Abstract
Background:
Skin cancer is the most prevalent cancer in the United States. Training medical students about the importance of sun-protective behaviors is critical to reducing skin cancer rates. However, minimal research has explored osteopathic medical students’ knowledge and behaviors with regard to the sun's effect on skin health.
Objective:
To assess first-year osteopathic medical students’ knowledge about skin cancer and UV radiation, attitudes toward tanning, and sun-protective behaviors to establish baseline values.
Methods:
Using a descriptive, cross-sectional study design, the authors evaluated students’ knowledge, attitudes, and behaviors through a quiz.
Results:
A total of 121 first-year osteopathic medical students completed the quiz. The mean (SD) score was 74.6% (11.5%). Two-thirds of participants (n=82) correctly identified basal cell carcinoma as the most common skin cancer, and the majority identified the ABCDs (asymmetry, border irregularity, color, and diameter) of melanoma detection (96 [79.3%], 106 [87.6%], 108 [89.3%], and 94 [77.7%], respectively). Most participants were aware that cloud cover and swimming underwater do not provide UV ray protection (121 [100%] and 109 [90.1%], respectively), a fact that is often misconceived. Forty participants (33.1%) usually or always used some form of sun protection when outdoors. Forty-seven participants (38.8%) believed that a tan makes one look healthy, and 43 participants (35.6%) sunbathed with the intention of tanning.
Conclusion:
Physicians are uniquely positioned to counsel patients regarding sun-protective behaviors. Thus, a medical school curriculum that includes education about the sun's effect on health is needed for the prevention and early recognition of skin cancer in future patients.
Skin cancer is the most common cancer in the United States,
1 with a lifetime risk of 1 in 2.
2 The most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma.
3 Malignant melanoma is less common, with a lifetime risk of 1 in 49.
4 However, melanoma is the most deadly form, accounting for the vast majority of skin cancer–related deaths.
3-5 In the United States, average estimated costs of skin cancer amount to $8.1 billion annually, and total costs continue to increase dramatically compared with other cancers.
6 Research has shown that the average annual cost of skin cancer from 2002-2006 to 2007-2011 increased 126.2%, and the average annual cost of all other cancers increased by 25.1%.
6 Thus, intervention strategies aimed at reducing the health and economic burden of skin cancer are needed.
One such strategy is to improve patient education that promotes sun-protective behaviors.
7 Primary sun-protective behaviors include decreasing exposure to natural and artificial UV light, applying sunscreen with adequate sun protection factor (SPF), wearing hats that provide coverage to the entire head, and wearing tightly woven clothing that covers the arms, torso, and legs.
7 Secondary sun-protective behaviors include regular self-skin examinations and total body skin examinations by a physician.
4 Estimates suggest that avoiding exposure to natural and artificial UV light could prevent more than 5 million cases of skin cancer each year,
8 and daily use of a sunscreen with SPF 15 or higher could reduce the risk of developing squamous cell carcinoma by 40%
9 and melanoma by 50%.
10
Training medical students, especially those who will go on to primary care, about the importance of sun-protective behaviors is critical to reduce skin cancer rates. Primary care physicians have the most frequent opportunities to perform skin cancer examinations and educate patients on sun-protective behaviors,
11 and more than half of osteopathic physicians practice in primary care fields.
12 Research suggests that medical students require more health promotion education regarding the effects of the sun on human health
13-16; however, to our knowledge, no known research has explored osteopathic medical students’ knowledge, attitudes, and behaviors with regard to the sun. Thus, the purpose of this study was to assess first-year osteopathic medical students’ knowledge about skin cancer and UV radiation, attitudes toward tanning, and sun-protective behaviors.
The University Office of Research Compliance approved the protocol and all recruitment procedures and materials.
An electronic, anonymous survey was distributed to all first-year osteopathic medical students enrolled at the 3 campuses of Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) (Athens, Dublin, and Cleveland) during the first semester of the 2016-2017 academic year. As part of a larger study assessing health-related knowledge, beliefs, and behaviors, the research team recruited first-year medical students to explore their knowledge of the sun's effects on health before attending formal lectures on the topic. The email invitation was sent by the study investigator (E.A.B.) via a school-maintained class listserv. The survey opened November 28, 2016, and a reminder email was sent December 13, 2016. Participation in the study was voluntary. Participants received a $15.00 gift card as compensation for participating. To prevent participants’ responses from being linked to their name or email address, a separate link was provided through which they could provide their personal information to receive the gift card.
