ATTITUDES TOWARDS SUN PROTECTION AND SKIN CANCER AMONG FACULTY MEMBERS AND STUDENTS OF MEDICINE AND OF ARTS/SCIENCES AT A TURKISH UNIVERSITY BİR TÜRK ÜNİVERSİTESİNDEKİ TIP VE FEN-EDEBİYAT FAKÜLTELERİ ÖĞRETİM ÜYELERİ VE ÖĞRENCİLERİNİN GÜNEŞTEN KORUNMA VE CİLT KANSERİNE KARŞI TUTUMLARI

Objectives: Public knowledge about and attitude towards sun protection practices are important factors in attempts to avoid skin cancer and other harmful effects of sun exposure. Such are the awareness levels of the students of medicine or their educators as they deliver the information to the general public and shape public health policies. The aim of this study was to reveal the knowledge and attitudes of the faculty members and students of medicine and of arts/sciences at a Turkish university towards the effects of sun exposure and protection. Materials and Methods: This descriptive cross-sectional study was conducted by administering a 37-item questionnaire to students and faculty members in the School of Arts/Sciences, School of Medicine, and Vocational School of Medical Sciences at Hitit University. The questions were formulated to evaluate the participants’ level of knowledge regarding the effects of sun exposure and protection, the source of their knowledge about these subjects, and their behaviors related to environmental factors. Responses were subjected to statistical analyses with appropriate tools and methods. Results: The study included a total of 217 participants with an average age of 26.0 ± 9.2 years: 145 (66.8%) students and 72 (33.2%) faculty members. Of these, 118 (55.1%) were female and 151 (69.6%) were in medical fields. A great majority of the participants (n=204, 94%) had used sunscreens, and sunscreens with SPF>30 were the most commonly used ones (%44). Brand (45.2%) and high SPF (46.2%) were the most frequently considered aspects when buying sunscreens. A comparison of subgroups of participants based on gender, position, and area of study indicated some differences in knowledge and practices related to sun exposure and sun protection.


Introduction
Skin cancers (more aggressive melanomas and less aggressive non-melanomas), one of the most common types of cancers worldwide, are a growing but preventable public health problem. 1,2 Depletion of stratospheric ozone layer, which absorbs as much as 99.9% and 95% of ultraviolet (UV)-B and -A lights (280-320 and 320-400 nm), has led to an increase in global ground-level UV irradiation in the last decades 3,4 and corresponding significant increases in the incidence of, in the number of treatments for, or in deaths due to skin cancers. 1,5,6 Exposure to sunlight, which is valued as an important means to generate vitamin D, also carries a greater risk for DNA damage and mutations. 7 Studies indicate that over 75-90% of skin cancers are considered to result from excessive exposure to outdoor or indoor UV radiation through sunlight or tanning beds. 8,9 Accordingly, UV radiation is considered a significant preventable environmental risk factor for all types of skin cancers. 9,10 Sunscreens of different strengths (sun protection factor -SPF) are applied onto the skin in order to limit the exposure of skin cells to UV light. However, the method and amount of sunscreen applied have been shown to vary among individuals significantly and to have a negative impact on the actual level of protection. 11,12 Moreover, public knowledge about and attitude towards UV protection practices are also important factors in attempts to protect the public from skin cancer and other harmful effects of UV exposure. 13,14 Public education programs are commonly implemented to educate the public and to promote appropriate UV protection practices. 15,16 On the other hand, the level of awareness among the students of medicine or their educators about UV protection practices is a subject of greater interest since they would be the ones delivering the information about this subject to the general public and shaping the public health policies. The aim of this study was to reveal the knowledge and attitudes of the faculty members and students of medicine and of arts/sciences at a Turkish university towards the effects of sun exposure, sun protection, and skin cancer in order to guide future educational programs and public health policies.

Materials and Methods
This descriptive cross-sectional study was conducted between October-December 2018 at Hitit University in Turkey. The university has over 14,000 students enrolled in undergraduate programs and accepts students in the mid-range for respective programs in terms of the nationwide entrance exam results. The participants were informed about the objectives and the procedures of the study, were given assurances of anonymity, and were asked to give their written approval. The local ethics committee for non-interventional studies at Hitit University approved this study (Approval #2018-77, Date 05.04.2018). The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in the approval by the institution's human research committee.
Statistical analyses were performed with SPSS (Version 22.0, SPSS Inc., Chicago, IL, USA). The normal distribution was examined by the Kolmogorov-Smirnov test. Descriptive statistics were presented as number and percentage for the demographic and other categorical variables and as mean ± standard deviation or median (min-max) for continuous variables. Independent-samples t-test or analysis of variance (ANOVA) was used for the comparison of two or multiple groups regarding the continuous variables with normal distribution, respectively. Mann-Whitney U test was used for the comparison of two groups regarding the data without normal distribution (i.e., responses to the statements given in the questionnaire). Relationships were analyzed with Spearman's correlation coefficient between numerical variables or chi-square test for categorical variables. Results with p<0.05 were considered statistically significant.

