Sun Protection Behaviors Among Puerto Rican Adults

The incidence of skin cancer has been increasing among US Hispanics for several decades. Hispanic individuals residing in the continental United States do not sufficiently engage in routine sun protection behaviors.^1-3 Hispanics are an important population to target for skin cancer prevention research and public health initiatives. However, there is a dearth of such efforts focusing on Hispanic populations outside the continental United States. From 1974 to 2005, the skin cancer incidence in Puerto Rico increased 4-fold, from 41.5 per 100 000 individuals to 167.9 per 100 000.⁴ The Puerto Rican population is 99% Hispanic, and most individuals report their race as white (75.8%) or black/African American (12.4%). Using data from the population-based 2009 Health Information National Trends Survey Puerto Rico (HINTS-PR),⁵ we examined the prevalence and demographic correlates of sun protection behaviors among Puerto Rican adults.

Institutional review board approval was waived. Detailed information regarding the HINTS-PR project is available elsewhere.⁵ In summary, 639 adults (a 76% response rate) in Puerto Rico were recruited via random-digit dialing to complete a telephone survey in Spanish or English on a variety of health-related topics. Individuals were excluded from the current analyses if they indicated that they never go out in the sun (n = 42) or were missing data for the 4 sun protection behavior questions (n = 25), leaving an analytic sample size of 572 participants. Participants reported their age, sex, and education level. Using a 5-point response scale (1, never; 2, rarely; 3, sometimes; 4 often; 5, always), standard single-item questions asked individuals to report the frequency with which they use sunscreen, wear a shirt that covers the shoulders, wear a hat, and stay in the shade (or under an umbrella) when outside on a hot sunny day.

We analyzed the data using SUDAAN statistical software (version 10.0; Research Triangle Institute) in order to handle the complex sample survey design, which included jackknife replicate weights and weighting of the data based on estimates of population demographics.⁵ For each sun protection behavior variable, we conducted a multiple regression analysis with the behavior as the dependent variable and age, sex, and education level as independent variables. We used a cutoff of P < .05 to determine statistical significance.

Descriptive statistics for the sun protection behaviors are shown in Table 1. The rates of using sunscreen (21.1%, often or always) and staying in the shade (38.5%, often or always) were lower than those reported in recent studies of Hispanic adults residing in the continental United States.^1,2 Approximately half of the participants reported never using sunscreen and never wearing a hat when outside on a hot sunny day. As shown in Table 2, less frequent use of sunscreen was reported by men and individuals with a lower education level, which is consistent with prior research.^1,2 Women reported wearing a hat less often than men. Individuals aged 50 to 64 years reported staying in the shade more often than those aged 18 to 34 years and 65 years or older.

This study provides much-needed, timely data regarding the population-based prevalence of sun protection behaviors in Puerto Rico. Overall, the results reveal considerable room for improvement in sun protection behaviors among Puerto Rican adults. In addition, identifying demographic differences in Puerto Rican adults’ engagement in sun protection behaviors highlights subpopulations to target in interventions to promote sun safety behaviors. Such interventions should also be informed by future research examining attitudes and beliefs regarding sun protection and exposure behaviors and skin cancer prevention among Puerto Rican adults.

Corresponding Author: Elliot J. Coups, PhD, Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, 195 Little Albany St, New Brunswick, NJ 08903 (elliot.coups@rutgers.edu).

Accepted for Publication: October 4, 2013.

Published Online: June 11, 2014. doi:10.1001/jamadermatol.2013.8852.

Author Contributions: Dr Coups had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Coups.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Coups.

Obtained funding: Tortolero-Luna.

Administrative, technical, or material support: Tortolero-Luna.

Conflict of Interest Disclosures: None reported.