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Table 1.  
Demographics of the Study Population by Caregiver Race/Ethnicity
Demographics of the Study Population by Caregiver Race/Ethnicity
Table 2.  
Perceptions, Behavior, and Knowledge of Skin Cancer Prevention
Perceptions, Behavior, and Knowledge of Skin Cancer Prevention
1.
Gloster  HM  Jr, Neal  K.  Skin cancer in skin of color.  J Am Acad Dermatol. 2006;55(5):741-760.PubMedGoogle ScholarCrossref
2.
Agbai  ON, Buster  K, Sanchez  M,  et al.  Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public.  J Am Acad Dermatol. 2014;70(4):748-762.PubMedGoogle ScholarCrossref
3.
Hamilton  K, Cleary  C, White  KM, Hawkes  AL.  Keeping kids sun safe: exploring parents’ beliefs about their young child’s sun-protective behaviours.  Psychooncology. 2016;25(2):158-163.PubMedGoogle ScholarCrossref
4.
Robinson  JK, Rigel  DS, Amonette  RA.  Summertime sun protection used by adults for their children.  J Am Acad Dermatol. 2000;42(5, pt 1):746-753.PubMedGoogle ScholarCrossref
5.
Miller  KA, Huh  J, Unger  JB,  et al.  Patterns of sun protective behaviors among Hispanic children in a skin cancer prevention intervention.  Prev Med. 2015;81:303-308.PubMedGoogle ScholarCrossref
6.
Rouhani  P, Parmet  Y, Bessell  AG, Peay  T, Weiss  A, Kirsner  RS.  Knowledge, attitudes, and behaviors of elementary school students regarding sun exposure and skin cancer.  Pediatr Dermatol. 2009;26(5):529-535.PubMedGoogle ScholarCrossref
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Research Letter
January 2017

Black and Hispanic Caregivers’ Behaviors, Motivations, and Barriers to Sun Protection in Children Aged 4 to 12 Years in Miami, Florida

Author Affiliations
  • 1Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
  • 2Department of Communication Studies, University of Miami, Coral Gables, Florida
JAMA Dermatol. 2017;153(1):97-99. doi:10.1001/jamadermatol.2016.3505

Major shortcomings in efforts to prevent skin cancer in minority communities include increased incidence of melanoma and higher rates of mortality.1 Culture, socioeconomic factors, knowledge and awareness of skin cancer, and perceived risk may account for these disparities.2 Limited studies of sun protective practices in caregivers of black and Hispanic children exist.3,4 We compare black, Hispanic white, and non-Hispanic white caregivers’ behaviors, motivations, and barriers to sun protection in children aged 4 to 12 years in Miami, Florida. This information is imperative to understanding family-based factors that can lead to lifelong, habitual sun safety behaviors.

Methods

Experts at the University of Miami (V.V.S., N.C., F.N.B., and K.N.) constructed a 52-question survey adapted for a sixth-grade reading level. Multiple choice, true or false, and free response questions were constructed, keeping in mind that our target population included both white and nonwhite participants. The University of Miami Institutional Review Board approved the study. Surveys were distributed to caregivers with children aged 4 to 12 years who brought their child to a general pediatric clinic from July 1 through September 30, 2015, and provided oral consent to participate. Caregivers identified their own race as well as their child’s race. Data were analyzed using SPSS, version 22 (IBM). One-way analysis of variance was performed, with child ethnicity as the independent variable and each survey item as a dependent variable. Bonferroni post hoc comparison tests were used.

Results

Of 200 caregivers, 163 (81.5%) were female; 99 children (49.5%) were male. Sixty-five caregivers (32.5%) were black, 52 (26%) were Hispanic white, and 28 (14%) were non-Hispanic white (Table 1). We categorized behavior into the following 2 categories: low or inconsistent sun protective practices or multiple sun protective practices.5 More than half of the caregivers (n = 133) fell into the low or inconsistent sun protective practices category. Among all groups, the most common sun protective behavior was sitting in the shade.

A total of 155 of 191 caregivers (81.2%) answered 5 of the 6 knowledge questions correctly. The most common question answered incorrectly was “People cannot get sunburned on a cloudy day” (n = 47). Black caregivers were less likely to use sunscreen or believe that their child looked healthier with a tan (mean [SD] score, 1.45 [0.68]) than were non-Hispanic white (2.45 [0.67]) and Hispanic white (1.95 [0.89]) caregivers (P < .001). Table 2 presents results between races and ethnicities. Sun protective behavior was low across all groups, but consistently lowest among black caregivers.

