Article Information
Corresponding author : Monika Fida

Article Type : Research Article

Volume : 3

Issue : 2

Received Date : 15 Mar ,2022


Accepted Date : 04 Apr ,2022

Published Date : 13 Apr ,2022


DOI : https://doi.org/10.38207/JCMPHR/2022/FEB03020529
Citation & Copyright
Citation: Cano E, Zekja I, M Fida, Abazaj E, Villani A (2022) Knowledge, attitudes, and behaviors of high school adolescents regarding sun protection, effects of the sun, and skin cancer. J Comm Med and Pub Health Rep 3(02): https://doi.org/10.38207/JCMPHR/2022/FEB

Copyright: © 2022 Monika Fida, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
  Knowledge, attitudes, and behaviors of high school adolescents regarding sun protection, effects of the sun, and skin cancer

Elna Cano1, Iliriana Zekja2, Monika Fida2*, Erjona Abazaj3, Alessia Villani4

1Dermatologist of Hygeia Hospital Tirana, Albania

2Hospital Center “Mother Teresa”, Tirana, Albania

3Institute of Public Health, Tirana, Albania

4University of “Federico II”, Naples, Italy

*Corresponding Author: Monika Fida, Hospital Center “Mother Teresa”, Tirana, Albania.

Abstract
Background:
Sun exposure during adolescence may lead to serious health problems, especially when adolescents are exposing themselves to  the harmful effects of the sun for longer times. For that reason, we conducted this study with the aim to determine the attitudes, knowledge, behaviors, and effect of sunʾs exposure among adolescents in four districts in Albania.

Methods: This is a cross-sectional survey in which adolescents from different high schools (public/private) in four districts of Albania are selected. The districts were Tirana, Durrës, Berat-Skrapar and Sarandë. We recruited adolescents of age 14 to 20 years irrespective of their gender. A standardized questionnaire regarding recent and previous sunburn history, knowledge about, attitudes towards and use of sunscreen, and protective measures, as well as socio-demographic factors, was answered by each participant. Data were analyzed using SPSS (version 20.0). Pearson’s Chi-square tests were used for categorical variables and a multivariate regression analysis was conducted to assess predictors of sun protection knowledge, attitude, behaviors, and sociodemographic factors. P-values less than 0.05 were taken as significant

Results: In this study, we enrolled 600 adolescents from four districts with 150 participants from each district. The mean age was 17.26 ±0.69 years, with a minimum age of 14 years and a maximum of 20 years 48 % were female and 52 % were male. Females presented predominance. Berat/Skrapar and Durrës district, males in Sarandë and Tirana district. Male adolescents presented with more improper sun-protecting behaviors versus females concerning the use of sunscreen (P < 0.001). Almost 38.5 % of adolescents knew what melanoma is but 57 % believed that sunlight is harmful to the skin only when they have a sunburn in summer. We found significant differences regarding knowledge, attitude, and protective measures between male and female adolescents. In all these questions the p-value was < 0.05.

Conclusion: In this study, adolescents presented some knowledge regarding sun effect and especially for sun protection behavior, while attitudes and general knowledge about sun protection were significantly different among male and female adolescents. But this was a self-reported study so we could not verifier the reason for these differences. We did not record the frequency of sunscreen use per day by the adolescents so we recommend that this may be explored in future studies.

Keywords: adolescents, sun protection measures, knowledge, and attitude, skin cancer

Introduction
The incidence of skin cancer has increased dramatically in Europe and worldwide over the past decades [1-4]. Skin cancer greatly affects the quality of life of more people, and it can be disfiguring or even deadly [5,6]. Skin cancer and malignant melanoma are among the most severe health effects, but a series of other health effects have been identified [7].

The most common environmental cause of the vast majority of skin disorders and skin cancer is ultraviolet radiation (UVR). Epidemiological studies have disclosed a strong association between solar UVR and all major types of skin cancer [8], but on the other hand, many factors such as advanced age, skin types, and male gender have been associated with an increased risk of developing skin cancer [9]. Melanoma is the most serious form of skin cancer and is now one of the most common cancers among adolescents and young adults ages 15-29. While melanoma accounts for about three percent of skin cancer cases, it causes more than 75 percent of skin cancer deaths [10].

Extended sun exposure may lead to serious health problems [11] especially for adolescents Also, ta a lot of epidemiological literature reports that sun exposure and especially sunburns from the UVR during an early age [12-16]. More adolescents do have no good knowledge about carcinogens, and factors that influence their development and consequences making them an ideal study population when we can determine their knowledge of individual sun exposure habits and photoprotection behavior or impact on the frequency of sunburn [17].

