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

Abstract

Background

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.

Method

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.

Results

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.

Conclusion

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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References

  1. 1.

    Donaldson MR, Coldiron BM. No end in sight: the skin cancer epidemic continues. Semin Cutan Med Surg. 2011;30:3–5.

    CAS  Article  Google Scholar 

  2. 2.

    Gordon R. Skin cancer: an overview of epidemiology and risk factors. Semin Oncol Nurs. 2013;29(3):160–9. https://doi.org/10.1016/j.soncn.2013.06.002.

    Article  PubMed  Google Scholar 

  3. 3.

    Nikolaou V, Stratigos AJ. Emerging trends in the epidemiology of melanoma. Br J Dermatol. 2014;170(1):11–9. https://doi.org/10.1111/bjd.12492.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Tuong W, Cheng LS, Armstrong AW. Melanoma: epidemiology, diagnosis, treatment, and outcomes. Dermatol Clin. 2012;30(1):113–24, ix. https://doi.org/10.1016/j.det.2011.08.006.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    US Department of Health and Human Services. The surgeon General’s call to action to prevent skin cancer. Washington, DC: US Dept of Health and Human Services; 2014. p. 2014.

    Google Scholar 

  6. 6.

    Goldberg MS, Doucette JT, Lim HW, Spencer J, Carucci JA, Rigel DS. Risk factors for presumptive melanoma in skin cancer screening: American Academy of Dermatology National Melanoma/Skin Cancer Screening Program experience 2001-2005. J Am Acad Dermatol. 2007;57(1):60–6. https://doi.org/10.1016/j.jaad.2007.02.010.

    Article  PubMed  Google Scholar 

  7. 7.

    Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM. Indoor tanning and risk of melanoma: a case-control study in a highly exposed population. Cancer Epidemiol Biomark Prev. 2010;19(6):1557–68. https://doi.org/10.1158/1055-9965.epi-09-1249.

    Article  Google Scholar 

  8. 8.

    Markovic SN, Erickson LA, Rao RD, McWilliams RR, Kottschade LA, Creagan ET, et al. Malignant melanoma in the 21st century, part 1: epidemiology, risk factors, screening, prevention, and diagnosis. Mayo Clin Proc. 2007;82(3):364–80. https://doi.org/10.4065/82.3.364.

    Article  PubMed  Google Scholar 

  9. 9.

    Psaty EL, Scope A, Halpern AC, Marghoob AA. Defining the patient at high risk for melanoma. Int J Dermatol. 2010;49(4):362–76. https://doi.org/10.1111/j.1365-4632.2010.04381.x.

    Article  PubMed  Google Scholar 

  10. 10.

    Qureshi AA, Zhang M, Han J. Heterogeneity in host risk factors for incident melanoma and non-melanoma skin cancer in a cohort of US women. J Epidemiol. 2011;21(3):197–203.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Buller DB, Cokkinides V, Hall HI, Hartman AM, Saraiya M, Miller E, et al. Prevalence of sunburn, sun protection, and indoor tanning behaviors among Americans: review from national surveys and case studies of 3 states. J Am Acad Dermatol. 2011;65(5 Suppl 1):S114–23. https://doi.org/10.1016/j.jaad.2011.05.033.

    Article  PubMed  Google Scholar 

  12. 12.

    Coups EJ, Manne SL, Heckman CJ. Multiple skin cancer risk behaviors in the U.S. population. Am J Prev Med. 2008;34(2):87–93. https://doi.org/10.1016/j.amepre.2007.09.032.

    Article  PubMed  Google Scholar 

  13. 13.

    Heckman CJ, Coups EJ, Manne SL. Prevalence and correlates of indoor tanning among us adults. J Am Acad Dermatol. 2008;58(5):769–80. https://doi.org/10.1016/j.jaad.2008.01.020.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Stanton WR, Janda M, Baade PD, Anderson P. Primary prevention of skin cancer: a review of sun protection in Australia and internationally. Health Promot Int. 2004;19(3):369–78. https://doi.org/10.1093/heapro/dah310.

    Article  PubMed  Google Scholar 

  15. 15.

