Awareness, knowledge and behavior of medical personnel regarding skin cancer, sun-related hazards and sunscreen utilization at King Abdulaziz University Hospital, Jeddah

INTRODUCTION

Worldwide, skin cancer is a major public health burden as it’s incidence has been increasing over the past decades.¹ It is a common malignancy in Saudi Arabia as it accounts for 3.2% of all newly diagnosed cancers in 2010.² In the United States, more than 3.5 million cases are recorded per year and over the past three decades, skin cancer affected more people than all other cancers combined.^3,4 The incidence of skin cancer varies significantly among different racial and ethnic groups. Specifically, Caucasians have very high rates of skin cancer and Asians have low rates.⁵

The three most prevalent types of skin cancer are basal cell carcinoma, squamous cell carcinoma and melanoma.⁶ Across these types, basal cell carcinoma and squamous cell carcinoma account for most cases of skin cancer.⁷ Exposure to ultraviolet (UV) radiation is the most common modifiable risk factor to reduce the risk of the major types of skin cancer.^8,9 Therefore, practicing protective measures such as application of sunscreens, avoiding direct sun exposure during peak hours, and wearing sunglasses can aid in decreasing the risk of developing skin malignancies.^8-10

A cross-sectional investigation in Saudi Arabia showed that only 55% of people were aware of the association between sun exposure and skin cancer. The pattern and prevalence of skin cancer among Saudi Arabians is currently undefined.¹¹ Healthcare workers play an integral role in educating patients about the sun exposure hazards and the preventive measures that can reduce the risk of developing skin cancer. Given the lack of knowledge of the link between sun exposure and skin cancer in Saudi Arabia, the purpose of the present study is to assess health care practitioner’s knowledge about the hazards of UV radiation and to assess their own practice of sunscreen utilization.

METHODS

Population and setting

This cross-sectional study was conducted between July-2017 and December-2017 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. All advanced year medical students involved in clinical care, medical interns, residents and nurses working at King Abdulaziz University Hospital were invited to participate. All participants were informed about the demands of the study and those who agreed to participate were enrolled. Verbal consent was obtained. Participants who refused to participate or failed to complete the questionnaires were excluded.

Data collection

Both electronic and paper copies of the questionnaires were used for data collection. The electronic forms were used to obtain data from medical students and interns. The paper copies were distributed to nurses and residents.

Measures/instruments

The questionnaire was developed based on previous research in the area, combined with questions that were developed to address the unique circumstances of our sample. The final survey was a 45-question, multiple-choice and Likert scale, self-report instrument. Three major domains were assessed. First, there were eight questions that assessed socio-demographic characteristics like gender, age, marital status, nationality, job title, the specialty or department of the healthcare provider and history of sunburn. Second, there were ten questions about behaviors for protection from the sun. Third, there were eighteen questions about knowledge of skin cancers, sun-related hazards, and sunscreen application and other methods of protecting against the sun. The survey took approximately 10 minutes for participants to complete.

Knowledge level score

The general knowledge of sun-related hazards, including skin cancer and methods of protection against the sun, was examined across 18 questions. The knowledge level score (KLS) was obtained by awarding one point for each of the correct responses (0 points were given for “Wrong/I do not know” answers). KLS was calculated by adding all the scores together. KLS ranged from zero (minimum knowledge) to 18 (maximum knowledge).

Behavior score

To calculate the Behavior Score for protection against the sun, the answer “always” was assigned three points, “sometimes” was assigned two points, “rarely” was assigned one point and “never” was assigned zero points. To obtain the Behavior Score, points were summed. The minimum score was zero and the maximum score was 24. Behavior score was calculated for questions with Likert scale only, those that had different answers were not included in the score.

Awareness score

Overall awareness score was obtained by summing KLS and behavior score. Awareness score ranged from minimum 0 to maximum 42.

