decrease risk factors that would interfere with prevention practices. Permission to conduct this study was obtained from the institutional review board of Kent State University and the board of directors of the Dermatology Nurses' Association.
Convenience sampling was used to obtain a sample of people between the ages of 18 and 65 years. Participants were recruited from college campuses, senior centers, workplace, and church groups. Requirements for participation include the ability to read, speak, and understand English and have no previous history of skin cancer or chronic dermatologic disorders such as psoriasis and eczema.
The instrument was developed from the results of a qualitative study that explored health beliefs and practices regarding skin cancer awareness and prevention (Shelestak & Lindow, 2009). The instrument contained 34 statements designed to measure beliefs based on constructs of the HBM. The responses to the statements were based on a 5-point Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree). The instrument was reviewed by experts in dermatology and instrument development for clarity and content. The reliability of the Health Belief section was acceptable (r = .87). Exploratory factory analysis with Varimax rotation revealed a factor structure with four components: susceptibility, motivation, awareness, and seriousness. Factor analysis is a statistical procedure used to examine the relationship and variability among observed variables or items and is often used to establish instrument validity in measuring the desired latent trait (such as beliefs or perceptions). Examination of the relationship allows for a reduction in the number of items by consolidating them into a fewer number of factors designed to describe the underlying structure of the desired traits. Exploratory factor analysis is used when there is no prior theory; the factor loadings of each item are used to construct the factor structure of the data; Varimax rotation is the most common rotation used to develop the factor structure. (See Table 2 for items and reliability of each factor).
Demographic questions included gender, race, age, zip code, level of education, and work status. Supplemental questions regarding routine exposure to sun, use of tanning booths, and use of sunscreen and protective clothing were also included. Finally, any history of skin cancer, frequency of skin self-assessment, and skin assessment by the primary care provider were also included.
Data collectors were instructed on the use of instrument and data collection methods. The data collectors made the initial contact with the participants either personally or via email and requested volunteers. Eligible participants were given a written explanation of the study and an opportunity to ask questions. Once written consent was obtained, subjects were asked to complete the questionnaire. The time required to complete the questionnaire ranged from 20 to 30 minutes. Participants were given the opportunity to complete the questionnaire in private and were free to withdraw at any time At no time was their name or other identifying information requested, which ensured confidentiality and anonymity.
Descriptive statistics include means, standard deviations, and frequencies. Factors are reported as calculated factor means with standard deviations. All statistical analyses were conducted using Statistical Program for Social Sciences (Version 16.0 for Windows).
The sample consisted of 205 adults with an average age of 37.3 years (SD = 14.2 years) and who were predominantly Caucasian (91%). They resided in northern and midwestern states including Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, and Pennsylvania. There were also participants from Ontario, Canada. As Table 3 shows, the participants were primarily women and college educated.
Mean scores were calculated for each of the four factors: susceptibility, motivation, awareness and seriousness. Each of the scores is based on the original Likert scale of 1 (Strongly Disagree) to 5 (Strongly Agree). Three of the factors had similar means, which ranged from 3.6 to 3.8. These include motivation, awareness, and seriousness. The fourth factor, susceptibility, had a much lower mean, 2.9. The mean scores and standard deviations for each factor can be found in Table 4.
Individual items not included in the factors were also examined. Figure 1 illustrates the frequency in which sunscreen is applied based on the amount of time spent in the sun. As the length of time increases, the likelihood of sunscreen being applied also increases. Most of the participants (71%) do not use tanning booths. Those that do, a majority (79%) use them prior to vacation or a special occasion. Most participants believed that melanoma is the most dangerous form of skin cancer but were less confident about the significance of moles changing in appearance (Figures 2 and 3). A large percentage (77%) agreed or strongly agreed that UVA and UVB rays can cause sunburn (Figure 4). When asked whether they had been taught skin self-assessment, the sample was split evenly, 50% responded yes and 50% indicated no (Figure 5). When asked who taught them, the results primarily indicated the physician (Figure 6).
The results of this study add to the body of knowledge regarding skin cancer awareness and preventive practices. It is hoped the following results provide evidence for targeting teaching efforts and educational materials. The results suggest that current emphasis on skin cancer prevention appears effective. However, low susceptibility scores support previous findings that, unless directly affected, participants tend to minimize their risk for skin cancer, regardless of their beliefs and practices.
The results also validated public knowledge about several key factors. As noted in Figure 4, most participants recognize that both UVA and UVB rays can be harmful to the skin. Participants also readily recognized melanoma as the most dangerous form of skin cancer (Figure 2). The figure notes that participants value the use of sunscreen for prolonged periods of sun exposure, greater than 2 hours. However, persons do not appear to recognize the need for sunscreen for shorter periods of sun exposure. This might suggest that the everyday use of sunscreen is not deemed essential. Teaching may need to emphasize the use of sunscreen before leaving home for any outdoor activities.