    Coups EJ, Phillips LA. A more systematic review of correlates of indoor tanning. J Eur Acad Dermatol Venereol. 2011;25(5):610–6; author reply 7-8. https://doi.org/10.1111/j.1468-3083.2011.03996.x.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Coups EJ, Stapleton JL, Medina-Forrester A, Natale-Pereira A, Tortolero-Luna G. Sun protection behaviors among Puerto Rican adults. JAMA Dermatol. 2014;150(8):899–901. https://doi.org/10.1001/jamadermatol.2013.8852.

    Article  PubMed  Google Scholar 

  17. 17.

    Heckman CJ, Coups EJ. Correlates of sunscreen use among high school students: a cross-sectional survey. BMC Public Health. 2011;11:679–87. https://doi.org/10.1186/1471-2458-11-679.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Heckman CJ, Darlow S, Cohen-Filipic J, Kloss JD, Manne SL, Munshi T, et al. Psychosocial correlates of sunburn among young adult women. Int J Environ Res Public Health. 2012;9(6):2241–51. https://doi.org/10.3390/ijerph9062241.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Manne S, Lessin S. Prevalence and correlates of sun protection and skin self-examination practices among cutaneous malignant melanoma survivors. J Behav Med. 2006;29(5):419–34. https://doi.org/10.1007/s10865-006-9064-5.

    Article  PubMed  Google Scholar 

  20. 20.

    Ratzan SCP, R. M. Introduction. In Selden, C.R., Zorn, M., Ratzan, S.C., & Parker, R.M. (Eds.), National Library of Medicine current bibliographies in medicine: health literacy. NLM Pub. No. CBM 2000–1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services. 2000.

  21. 21.

    Bellinger JD, Brandt HM, Hardin JW, Bynum SA, Sharpe PA, Jackson D. The role of family history of cancer on cervical cancer screening behavior in a population-based survey of women in the Southeastern United States. Womens Health Issues. 2013;23(4):e197–204. https://doi.org/10.1016/j.whi.2013.03.003.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Garbers S, Chiasson MA. Inadequate functional health literacy in Spanish as a barrier to cervical cancer screening among immigrant Latinas in New York City. Prev Chronic Dis. 2004;1(4):A07.

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Morris NS, Field TS, Wagner JL, Cutrona SL, Roblin DW, Gaglio B, et al. The association between health literacy and cancer-related attitudes, behaviors, and knowledge. J Health Commun. 2013;18(Suppl 1):223–41. https://doi.org/10.1080/10810730.2013.825667.

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Pagan JA, Brown CJ, Asch DA, Armstrong K, Bastida E, Guerra C. Health literacy and breast cancer screening among Mexican American women in South Texas. J Cancer Educ. 2012;27(1):132–7. https://doi.org/10.1007/s13187-011-0239-6.

    Article  PubMed  Google Scholar 

  25. 25.

    Sentell T, Braun KL, Davis J, Davis T. Colorectal cancer screening: low health literacy and limited English proficiency among Asians and Whites in California. J Health Commun. 2013;18(Suppl 1):242–55. https://doi.org/10.1080/10810730.2013.825669.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    von Wagner C, Good A, Wright D, Rachet B, Obichere A, Bloom S, et al. Inequalities in colorectal cancer screening participation in the first round of the national screening programme in England. Br J Cancer. 2009;101(Suppl 2):S60–3. https://doi.org/10.1038/sj.bjc.6605392.

    Article  Google Scholar 

  27. 27.

    Herndon JB, Chaney M, Carden D. Health literacy and emergency department outcomes: a systematic review. Ann Emerg Med. 2011;57(4):334–45. https://doi.org/10.1016/j.annemergmed.2010.08.035.

    Article  PubMed  Google Scholar 

  28. 28.

    Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med. 2005;20(2):175–84. https://doi.org/10.1111/j.1525-1497.2005.40245.x.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: a national study. Am J Health Behav. 2008;32(3):227–42. https://doi.org/10.5993/AJHB.32.3.1.

    Article  PubMed  Google Scholar 

  30. 30.

    Altsitsiadis E, Undheim T, de Vries E, Hinrichs B, Stockfleth E, Trakatelli M. Health literacy, sunscreen and sunbed use: an uneasy association. Br J Dermatol. 2012;167(Suppl 2):14–21. https://doi.org/10.1111/j.1365-2133.2012.11082.x.