Statistical analysis

Descriptive statistics were used to describe demographic characteristics, KLS and Behavior Scores for all respondents. A Chi-squared test was conducted to examine the link between the KLS, the Behavior Score, and demographic characteristics. Differences in mean awareness scores for different socioeconomic groups were obtained by using an independent samples t-test and one-way ANOVA test. Simple linear regression and multivariate linear regression analysis were conducted to examine the associations between the Awareness Score and the covariates. Again, one-way ANOVA test was conducted to compare the Behavior Score with demographic variables. The analysis was performed with the confidence interval set at 95%. The software program used was the Statistical Package for Social Science (SPSS), version 20.

RESULTS

The study assessed the awareness, knowledge, and behavior of healthcare professionals’ sun protection practices. All participants worked at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. A total of 414 participants completed the questionnaire and were included in the final analysis. Of the 414 respondents, 58.5% were female and 41.5% were male. The mean age was 25.31 years (SD=6.39). Most participants were single (78%). The majority (81.9%) of the sample participants were Saudi Arabia citizens. Medical students in their clinical training years comprised half of the study sample, but interns (14.3%), nurses (14.7%), and medical residents (15.0%) were also represented. The respondents worked in various specialties, as shown in Table 1. The socio-demographic information for the study sample is also presented in Table 1.

Knowledge level

The percentage of correct answers on the knowledge about skin cancer and risk-related behaviors are illustrated in Table 2. Those with correct answers ranged from 17% to 82%.

Behavior

In terms of behavior of respondents towards sun exposure and UV light avoidance, 40% of the sample indicated that they always seek shade or avoid sun during peak hours of the day. Furthermore, 40% of the sample rarely practice outdoors during the day, 31.4% sometimes do, and 20.0% never spend time outside during the day. The use of tanning beds is an uncommon behavior among healthcare professionals and more than half of the sample (63.8%) never used tanning beds. Less than half of the participants (44.4%) never use sunscreen of SPF 30 or above, 41.1% indicated they never use sunscreen while sunbathing on holidays, and only 12.3% use sunscreen during their daily activities. The majority of those that use sunscreen (82.1%), do not reapply it throughout the day. A small percentage of participants (4.6%) indicated that their skin gets checked by a physician for potential cancerous lesions, whereas the majority (79.5%) has never had a skin check for cancer. The majority of the sample (61%) reported that they do no perform self-examination of their skin for potential cancerous lesions. In exploring the reasons for not using sunscreen, 35.7% responded that they do not use it because of tiredness/laziness or lack of time, and 27.1% felt no need for sunscreen. Most of the respondents (84.8%) denied sunburns before the age of 15, and 15.2% have suffered it recently.

Knowledge and behavior

Please refer to Table 4 for means and standard deviations for the awareness score, knowledge level scores and the behavior level scores. Median scores and ranges are also provided in Table 4. There were no statistically significant differences in mean awareness score for the various demographic variables i.e., gender, age, marital status and nationality. One-way-ANOVA revealed statistically significant difference among the different job titles in terms of awareness score (p<0.001). See Table 5 for more information. Simple linear regression revealed that the awareness about skin cancer could not be predicted by any demographic variables (all p>0.05). The results of multiple regression analysis showed that marital status was a significant predictor of awareness score (β=0.111, p=0.025). The overall model fit was R²=0.012. Hence, awareness score increased by 0.11 points for the married respondents in comparison with single respondents (CI=0.79). Please see Table 6 for more information.

The practice of reapplying sunscreen was similar across the different demographic groups. When asked about what is keeping them from using sunscreen, male and female respondents responded differently (p<0.001). There were also differences based on marital status (p=0.042), Saudi and non-Saudi status (p=0.015), job titles (p= 0.030) and the specialty (p=0.010). There were no demographic differences in responses to the question of whether they had experienced a sun burn before age 15 as in Table 7. There were gender differences in the report of having had recent sunburns (p=0.015). See Table 8 for more information.

DISCUSSION

Throughout the previous three decades it has been reported that skin malignancy incidence has increased more than all other types of cancer combined together.⁴ As stated by the latest record by the Saudi Cancer Registry (SCR) in 2010, it has been showed that nonmelanoma skin cancer is considered to be the 9th most prevalent cancer for both males and females in Saudi Arabia, which was approximately 3.2% of all recently reported cancer cases (52.7% males & 47.3% females with a female to male ratio of 100:111).¹¹ Not much is known about the awareness of medical personnel regarding exposure to the sun and its associated risks. As to our knowledge, currently there are no previous studies done on this population. Due to the limited knowledge in this field, this study aimed to assess skin cancer awareness, sunscreen and UV exposure among medical students and healthcare providers in Jeddah, Saudi Arabia. (n=414).