In Albania, there are data about the knowledge and attitudes related to sun exposure habits and sun protection behaviors in the population and particularly in adolescents as the most risk group. Center for Disease Control and Prevention mention in their report in 2019 that skin cancer prevention policies in schools are an important setting for addressing skin cancer prevention among youth.

Adolescents and students are typically at school during midday hours when UV radiation from the sun is strongest. Recess and other outdoor activities during the midday can put students at risk if they are not protected [18]. For that reason, we conduct this study with the aim to determine the attitudes, knowledge, behaviors, and effect of sun exposure as a cause of skin cancer among adolescents in four districts in Albania.

Methods
Subject

During the period January to December 2019, a standardized questionnaire regarding knowledge, attitude, and behaviors on skin protection from sun exposure, among adolescents was distributed in four different districts in Albania. Albania is a southeastern Europe country, situated in the western part of the Balkan. Albania has mountainous geography and about three-fourths of its territory consists of mountains and hills; the remainder consists of coastal and alluvial lowlands. This country is bounded by the Adriatic and Ionian seas to the west and southwest, respectively. The climate of Albania like other Mediterranean countries, has characteristically warm, dry summers and mild, wet winters. Local climatic variation can occur, however, from one region to another. The western part of the country, which is under the influence of warm maritime air from the Adriatic and Ionian seas, has more-moderate temperatures than the rest of Albania. We have focused to involve a considerate number of adolescents that live in Tirana, Durrës, Berat (also in Skrapar), and Saranda. In total, we have interviewed 600 adolescents separately equal to four districts. The participants of this study were selected randomly.

Tirana: Tirana is the capital city, and largest city of Albania and is located in the center of the country. Due to its location at the Plain of Tirana and the close proximity to the Mediterranean Sea, the city is particularly influenced by a Mediterranean seasonal climate. It is among the wettest and sunniest cities in Europe, with 2,544 hours of sun per year. Tirana has a humid subtropical climate. Temperatures vary throughout the year from an average of 6.7°C in January to 24°C in July. Spring is very warm to hot often reaching over 20°C. During autumn and winter, from November to March, the average temperature drops and is not lower than 6.7°C but during the months of June to September, the temperature ranges from 35-43°C.

Durrës: Durrës is the second most populous city in Albania. It is located on a flat plain along the Adriatic Sea Coast. Durrës climate is profoundly influenced by a seasonal Mediterranean climate. The summers are predominantly hot and dry, the winters relatively mild, and falls and springs mainly stable, in terms of precipitation and temperatures. The mean monthly temperature ranges between 7.5°C in winter to 23.8 °C in summer. The highest temperature arrived until to 39°C.

Berat-Skrapar: Berat is the ninth most populous city of the Republic of Albania. This city is located in the south of the country and is surrounded by mountains and hills. Berat has a Mediterranean climate, and the summers are characterized as hot and dry with a maximum average of 28.2°C but during the months of June until September the temperature range from 42-44°C. The municipality of Skrapar is part of the Berat district. It is located in the north-eastern part of the southern region of the country and occupies 43% of the surface of the whole district of Berat. This municipality has a position at an average 788m altitude above sea level and its relief is quite varied throughout the district. The highest temperature arrived until to 33°C.

Saranda: Saranda is a city in the Republic of Albania and the seat of Sarandë Municipality. Geographically, the city is located on an open sea gulf of the Ionian Sea within the Mediterranean Sea. Stretching along the Albanian Ionian Sea Coast, Saranda typically has a Mediterranean climate with over 300 sunny days a year. Sarandë is known for its blue deep waters of the Mediterranean. The highest temperature arrived until to 35°C.

The standardized questionnaire has five sections. The first section gave data regarding demographic information. It included questions on gender, age, education level and employment status of parents, high school level of students interviewed, city/district, and living areas. The second part includes questions on skin type, eye color, and the presence of moles in their body. The third and the fourth part of the questionnaire is about the knowledge of adolescents that were included in our study regarding the effects of the sun on the skin and knowledge of skin cancer. We asked in the fifth part of a questionnaire about recent and previous sunburn history, the use and efficiency of sunscreen, and protective measures (like hast, protective clothes, glasses, etc) used during sunbathing.

Data Analysis
Data were analyzed using SPSS (version 20.0) tool. The participants were divided into four groups (based two the respective districts) for comparison. Descriptive statistics were used to show the distribution of the outcome and independent variables. The groups of the participants were compared using Pearson’s Chi-square tests for categorical variables and analysis of variance (ANOVA) for continuous variables. General linear model multivariate regression analysis was conducted to assess predictors of sun protection knowledge, attitude, behaviors, and sociodemographic factors. P- values less than 0.05 were considered significant.