    Article  PubMed  Google Scholar 

  31. 31.

    Trakatelli M, Barkitzi K, Apap C, Majewski S, De Vries E. Skin cancer risk in outdoor workers: a European multicenter case-control study. J Eur Acad Dermatol Venereol. 2016;30 Suppl 3:5–11. https://doi.org/10.1111/jdv.13603.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Leung AY, Cheung MK, Chi I. Supplementing vitamin D through sunlight: associating health literacy with sunlight exposure behavior. Arch Gerontol Geriatr. 2015;60(1):134–41. https://doi.org/10.1016/j.archger.2014.10.005.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Cokkinides VE, Bandi P, Weinstock MA, Ward E. Use of sunless tanning products among US adolescents aged 11 to 18 years. Arch Dermatol. 2010;146(9):987–92. https://doi.org/10.1001/archdermatol.2010.220.

    Article  PubMed  Google Scholar 

  34. 34.

    Stryker JE, Yaroch AL, Moser RP, Atienza A, Glanz K. Prevalence of sunless tanning product use and related behaviors among adults in the United States: results from a national survey. J Am Acad Dermatol. 2007;56(3):387–90. https://doi.org/10.1016/j.jaad.2006.08.051.

    Article  PubMed  Google Scholar 

  35. 35.

    Glanz K, Schoenfeld E, Weinstock MA, Layi G, Kidd J, Shigaki DM. Development and reliability of a brief skin cancer risk assessment tool. Cancer Detect Prev. 2003;27(4):311–5.

    Article  PubMed  Google Scholar 

  36. 36.

    Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36(8):588–94.

    PubMed  Google Scholar 

  37. 37.

    Jeppesen KM, Coyle JD, Miser WF. Screening questions to predict limited health literacy: a cross-sectional study of patients with diabetes mellitus. Ann Fam Med. 2009;7(1):24–31. https://doi.org/10.1370/afm.919.

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Glanz K, Yaroch AL, Dancel M, Saraiya M, Crane LA, Buller DB, et al. Measures of sun exposure and sun protection practices for behavioral and epidemiologic research. Arch Dermatol. 2008;144(2):217–22. https://doi.org/10.1001/archdermatol.2007.46.

    Article  PubMed  Google Scholar 

  39. 39.

    Ingledew DK, Ferguson E, Markland D. Motives and sun-related behaviour. J Health Psychol. 2010;15(1):8–20. https://doi.org/10.1177/1359105309342292.

    Article  PubMed  Google Scholar 

  40. 40.

    Lazovich D, Stryker JE, Mayer JA, Hillhouse J, Dennis LK, Pichon L, et al. Measuring nonsolar tanning behavior: indoor and sunless tanning. Arch Dermatol. 2008;144(2):225–30. https://doi.org/10.1001/archdermatol.2007.45.

    Article  PubMed  Google Scholar 

  41. 41.

    Glanz K, Mayer JA. Reducing ultraviolet radiation exposure to prevent skin cancer methodology and measurement. Am J Prev Med. 2005;29(2):131–42. https://doi.org/10.1016/j.amepre.2005.04.007.

    Article  PubMed  Google Scholar 

  42. 42.

    Glanz K, McCarty F, Nehl EJ, O'Riordan DL, Gies P, Bundy L, et al. Validity of self-reported sunscreen use by parents, children, and lifeguards. Am J Prev Med. 2009;36(1):63–9. https://doi.org/10.1016/j.amepre.2008.09.012.

    Article  PubMed  Google Scholar 

  43. 43.

    O'Riordan DL, Steffen AD, Lunde KB, Gies P. A day at the beach while on tropical vacation: sun protection practices in a high-risk setting for UV radiation exposure. Arch Dermatol. 2008;144(11):1449–55. https://doi.org/10.1001/archderm.144.11.1449.

    Article  PubMed  Google Scholar 

  44. 44.

    Hoerster KD, Mayer JA, Woodruff SI, Malcarne V, Roesch SC, Clapp E. The influence of parents and peers on adolescent indoor tanning behavior: findings from a multi-city sample. J Am Acad Dermatol. 2007;57(6):990–7. https://doi.org/10.1016/j.jaad.2007.06.007.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Berinsky AJ, Huber GA, Lenz GS. Evaluating online labor markets for experimental research: Amazon.com's mechanical Turk. Polit Anal. 2012;20(3):351–68. https://doi.org/10.1093/pan/mpr057.