The study also noted some erroneous perceptions. Figure 3 shows that most participants were unaware that moles can often change in appearance. It is not known from this study whether participants are assessing moles on a regular basis or if they would seek medical attention if changes were noted.
When asked about the use of tanning booths, 71% indicated that they did not use them. For those who did use tanning booths, an overwhelming majority responded that they used tanning booths primarily prior to a vacation or special occasion. This finding suggests that many still view a baseline tan as a protective measure against further sun exposure.
It was also interesting to note (Figure 5) that only half of the participants had been taught skin self-assessment. Of those who had been taught, most were taught by the physician. Only a few were taught by a nurse practitioner or office nurse. This might suggest that nurses need to be more aware of and involved in teaching efforts.
There were several limitations that prevent broad generalizations of the findings. The sample was a convenience sample that consisted of participants who were predominantly White, women, college educated from the midwestern and northern states or provinces. Many of the participants had a connection to healthcare (nursing students and hospital or clinic employees), which may have led to them being more knowledgeable about skin cancer in general.
It is recommended that this study be replicated with more heterogeneous samples, especially different age and racial groups. Because the participants of this study were predominantly from northern areas of the country, it would be interesting to include sampling from southern and southwestern areas, where yearlong bright sun is the norm. Sampling, which includes a cross section of varying educational backgrounds, would also be important to future studies.
It is hoped that the results of this study will encourage further research and educational efforts in skin cancer awareness and preventive practices. The initial findings of this study suggest that the public has a growing awareness of skin cancer prevention methods but may not necessarily believe that they as individuals are at risk. Continuing educational efforts are essential in counteracting this perception.
American Academy of Dermatology. (2008a). Skin examinations. Retrieved October 5, 2009, from http://www.skincarephysicians.com/skincancernet/skin_examinations.html[Context Link]
American Academy of Dermatology. (2008b). Skin cancer prevention. Retrieved October 5, 2009, from http://www.skincarephysicians.com/skincancernet/prevention.html
American Cancer Society. (2009). Skin Cancer Prevention and Early Detection. Retrieved October 5, 2009, from http://www.cancer.org/docroot/PED/content/ped_7_1_Skin_Cancer_Detection_What_You[Context Link]
Baron, E., Kirkland, E., & Domingo, D. (2008). Advances in photoprotection. Dermatology Nursing, 20(4), 265-273. [Context Link]
Bradford, P. (2009). Skin cancer in skin of color. Dermatology Nursing, 21(4), 170-177. [Context Link]
Environmental Protection Agency. (2010). Health effects of UV overexposure. Retrieved April 30, 2010, from http://www.epa.gov/sunwise/UVandhealth.html[Context Link]
Geller, A., O'Riordan, D., Oliveria, S., Valvo, S., Teich, M., & Halpern, A. (2004). Overcoming obstacles to skin cancer examinations and prevention counseling for high-risk patients: results of a national survey of primary care physicians. Journal of the American Board of Family Medicine, 17(6), 416-423 [Context Link]
Kravitz, M. (2010). Indoor tanning, skin cancer and tanorexia. Journal of Dermatology Nursing Association, 2(3), 110-115. [Context Link]
Linton, C. & Jones, K. (2009). Ultraviolet protection behaviors and beliefs among young adult dermatology patients. Journal of the Dermatology Nurses' Association, 1(3), 182-189. [Context Link]
Meyer, N., Pruvost-Balland, C., Bourdon-Lanoy, E., Maubec, E. & Avri, M-F. (2007). Awareness, knowledge and attitudes towards sun protection among skin cancer treated patients in France. Journal of the European Academy of Dermatology & Venereology, 21(4), 520-525. [Context Link]
National Council on Skin Cancer Prevention. (2011). Indoor tanning beds. Retrieved January 24, 2011, from http://www.skincancerprevention.org/skin-cancer/tanning-beds[Context Link]
Pinchon, L. C., Corral, I., Landrine, H., Mayer, J. A., & Norman, G. J. (2010). Sun protection behaviors among African Americans. American Journal of Preventive Medicine, 38(3), 288-295. [Context Link]
Shelestak, D., & Lindow, K. (2009). Awareness of skin self-assessment as an early detection tool for skin cancer. Journal of the Dermatology Nurses' Association, 1(2), 119-123. [Context Link]
Skin Cancer Foundation. (2009). Skin cancer facts. Retrieved October 10, 2009, from http://www.skincancer.org/Skin-Cancer-Facts/[Context Link]
Torrens, R., & Swan, B. (2009). Promoting prevention and early recognition of malignant melanoma. Dermatology Nursing, 21(3), 115-122. [Context Link]
World Health Organization. (2010). Health effects of UV radiation. Retrieved from http://www.who.int/UV/health/en[Context Link]
World Health Organization. (2009). How common is skin cancer? Retrieved from http://www.who.int/uv/faq/skincancer/en/index1.html[Context Link]
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