Figure 1: Maps of four districts in Albania

a) Tirana; b) Durrës; c) Berat-Skrapar; d) Sarandë

Results
In this study, female and male interviews presented a difference in percentage, 48 % (288 participants) were female and 52 % (312 participants) were male (figure 1). Females presented a predominance versus males for the district of Berat/Skrapar and for the Durrës district. For Berat/Skrapar district 65.3 % (98/150) of adolescents were female and 34.7 % (52/150) were male, and for Durrës district 71.3 % (107/150) were female and 28.7 % (43/150) were male. On the other hand, we have another situation regarding the gender of the Saranda and Tirana districts. In Saranda district female adolescents resulted in 39.3 % (59/150) and males 60.7 % (91/150) and in Tirana district, we have the lowest number of females 16 % (24/150) and the highest number of male adolescents 84 % (126/150). Based on analyses of data, Chi-square 23.2 p-value resulted in 0,001.

Figure 1: Frequency distribution of gender according to districts

Table 1 presents the socio-demographic characteristics among our adolescents. For comparison, all 600 participants are divided into four groups (based on the respective district). Each district has the same number of adolescents (150 participants). The mean age for adolescents resulted in 17.26 ±0.69 Std, with a minimum age of 14 years and a maximum of 20 years old. Related to the age, we have used two age groups of our adolescents, in the first we have included all adolescents from 14 to 16 years old, and the second group is included adolescents from 17 to 20 years old. Participants of the age groups 17-20 years old presented the higher number 67.2 % (403/600) compared to age groups 14-16 years old 32.8 % (196/600). A strong significant association was found for the age based on different district analyses of 0,0001. Regarding residence, only 28.2 % of adolescents referred that living in a rural area and 71.8 % referred that living in urban areas. Adolescents from the Berat-Skrapar district presented the highest number according to their residence in rural areas compared to other districts. 0,001

Table 1: Socio-demographic characteristics of participant´ adolescents

Variables

Total number

Berat- Skrapar`

adolescents

Durrës` adolescents

Saranda` adolescents

Tirana` adolescents

P

value

Gender

600

150

150

150

150

0,001

Female

288

98

107

59

24

 

Male

312

52

43

91

126

 

Age

mean

16.71±0.82

17.01±0.95

16.42±0.79

17.18±1.19

0,0001

14-16 years old

197

69

48

56

24

 

17-19 years old

403

81

102

94

126

 

Living area

 

 

 

 

 

 

Rural area

169

58

23

21

19

0,001

Urban area

431

92

127

129

131

 

Grade of the class

 

 

 

 

 

0,051

Ten (10 class)

100

37

20

23

20

 

Eleven (11 class)

220

80

85

34

21

 

Twelve (12 class)

241

26

45

93

77

 

Thirteen (13 class)

32

0

0

0

32

 

Education level (Father)

 

 

 

 

 

0,03

≤ 12 years of study

341

99

89

78

74

 

> 12 years of study

259

51

61

72

76

 

Employment of (Father)

 

 

 

 

 

0,069

Yes

451

130

94

121

106

 

NO

149

20

56

29

44

 

Education level (Mother)

 

 

 

 

 

0,57

≤ 12 years of study

401

135

72

112

82

 

> 12 years of study

199

15

78

38

68

 

Employment of (Mother)

 

 

 

 

 

0,89

Yes

138

15

48

16

59

 

No

462

135

102

134

91

 

In section two we have included questions about skin type, hair and eyes color, presence of the mole in their body, and family history of skin cancer. As seen in table 2 we have presented the information data regarding the type of skin among our participants. 11.2 % (67/600) have light skin, 71 % (426/600) have fair skin, 12.5 % have brown skin and 5.3 % have dark brown skin. Related to the question; Do you have sunburn during childhood? About 32.2 % of adolescents referred that have not sunburn during their childhood and 67.8 % have at least 1 more burn during childhood. Adolescents from Berat-Skrapar and Tirana districts presented the highestnumber of cases without sunburn during childhood 36.6 % (55/150) and 50 % (75/150) respectively. For the question, “Does your skin burn when you go to the beach for sunbathing?”. We have classified them based on the type of skin. So, type 1 resulted in 8.3% of participants, type 2 resulted in 47 %, type 3 resulted in 27.5 %, and type 4 resulted in 9 % of participants. Also, 8.8 % of participants have not specified if their skin burn when they went to the beach for sunbathing. For the presence of a mole in their body, only a few of them referred that haven`t any mole (11.7 %) in their bodies, and the others have at least one mole in their body (88.3 %).