    Article  Google Scholar 

  46. 46.

    Chang L, Krosnick JA. National surveys via Rdd telephone interviewing versus the Internet: comparing sample representativeness and response quality. Public Opin Q. 2009;73(4):641–78. https://doi.org/10.1093/poq/nfp075.

    Article  Google Scholar 

  47. 47.

    Liu H, Cella D, Gershon R, Shen J, Morales LS, Riley W, et al. Representativeness of the Patient-Reported Outcomes Measurement Information System Internet panel. J Clin Epidemiol. 2010;63(11):1169–78. https://doi.org/10.1016/j.jclinepi.2009.11.021.

    Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Heckman CJ, Darlow SD, Ritterband LM, Handorf EA, Manne SL. Efficacy of an intervention to alter skin cancer risk behaviors in young adults. Am J Prev Med. 2016;51(1):1–11. https://doi.org/10.1016/j.amepre.2015.11.008.

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Heckman CJ, Handorf EA, Darlow SD, Ritterband LM, Manne SL. An online skin cancer risk-reduction intervention for young adults: mechanisms of effects. Health Psychol. 2017;36(3):215–25. https://doi.org/10.1037/hea0000420.

    Article  PubMed  Google Scholar 

  50. 50.

    Schneider S, Zimmermann S, Diehl K, Breitbart EW, Greinert R. Sunbed use in German adults: risk awareness does not correlate with behaviour. Acta Derm Venereol. 2009;89(5):470–5. https://doi.org/10.2340/00015555-0689.

    Article  PubMed  Google Scholar 

  51. 51.

    NCI N, DHHS. Cancer Trends Progress Report. Bethesda, MD; 2018 February.

  52. 52.

    Wolf MS, Gazmararian JA, Baker DW. Health literacy and health risk behaviors among older adults. Am J Prev Med. 2007;32(1):19–24. https://doi.org/10.1016/j.amepre.2006.08.024.

    Article  PubMed  Google Scholar 

  53. 53.

    Ziehfreund S, Schuster B, Zink A. Primary prevention of keratinocyte carcinoma among outdoor workers, the general population and medical professionals: a systematic review updated for 2019. J Eur Acad Dermatol Venereol. 2019. https://doi.org/10.1111/jdv.15525.

  54. 54.

    Ashinoff R, Levine VJ, Steuer AB, Sedwick C. Teens and tanning knowledge and attitudes. J Clin Aesthet Dermatol. 2009;2(2):48–50.

    PubMed  PubMed Central  Google Scholar 

  55. 55.

    Glanz K, Maddock JE, Lew RA, Murakami-Akatsuka L. A randomized trial of the Hawaii sunsmart program’s impact on outdoor recreation staff. J Am Acad Dermatol. 2001;44(6):973–8. https://doi.org/10.1067/mjd.2001.113466.

    CAS  Article  PubMed  Google Scholar 

  56. 56.

    Buller DB, Walkosz BJ, Buller MK, Wallis A, Andersen PA, Scott MD, et al. Results of a randomized trial on an intervention promoting adoption of occupational sun protection policies. Am J Health Promot. 2018;32(4):1042–53. https://doi.org/10.1177/0890117117704531.

    Article  PubMed  Google Scholar 

  57. 57.

    Sheridan SL, Halpern DJ, Viera AJ, Berkman ND, Donahue KE, Crotty K. Interventions for individuals with low health literacy: a systematic review. J Health Commun. 2011;16(Suppl 3):30–54.

    Article  PubMed  Google Scholar 

  58. 58.

    Seidenberg AB, Mahalingam-Dhingra A, Weinstock MA, Sinclair C, Geller AC. Youth indoor tanning and skin cancer prevention: lessons from tobacco control. Am J Prev Med. 2015;48(2):188–94. https://doi.org/10.1016/j.amepre.2014.08.034.

    Article  PubMed  Google Scholar 

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Acknowledgments

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.

Funding

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). https://doi.org/10.1007/s12529-019-09788-1

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Keywords

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