Participants completed a short demographic form as well as the Sun Awareness Quiz,
17 a 24-item multiple choice quiz originally developed to assess sun-related knowledge, attitudes, and behaviors of first-year medical students in Canada. In the current study, the research team adapted the quiz to include 23 of the 24 items; the item regarding the lifetime risk for Canadians developing skin cancer was removed. The survey also included items about participants’ skin type (eg, always burn and never tan, usually burn and tan with difficulty, sometimes mildly burn and tan with ease, never burn and always tan
18) and personal and family history of skin cancer.
19 This survey was not validated.
Participants completed the survey via the online questionnaire service Qualtrics. To consent, participants clicked a radio button indicating “Yes, I consent to participate in this study. I may withdraw my participation at any time.” To decline, participants clicked a radio button indicating “I decline to participate.” To avoid coercion, the online screen to the survey and the informed consent document both specified the voluntary nature of participation. The informed consent document explicitly informed potential participants that their responses had no bearing on academic performance. No researchers were present when potential participants decided to participate or decline and, thus, participants may have felt less pressure than in a face-to-face consent process. Participants with questions about the study were directed to email or telephone the research investigators. Completion of the survey took approximately 15 minutes. Qualtrics permitted the research team to download participants’ survey responses into a spreadsheet without including identifying information (eg, name, email address) to ensure anonymity at the level of data.
Basic sociodemographic characteristics of participants were assessed using descriptive statistics. Frequencies of individual item responses were also calculated. Scores were calculated by summing the number of correct responses divided by total items multiplied by 100 to yield a percentage score. Independent sample t tests were conducted to examine differences in quiz scores by gender. In addition, χ2 tests were conducted to examine differences in individual quiz items and gender. χ2 tests were also conducted to examine differences in behaviors and attitudes related to sun exposure by gender, skin type, history of skin cancer, family history of skin cancer, and attitude toward a tanned appearance. Statistical significance was defined as P<.05. All analyses were conducted with SPSS statistical software version 23.0 (IBM).
Of the 243 first-year osteopathic medical students enrolled at the 3 campuses, 121 participants had complete data and were included in the analyses for a response rate of 49.8% (Athens, 72 [50.3%]; Cleveland, 21 [40.4%]; Dublin, 28 [58.3%]). The mean (SD) age of the participants was 24.1 (2.0) years, 64 (52.9%) were women, 87 (71.9%) were white, and 45 (37.2%) grew up in a town with a population of 2500 to 50,000 people. The majority of participants (101 [83.5%]) had a primary care physician and, of these, 36 (35.6%) had an osteopathic primary care physician. Regarding skin type, 5 participants (4.1%) reported always burning and never tanning, and 25 (20.7%) reported never burning and always tanning. One participant (0.8%) reported a history of skin cancer, and 26 (21.5%) reported a family history of skin cancer. Additional demographic data are presented in
Table 1.
The mean (SD) score on the Sun Awareness Quiz was 74.6% (11.5%) (range, 39.0%-94.0%;
Table 2). No significant differences were observed between female and male participants in mean quiz score (75.8% vs 73.3%, respectively;
t=1.19;
P=.237). Female participants more frequently correctly answered true to item 12, which stated that a suntan offers adequate protection to prevent sunburn, than male participants (100% vs 89.5%, respectively;
χ2=7.088;
P=.008). No other gender differences were found. Participants were knowledgeable about some of the facts about sun-protective behaviors that are often misconceived, including the fact that thin cloud cover does not provide protection from UV rays (item 3, 121 [100%]), tanning salons are not a safe alternative to sun-tanning outdoors (item 4, 119 [98.3%]), and swimming under water does not provide protection from UV rays (item 9, 109 [90.1%]). Participants knew less about the protection offered by dark clothing (item 7, 39 [32.3%]) and dry clothing (item 8, 41 [33.9%]). Fifty-one participants (42.1%) knew that the ozone layer did not filter the majority of UVA rays, and 30 participants (24.8%) were aware that sunscreen did not give immediate protection as soon as it contacts the skin. Participants were generally knowledgeable about skin cancer, with two-thirds of participants (82 [67.8%]) correctly identifying basal cell carcinoma as the most common skin cancer and the majority of participants correctly identifying the ABCDs (asymmetry, border, color, and diameter) of melanoma detection (96 [79.3%], 106 [87.6%], 108 [89.3%], and 94 [77.7%], respectively).
