Assessment of Sun Protection Knowledge and Behaviors of US Youth

Skin cancer is the most common cancer in the United States, and the incidence continues to rise. Greater than 5 lifetime sunburns double one’s risk of melanoma.¹ Skin protection among youth is the most effective means to prevent new cases of melanoma and nonmelanoma skin cancers. Despite this, less than one-third of youth aged 11 to 18 years routinely use sun protection.²

Efforts are underway to increase the priority of sun protection among youth.^3,4 Changing sun exposure behaviors is difficult to implement⁴ and even those who do use sunscreen often do so incorrectly.⁵ The goal of this study is to identify youths’ knowledge and experiences using sun protection and to understand what interventions would be most beneficial in increasing the use of sun protection among their peers.

This survey study used MyVoice, a national text message–based polling platform of youth. The University of Michigan institutional review board approved this study with a waiver of parental consent for minor participants as this study was deemed of minimal risk to participants. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline for survey research. MyVoice participants ranged from age 14 to 24 years and were recruited from social media based on national benchmarks from the American Community Survey. Race and ethnicity data were self-reported. Participants were given $1 for responding to each week’s survey topic.⁶

Five open-ended probes focused on sun protection were sent to 1151 youths on April 9, 2021. Two investigators created a codebook based on salient topics and independently analyzed each question. Discrepancies in coding were resolved by a third investigator. Prevalence of themes was summarized using descriptive statistics. Statistical analyses were performed using SAS version 9.4 (SAS Institute) on May 23, 2021.

Our survey had an 84.9% response rate (977 of 1151). Among 977 respondents included in this study, 473 (48.1%) identified as female, 104 (10.7%) as Hispanic, 64 (6.6%) as non-Hispanic Black, and 607 (62.2%) as non-Hispanic White; the mean (SD) age was 19.3 (2.4) years (Table 1).

When asked how important it is to protect their skin from the sun, 62.1% (594 of 957) stated very important, 25.5% (244 of 957) stated important, and 5.4% (54 of 957) stated somewhat important. Skin cancer was the most frequently cited reason for sun protection (51.7%; 495 of 957). Although 90.1% of youth (840 of 932) reported use of sunscreen, 81.1% (751 of 926) noted having had 1 or more sunburns, with 28.4% (263 of 926) reporting 5 or more. To increase the use of sun protection among youth, respondents suggested demonstrating the consequences of sun exposure (41.1%; 405 of 932), using traditional media (16.8%; 165 of 932), and increasing product accessibility (10.6%; 104 of 932) (Table 2).

Our findings suggest that youth understand the short and long-term risks of sun damage yet have difficulty successfully implementing sun protection. Despite nearly all youth (90.1%) stating they use sunscreen, the high number of self-reported burns suggests public health personnel and clinicians must change their approach.

This study had some limitations. Although text messaging allows us to elicit the open-ended responses of youth, it does not allow us to engage in a 2-way dialogue to clarify any responses. Also, although our sample is nationwide, it is not nationally representative, which may limit generalizability.

This study adds to current literature by revealing what may be preventing US youth from using consistent sun protection. Based on youths’ desire for increased product accessibility, cost and inconvenience are likely barriers preventing consistent sunscreen use. Approximately 40% believe poor sun protection behaviors would improve with education specifically illustrating the consequences of sun damage. Strategies suggested by youth to increase the use of sun protection include increasing sunscreen accessibility, widely distributed media campaigns, and improved government policies to strengthen sun protection standards and education in schools and workplaces. Implementing these strategies suggested by youth may help prevent sunburns during childhood and adolescence and, ultimately, decrease the risk of skin cancer later in life.

Accepted for Publication: September 21, 2021.

Published: November 15, 2021. doi:10.1001/jamanetworkopen.2021.34550

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Strome A et al. JAMA Network Open.

Corresponding Author: Tammy Chang, MD, MPH, MS, 2800 Plymouth Rd, Bldg 14, Rm G128, Ann Arbor, MI 48109 (tachang@med.umich.edu).

Author Contributions: Dr Chang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Ms Strome and Ms Herbert were co–first authors.

Concept and design: Strome, Herbert, Waselewski, Chang.

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

Drafting of the manuscript: Strome, Herbert, Walsh, Lamberg, Chang.

Critical revision of the manuscript for important intellectual content: Herbert, Walsh, Waselewski, Chang.

Statistical analysis: Strome, Herbert, Waselewski.

Obtained funding: Herbert.

Administrative, technical, or material support: Waselewski, Chang.

Supervision: Waselewski, Chang.

Conflict of Interest Disclosures: None reported.