Discussion

Our results suggest that caregivers of children aged 4 to 12 years of all races/ethnicities and skin types in South Florida engage in suboptimal sun protective behavior. Hispanic white and non-Hispanic white caregivers are fairly comparable in terms of their attitudes and behaviors toward sun protection, with Hispanic white caregivers achieving higher means than non-Hispanic white caregivers in some areas. Black caregivers used sunscreen the least frequently and performed significantly different on questions about tanning preferences and sunburn. As black people comprise the lowest-risk, but not risk-free, group, this finding may suggest a perception bias and cultural distinction that should be taken into account in efforts to prevent skin cancer. Our results are consistent with those of other studies in black adults and adolescents.6

Perceived lack of risk of skin cancer, as well as lack of knowledge and access to health care, are well-established barriers to photoprotection strategies in black and Hispanic patients.2 Black and Hispanic individuals are more likely to believe that little can be done to prevent skin cancer, suggesting a degree of fatalistic thinking.2 In our study, almost all caregivers were aware of recommended sun protection practices. However, lower education correlated with inconsistent sun protection behavior, suggesting that children in low socioeconomic groups may be at higher risk.

Our participants were highly representative of regional demographics, including a high percentage of families in low socioeconomic minority groups. In contrast to prior studies, our study had fewer non-Hispanic white participants, distinguishing important information about black and Hispanic individuals in an area with high UV exposure.

Our findings suggest that parental influences are critical to child sun protection among racial/ethnic minorities. With a high burden of late-stage melanoma in minority populations, influencing black and Hispanic caregivers’ perceptions regarding skin cancer prevention in childhood may affect morbidity and mortality.2 Prevention efforts should not only influence behaviors at an early age but also educate minorities and health care professionals about the increased potential for acral melanomas in patients with darker skin tones.

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Article Information

Corresponding Author: Vidhi V. Shah, BA, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 (shahvidhiv@gmail.com).

Accepted for Publication: August 1, 2016.

Published Online: October 5, 2016. doi:10.1001/jamadermatol.2016.3505

Author Contributions: Ms Shah 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: Shah, Mlacker, Aldahan, Carcioppolo, Bray, Nouri.

Acquisition, analysis, or interpretation of data: Shah, Jacobsen, Aldahan, Carcioppolo, Nouri.

Drafting of the manuscript: Shah, Jacobsen, Mlacker, Aldahan, Nouri.

Critical revision of the manuscript for important intellectual content: Shah, Aldahan, Carcioppolo, Bray, Nouri.

Statistical analysis: Shah, Jacobsen, Carcioppolo.

Administrative, technical, or material support: Shah, Mlacker, Aldahan, Bray, Nouri.

Study supervision: Carcioppolo.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Harleen Arora, BS, University of Miami Miller School of Medicine, assisted with the distribution of surveys. Lourdes Forster, MD, UHealth Pediatrics Professional Arts Center, helped initiate the study. We also thank the entire faculty and staff of UHealth Pediatrics Professional Arts Center for their support. They received no compensation for their contributions.

References
1.
Gloster  HM  Jr, Neal  K.  Skin cancer in skin of color.  J Am Acad Dermatol. 2006;55(5):741-760.PubMedGoogle ScholarCrossref
2.
Agbai  ON, Buster  K, Sanchez  M,  et al.  Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public.  J Am Acad Dermatol. 2014;70(4):748-762.PubMedGoogle ScholarCrossref
3.
Hamilton  K, Cleary  C, White  KM, Hawkes  AL.  Keeping kids sun safe: exploring parents’ beliefs about their young child’s sun-protective behaviours.  Psychooncology. 2016;25(2):158-163.PubMedGoogle ScholarCrossref
4.
Robinson  JK, Rigel  DS, Amonette  RA.  Summertime sun protection used by adults for their children.  J Am Acad Dermatol. 2000;42(5, pt 1):746-753.PubMedGoogle ScholarCrossref
5.
Miller  KA, Huh  J, Unger  JB,  et al.  Patterns of sun protective behaviors among Hispanic children in a skin cancer prevention intervention.  Prev Med. 2015;81:303-308.PubMedGoogle ScholarCrossref
6.
Rouhani  P, Parmet  Y, Bessell  AG, Peay  T, Weiss  A, Kirsner  RS.  Knowledge, attitudes, and behaviors of elementary school students regarding sun exposure and skin cancer.  Pediatr Dermatol. 2009;26(5):529-535.PubMedGoogle ScholarCrossref
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