One-third of participants (40 [33.1%]) usually or always used some form of sun protection when outdoors; this behavior differed between female and male participants, with more female participants using more sun protection than male participants (28 [43.8%] vs 12 [21.1%];
P=.022;
Table 3). When asked when they used sunscreen in the past year, more than half of participants used SPF 30 or higher on their body and extremities (66 [54.5%]), as well as on their face (76 [62.8%]). Thirteen participants (10.7%) routinely wore a baseball cap; this finding did not differ by sex (
P=.118). The majority of participants (107 [88.4%]) wore shorts and t-shirts as clothing in the summer and did not give any thought to the time of day when they scheduled outdoor activities (91 [75.2%]). One hundred nine participants (90.1%) did not use tanning salons, and 121 (100%) believed that tanning beds were not safe. However, 47 participants (38.8%) believed that a tan made one look healthy, and 43 participants (35.6%) sunbathed at least occasionally with the intention of tanning; this behavior was more common among female participants (
P<.001). As expected, participants with a skin type that “always burns and never tans” more frequently wore SPF 30 or higher on their body and extremities (χ
2=17.598,
P=.007) and their face (χ
2=14.565,
P=.024) and were less likely to sunbathe with the intention of getting a tan (χ
2=24.144;
P=.019). One participant had a personal history of skin cancer; thus, statistical comparisons were not possible. Participants who reported a family history of skin cancer more frequently wore SPF 30 or higher on their body and extremities (χ
2=7.057,
P=.029) and face (χ
2=7.795,
P=.020). The belief that a tan makes one look healthy was not associated with any of the participants’ behaviors related to sun exposure.
The majority of participants were knowledgeable about skin cancer and correctly identified several common misconceptions about sun-protective behaviors. However, only one-third of participants used some form of sun protection when outdoors, thought a tan looked healthy, and sunbathed with the intention of tanning. Thus, many of the participants would benefit from additional instruction about the dangers of UV radiation and proper use of sun protection to prevent skin damage.
A 1-week Sun Awareness curriculum at the University of Western Ontario improved the knowledge, attitudes, and behaviors of first-year medical students.
15,17 In general, most students retained or improved their knowledge of skin cancer, the safety of tanning, and sun-protective behaviors.
15,17 Half of the number of sunburns were reported at a 1-year follow-up compared with the previous year, demonstrating a marked improvement in sun-protective behaviors.
17 After the intervention, the intention to use sun protection increased from 34.8% to 76.9% (
P<.001) among male students and 50.0% to 74.2% (
P=.20) among female students, but these increases did not achieve significance.
15,17
Interventions to reduce sun exposure have focused largely on community campaigns and individual stratagem.
20 Appearance-based approaches (eg, UV photography), as well as personalized risk feedback, media campaigns, and multicomponent interventions, have predominantly been used to assess and influence sun-protective behaviors among university students.
21-23 A 2013 systematic review by Williams et al
21 (N=6344, majority aged 18-21 years) evaluated 21 studies designed to increase sun protection intentions and behaviors. All reviewed articles included appearance-based interventions, specifically UV photography showing the degree of existing skin damage caused by sun exposure or photoaging imaging showing a face at age 72 years with and without sun exposure. Interventions using UV photography had a significant effect on reducing indoor tanning behavior, increasing sun protective behavior, and increasing perceived susceptibility to and severity of photoaging and the benefits of sun protection.
21 Mahler et al
22,23 also suggested incorporating UV photography and associated educational materials as part of student health center services to increase sun-protective behaviors.
Taking into consideration the 38.8% of participants in the current study who believed that a tan made them look healthy, the research team at OU-HCOM plans to devise an appearance-based health promotion campaign designed to reduce sun exposure and increase sun-protective behaviors among medical students across the 3 campuses. The research team will build off the success of previously reported interventions that incorporated UV photography and photoaging to influence sun-protective behaviors. The campaign will occur in May 2019. Pre- and postassessments of knowledge, attitudes, and behaviors will be measured at the beginning of the academic year (August 2018) and subsequent academic year (August 2019) to measure changes in attitudes toward tanning, as well as attitudes toward exposure to the sun and sun-protective behaviors.
Childhood is an ideal time to intervene for the purpose of promoting sun-protective behaviors.