Results
A total of 217 participants were included in the study: 145 (66.82%) students and 72 (33.18%) faculty members. Of these, 118 (55.14%) were female, 151 (69.58%) were in medical fields (medical school or vocational school of health), and 139 (64.65%) had medium to dark skin tones ( Table 1). The average age of participants was 26.02 ± 9.18 years. The great majority of the participants (n=208, 95.85%) did not have a close relative who had had skin cancer; none had skin cancer in the family.
Most of the participants (n=117, 53.92%) had 1-4 hours of daily sun exposure during summer and (n=140, 64.52%) had sunburn ( Table 2). A great majority of the participants (n=204, 94.01%) had used sunscreens, and sunscreens with SPF>30 were the most commonly used ones (%44.61). No significant relationship was found between having sunburn and not using sunscreen (Fisher's exact test p=0.775).   Table 3. Participants' source of information and opinion regarding sun protection and UV light.  and found it necessary to protect from the sun (88.94%) ( Table 3). The Internet was found to be the most common source of information about the harmful effects of the sun (52.17%), followed by television (25.60%).

Most common source of information about the harmful effects of the sun
A comparison of subgroups of participants based on gender, position, and area of study indicated some differences in practices related to sun exposure and sun protection (Table 4). No significant difference was found between males and females regarding the duration of daily sun exposure in summer (p=0.113), but females had a higher rate of sunscreen use (p=0.014), a lower rate of sunburn (p=0.045), and used sunscreen with higher SPF (p=0.001). Students had longer daily sun exposure during summer (p<0.001) and used lower SPF sunscreens or were less aware of the sunscreen SPF they used (p=0.002) compared with faculty members.
Students considered the price first when buying sunscreens while faculty members paid attention to the brand more often (p=0.006). Television and the Internet were the sources of information about sun exposure and protection more commonly for students than they were for faculty members who got information at school more often than students (p<0.001). Students and faculty members in non-medical departments had higher daily sun exposure during summer (p<0.001). Formal education at school was the source of information about sun exposure and protection more commonly for those in medical departments (p=0.031).
The participants' responses to various statements regarding solarium use, sun exposure, sun protection, sunscreen use, and skin cancer were given in Table 5. A graphical presentation of the participant responses was also given in Figure 1. Subgroups were also analyzed and compared in terms of their responses to the statements about the effects of ultraviolet exposure from the sun or at the solarium and the methods of protection (Table 6).  Stacked-bar graph showing the participants' opinions regarding sun exposure, sun protection, sunscreen use, and skin cancer. The statements were stratified as "True" (statements on y-axis were shaded in green) and "False" (statements on x-axis were shaded in red), and based on the percentages for consolidated response groups (Strongly agree & Agree, greens; Not sure, yellow; Disagree & Strongly disagree, reds).

