Association of Skin Cancer Risk and Protective Behaviors with Health Literacy Among Young Adults in the USA



The goal of this study was to investigate the association of health literacy with skin cancer risk and protective behaviors among young adults at moderate to high risk of skin cancer, the most common cancer.


A US national sample of 958 adults, 18–25 years old, at moderate to high risk of developing skin cancer, completed a survey online. Behavioral outcomes were ultraviolet (UV) radiation exposure (e.g., indoor and outdoor tanning, sunburn) and protective (e.g., sunscreen use, sunless tanning) behaviors. Multivariable regression analyses were conducted to determine whether health literacy (a four-item self-report measure assessing health-related reading, understanding, and writing) was associated with behavioral outcomes while controlling for demographic factors.


Higher health literacy was independently associated with less sunbathing, odds ratio (OR) = 0.77, 95% confidence interval (CI) = 0.60–0.98; less indoor tanning, OR = 0.38, CI = 0.31–0.48; and less use of tanning oils, OR = 0.54, CI = 0.43–0.69. However, health literacy was also associated with a lower likelihood of wearing long pants, OR = 0.76, CI = 0.58–0.99, or a hat, OR = 0.68, CI = 0.53–0.87, when outdoors. On the other hand, higher health literacy was associated with higher incidental UV exposure, OR = 1.69, CI = 1.34–2.14, and a greater likelihood of ever having engaged in sunless tanning, OR = 1.50, CI = 1.17–1.92.


Interestingly, higher health literacy was associated with lower levels of intentional tanning yet also higher incidental UV exposure and lower skin protection among US young adults. These findings suggest that interventions may be needed for young adults at varying levels of health literacy as well as populations (e.g., outdoor workers, outdoor athletes/exercisers) who may be receiving large amounts of unprotected incidental UV.

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The authors thank Mary Riley, MPH for assistance with data processing and analysis and Lee Ritterband, PhD and the staff of BeHealth Solutions, LLC for developing the online assessment and data management system used in this project.


This work was funded by the US National Institutes of Health grants: R01CA154928 (CH), T32CA009035 (MA and SD), P30CA072720 and P30CA006927 (Cancer Center Support Grants).

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Correspondence to Carolyn J. Heckman.

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All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

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Heckman, C.J., Auerbach, M.V., Darlow, S. et al. Association of Skin Cancer Risk and Protective Behaviors with Health Literacy Among Young Adults in the USA. Int.J. Behav. Med. 26, 372–379 (2019).

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  • Health literacy
  • Skin cancer
  • Prevention
  • Young adults
  • Risk behaviors