24 However, primary care physicians—in particular, osteopathic physicians, given that 56% practice in primary care fields
12—are well positioned to reinforce this information considering the frequency of patient visits. Furthermore, education on preventive behaviors and early detection of skin cancer are most likely to occur in the primary care setting, where physicians are likely to discuss other health-promoting behaviors, including nutrition and physical activity.
25,26 As with other health-promoting behaviors, however, variations in physician knowledge and beliefs regarding sun-protective behaviors influence how they communicate this information to their patients.
27 Therefore, osteopathic physicians must possess a proper understanding of the osteopathic principle of self-regulation and health maintenance to accurately relay information regarding sun-protective behaviors. Prevention stems from self-regulation and health maintenance, and, through education, physicians can promote sun-protective behaviors, such as applying sunscreen with an SPF of 15 or higher, wearing sun-protective clothing, seeking shade, performing self-examinations, and undergoing skin examinations by a primary care physician or dermatologist.
28
A substantial number of osteopathic physicians who practice in primary care work in rural, medically underserved areas.
29,30 It is well established that cancer screening rates and timely follow-up on abnormal test results are lower in rural areas.
31 Treatment protocols may also vary based on proximity to a hospital. The Appalachian region, in particular, has a consistently higher cancer incidence and mortality rate compared with the rest of the United States.
32 Although melanoma rates are similar between the Appalachian region and non-Appalachian regions, there is a higher prevalence of late-stage diagnoses in the Appalachian region.
32,33 A number of factors may explain these disparities, and some may be easily addressed in primary care. Low-income patients tend to engage in fewer sun-protective behaviors and may perceive risk less accurately than higher-income patients.
34 Poor access to health care may reduce specialist access and affect treatment plans (eg, reduced use of radiation treatment).
31 Sun-protective behaviors also tend to be low among rural residents, among whom there is also an inverse relationship between educational achievement and use of sunscreen with SPF 15 or greater.
35 And rural residents may receive little encouragement to perform skin self-assessments and may not be taught how to do so.
35
The mission of OU-HCOM is to graduate physicians committed to practicing primary care in the state of Ohio. The participants in the current study will likely serve as primary care physicians in low-income and rural areas; thus, it is especially important to ensure that they are fully equipped to provide adequate counseling regarding sun-protective behaviors. Treating the whole person requires attention to every detail of a person's history, review of systems, and physical examination findings. An osteopathic tenet recognizes that a person is a combination of body, mind, and spirit.
36 Physicians must consider more than their patients’ physical health when counseling patients about sun-protective behaviors or diagnosing skin cancer in a patient. Research shows that 30% of patients with melanoma
37,38 and 19% of patients with nonmelanoma skin cancer
39 report high levels of psychological distress. Thus, physicians must be aware of signs and symptoms of distress and treat patients accordingly.
The homogeneity of the study sample from 1 osteopathic medical school with 3 campuses in a Midwestern state, the cross-sectional study design, and participants’ self-reported data were limitations. Furthermore, only first-year medical students were included in the study; thus, we are unable to determine whether the misconceptions and inadequate sun-protection behaviors shown here persist throughout medical training. The purpose of the study was to establish a baseline understanding of students’ knowledge, attitudes, and behaviors about skin health before they received dermatology education. Another limitation was a response rate of 49.8%. In addition, the students who volunteered to participate may have been more willing or motivated to answer items about skin health compared with students who did not participate. For these reasons, the self-reported findings are susceptible to selection bias. Future research with a larger, more heterogeneous sample should include medical students from all 4 years and from multiple osteopathic medical schools in different geographic regions. Behavioral interventions designed specifically for osteopathic medical students are needed to address knowledge about skin cancer and UV radiation, attitudes toward tanning, and sun-protective behaviors. In doing so, future research should also follow students over time to assess changes in knowledge, attitudes, and behaviors.
Although participants were knowledgeable about skin cancer and sun-protective behaviors, the majority of them did not use sun protection when outdoors. Furthermore, a substantial number of participants believed that a tan made them look healthy. A sun awareness curriculum for osteopathic medical schools is needed to reduce sun exposure and teach proper sun-protective behaviors. In addition, incorporating appearance-based interventions into the curriculum, such as UV photography and photoaging, may help dispel the belief that a tan is associated with good health. Medical students will ultimately be in the position to influence hundreds—if not thousands—of patients’ sun-protective behaviors. Physicians can positively influence their patients’ health behaviors by counseling them about prevention
40 and by modeling healthy behaviors.
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.