Females represented more than half of the respondents (58.5%) which was similar to two previous studies.^12,13 According to our findings, it has been shown that medical students and health care providers at this tertiary hospital have narrow knowledge in regard to skin cancer which was collateral to the conclusion of previous studies conducted among the general population in Saudi Arabia, Medical students in France, Nursing students and by the American Academy of Dermatology in 1995.^12,14-16 In contrast, skin cancer knowledge and perceived severity to sun exposure were shown to be high in a study in Italy among school students.¹⁷ A research paper established among non-dermatologist physicians concluded that participants had adequate knowledge on skin cancer hazard factors and sun protection measures and knew that UV light can lead to skin cancers.¹⁸

Similar to the findings of Alamri et al, more than 70% of the respondents were aware of the most harmful time of the day regarding sun exposure. Also, only 32.1% were aware that severe sunburn occurring during childhood duplicates an individual’s risk of acquiring melanoma subsequently in life, which was similar to the findings of the same study with the percentage of 31.4%, compared to other studies done in the UK, USA and France; awareness levels were 82%, 58% & 97.4% respectively.^12,14,16,19

There was no statistically significant difference in mean awareness score for the various categories of demographic variables e.g. gender, age, marital status and nationality. In contrast, age was found to have statistically significant associations with awareness about skin cancer in other studies.^12,20-22 One interesting finding was the marital status (β=0.111, p=0.025) which was a significant predictor of awareness score, also coinciding with the findings of Alamri et al.¹²

The mean behavior score was 8.57±5.00 with a possible maximum score of 24 which reveals a low level of sun protection behavior in agreement to the results of other studies.^15,23 The current work found that half of the participants recognized that sun block should be applied 15-30 minutes before getting exposed to the sun, and should be re-applied every 2 hours. In a study done among college athletes, a population that spend a lot of time exposed to the sun, less than half of them (45%) knew that individuals should utilize sunscreen 15–30 minutes before going outdoors and only 35% recognized that sun block should be reapplied every hour.

Another important finding was that the principal barriers to using sunscreen, 35% reported that they’re lazy, tired or don’t have time and 27% claimed they don’t need it. Suppa et al evaluated the principal barriers to sun protection among school students in Italy, and found that 46.77% reported tiresome ⁄ bothering and 36.5% had the desire to attain a tan as the main barriers.¹⁷ Also, less than half of the participants (44.4%) never use sunscreen of SPF 30 or above, similar to the same study that was done among school students as 39.1% never use any sunscreen despite knowledge of dermatological cancer and the hazard of sun exposure.¹⁷ Among physicians, 79.6% declared the application of sun block as a method of protection against the sun.¹⁸

In this study, only a minority of participants 20.5% disclosed visiting a physician to have their skin checked for possible malignant lesions, similar to the college athletes paper findings (20.7%).²³ Yilmaz et al noted that a considerable proportion of nursing students did not know the number of moles on their bodies and did not perform self-examination for the early determination of skin cancers.¹⁵ What was surprising was that a large proportion of the participants (78%) know that self-examination for any suspicious lesions help detect early stages of skin cancers, despite that, only 39% performed self-examination of their skin. However, among health professionals and educators in Portugal 82% of them preformed skin self-examination.²⁴

More than 90% of skin cancers are preventable and as prevention is better than cure, it is imperative to incorporate the skills of self-examination in future teaching activities for medical personnel, in medical schools and as pre-employment courses.²⁵ Increasing health care providers’ awareness about the importance and methods of self-examination, will definitely influence the general populations’ awareness.

CONCLUSION

In conclusion, the results of this study have shown that knowledge regarding skin cancer and behavior towards sun exposure among healthcare providers is inadequate. Therefore, educational awareness campaigns are recommended.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee of King Abdulaziz University Hospital

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