Discussion
Effectiveness of the sunscreens applied onto the skin depends on the SPF and appropriate usage of the product, both of which are significantly influenced by the knowledge and awareness of the public. 11,12,18 However, studies have indicated that sun exposure behavior was difficult to change, and non-adherence to medical advice was common even in the face of skin cancer risks. 19,20 It is, therefore, necessary to implement public awareness programs at the right time, to the right audience, with the right message, and through the right channels. This study investigated the level of knowledge and awareness about UV protection practices among the students of medicine or their educators and compared them to those from non-medical areas of study. Although students and faculty members from medical areas were generally found to have a higher level of knowledge about the subject matter, there was still room for improvement.
The rate of sunscreen use among university students and faculty members was found to be quite high (92.41% and 97.22%), especially compared to those reported in previous studies on high school students (41.8%) and their teachers (81.9%) or other undergraduate populations (63.5%) in Turkey as well as other medical students in several other countries (range from 52% to 86%). 17,21,22 The higher rate of sunscreen use in this study might be attributed to the differences in the target populations. Female participants were found to be more likely to use sunscreen, less likely to have a sunburn, and to use sunscreens with higher SPF compared to their male counterparts. A previous study similarly found a significantly higher rate of sunscreen use among female college students compared to males (73.3% vs. 52.5%). 21 This trend is in parallel with more common sunscreen usage among females in previous studies and reviews covering diverse populations. [23][24][25][26][27] However, no significant differences were found between males and females regarding their responses to the majority of the statements about sun exposure and protection, sunscreen use, and other health issues related to tanning practices. This suggests that the lack of knowledge is not likely to be the reason for a lower rate of sunscreen use or a higher rate of sunburns among males. Congruently, cosmetic reasons were reported in a previous study to be the main behavioral motivation rather than health concerns or skin cancer risk. 23 Although a low rate of sunscreen use might be associated with a higher rate of sunburns, we did not find a relationship between the two, which might be due to the fact that the number of participants who did not use sunscreens was very low.
Students and faculty members were found to have similar rates of sunscreen use and sunburn. Interestingly, a significantly higher number of students were found to consider price first when buying sun protection products, which contrasted the faculty members who more often indicated paying attention to brand name first. In a similar study, high school students were reported to considered price as a criteria in the selection of sunscreen more often than their teachers did. 17 This is likely due to the financial differences between the two groups. In addition, the significantly higher unawareness among students about the SPF of the sunscreen product they used might be a manifestation of their price-focused attitude. Longer duration of daily sun exposure of students might be attributed to the lifestyle differences between younger and older groups of participants (see the age difference in Table 1). Television and the Internet were more commonly the source of information about the issues related to sun protection for students compared to faculty members, which might also be attributed to age and lifestyle differences between the two groups. Previous studies on college students also reported that the internet and television were primary sources of information about sun protection. 23,24,26 Therefore, awareness campaigns targeting such (i.e., younger) audiences should take into consideration the alternative media outlets fitting their age and lifestyle to reach them more effectively. 28 Lower daily sun exposure among the students and faculty members of medical departments might be due to a more demanding study and work schedule in medical fields. Formal education at school was more commonly the source of information about sun exposure and protection for the participants in medical departments as it was part of their subject of study and profession. Family was not found to be a significant source of information for the participants of our study (3.86%) although parents and family were indicated to be a common source of knowledge about sun protection behavior in previous studies. 26,29 The differences might be due to the variations in the preferences of the populations targeted in other studies.
The participants were asked to respond to various statements regarding various aspects of UV exposure and protection. These statements covered the subjects related to the use and knowledge of solarium, tanning, harmful effects of sunrays, risk factors for skin cancer, protective measures in summer, and sunscreen use.
Some of these statements were in parallel with clinical knowledge (true) while others contradicted the clinical knowledge and reflected some common misconceptions (false). It was found that six out of 16 correct statements were identified by three-quarters or more of the respondents; 13 out of 16 correct statements were identified by more than half of the respondents (bars in shades of green in Figure 1). Six out of ten false statements were identified by about half of the respondents (bars in shades of red in Figure 1). Most of the participants failed to set opinions on three of the correct statements (S23, S29, S35) and two of the false statements (S25, S36) (yellow bars in Figure 1). Some of these statements were related to sun-exposure-related risk factors for skin disease or cancer, which indicated a lack of knowledge about these issues. Almost half of the respondents identified two false statements as correct (S31, S34). These statements were related to the common misconceptions that one could tan in the sun without an adverse effect when sunscreen was used (S31) and that gradual/slow tanning prevented the harmful effects of the sun (S34). 22 Significant differences between the response patterns of males and females existed in only four statements (S21, S27, S28ae); female participants more correctly responded to three of these statements. Significant differences between the response patterns of students and faculty members existed in most of the statements; faculty members more correctly responded in all such cases. The participants from medical and non-medical departments also exhibited significant differences in terms of their ability to respond correctly; those from medical fields responded more correctly in all such cases.
Although the majority of the responses from the participants in medical fields were in parallel with the clinical knowledge, there were instances where a significant portion of them responded incorrectly. Nine out of 16 correct statements were identified by three-quarters or more of the respondents (4 items for non-medical participants); 14 out of 16 correct statements were identified by more than half of the respondents (11 items for non-medical participants). Six out of ten false statements were identified by about half of the respondents (2 items for non-medical participants). Participants from medical fields failed to set opinions on two of the correct statements and one of the false statements (this was the case in 5 correct and 5 false statements for non-medical participants). Three statements, in particular, ("S18. It is appropriate to go to beach between 10 AM -4 PM during summer", "S31. One can tan in the sun without an adverse effect when sunscreen is used", and "S34. Gradual/slow tanning prevents the harmful effects of the sun"), were erroneously taken as correct statements by a significant portion of the participants, even so among those from medical backgrounds. These findings indicate a need for educating students of medicine about skin cancer risks and preventive measures as emphasized by a recent comprehensive review of skin-cancer-related knowledge, attitudes, and practices among medical students. 22 This study has some limitations regarding the data collection tool. Although items and elements from other studies were adapted and used in this study, the fact that the questionnaire used in this study was not a validated scale to assess the participants' behavior or knowledge regarding the hazards of sun exposure, protection from such hazards, and related subjects inhibited us from going beyond making a qualitative analysis and reaching some general conclusions. 13,17,30 Another significant limitation of this study was the sample size and restriction of sampling to a single institution of higher education. Although the sample was believed to reflect the average among the institutions of higher education in Turkey in terms of behaviors and practices, this was not a confirmed assumption. Further studies with more comprehensive and well-managed data collection tools including a larger sample from a more diverse set of institutions are warranted to determine the knowledge and behaviors of the target population regarding the hazards of sun exposure and sun protection.
In conclusion, this study investigated the level of knowledge and awareness among the students of medicine and their educators about UV protection practices and compared them to those from non-medical areas of study. The results indicated that although students and faculty members of medical areas generally had higher level of knowledge about the issues surrounding sun exposure, sun protection, sunscreen use, and other tanning practices in comparison with those from non-medical backgrounds, there is still a significant knowledge deficit about the severity of the risks associated with sun exposure and some room for improvement even among the students and faculty members of medical schools. The methods and media channels that would be used to increase public awareness should be adapted to the target audiences regarding the demographic characteristics.