Table 2: Information data regarding type of skin and presence of mole

Type of skin

Berat- Skrapar`

adolescents

Durrës` adolescents

Saranda` adolescents

Tirana` adolescents

What color is your skin

 

 

 

 

Light

25

19

11

12

Fair

88

112

117

109

Brown

37

10

20

8

Dark brown

0

9

2

21

Do you have sunburn during the

childhood

 

 

 

 

No

55

37

26

75

1 time

19

30

34

12

2 times

39

19

24

8

More than 2 times

37

64

62

55

*Does your skin burn when you go to

the beach for sunbathing?

 

 

 

 

Type I

14

20

4

12

Type II

60

76

95

51

Type III

49

27

30

58

Type IV

14

15

6

19

Not specified

13

15

15

10

Do you have mole in your body?

 

 

 

 

No

16

15

22

17

Yes

134

135

128

133

Did you have controlled your mole?

 

 

 

 

Yes

0

10

2

11

No

150

140

148

139

*Tipi 1: Always get sunburn without getting suntans; Tipi 2: Firstly, get a sunburn before having tan; Tipi 3: Tan, but sometimes sunburn; Tipi 4: Get suntans without sunburn. Not specified.

In the other table (3) we describe sun exposure as a risk factor problem causing skin cancer. We also describe the opinions of adolescents regarding the relationship between exposure to ultraviolet (UV) radiation and health for four districts. So, related to the information collected in this study, most adolescents had knowledge about sun exposure, skin cancer, and its impact on health. Also, the knowledge about sunscreen provides protection from UV rays was good. Regarding melanoma information, only 38.5 % of adolescents have knowledge. Also, regarding questions about a family history of skin cancer, no more than 1.5 % (9/600) of adolescents referred that have.

Table 3: Knowledge level of adolescents regarding sun effect in health

Questions

Total

number

Berat-Skrapar

Durrës

Saranda

Tirana

Sun exposure causes skin cancer

 

 

 

 

 

Yes

451

105

113

125

108

No

139

45

37

25

32

The sunlight is more harmful to dark skin than to light skin

 

 

 

 

 

Yes

112

37

19

22

34

No

488

113

131

128

116

The sunlight is harmful to your skin only when you have sunburn in summer

 

 

 

 

 

Yes

342

96

87

78

81

No

258

54

63

72

69

Suntan is a sign of being healthy

 

 

 

 

 

Yes

296

93

68

69

66

No

304

57

82

81

84

Sunlight is stronger and harmful from 11:00 to 16:00

 

 

 

 

 

Yes

532

132

130

140

130

No

68

18

20

10

20

Sunscreens provide protection from UV rays

 

 

 

 

 

Yes

495

143

122

128

102

No

105

7

28

22

48

Sunscreens with a factor 15 or less cannot protect you

 

 

 

 

 

Yes

337

100

54

101

82

No

263

50

96

49

68

One application of sunscreen protects you for at least 4 hours

 

 

 

 

 

Yes

401

103

83

104

111

No

199

47

67

46

39

Do you know what melanoma is?

 

 

 

 

 

Yes

231

82

49

58

42

No

369

68

101

92

108

Where did you get the information about melanoma?

 

 

 

 

 

TV and radio

52

15

9

17

11

newspapers and magazines

30

9

5

9

7

Internet

83

29

14

21

19

Doctors

16

5

8

1

2

School

16

7

3

5

1

Others

34

17

10

5

2

Family history of skin cancer

 

 

 

 

 

Yes

9

4

2

1

2

No

591

146

148

149

148

In accordance with the knowledge level, attitudes, and behaviors we have continued with additional questions among participants of this study. Most adolescents 69.5 % (417/600) think that nothing can prevent skin cancer. Almost half of the adolescents 52.3 % (314/600) think that melanoma is the most dangerous skin cancer type that can cause death. Related to the question; Frequent sunburns in childhood increase the risk of skin cancer in older age most adolescents are answered Yes 56.3 % (338/600). For the question, The number of moles in an individual is related to the risk of developing melanoma, 46.8 % know that and 53.2 % do not. According to other questions, the adolescents are answered Yes in 49 % of participants for the question My skin will age faster if I stay longer in the sun; 64.8 % for the question I am aware that sun / UV exposure can cause skin cancer; 51 % for question A suntan makes me look more beautiful; 50.3% for question A suntan makes me feel healthier and 38.2 % for question Solariums are a safe way to get skin tan.

Table 4: Knowledge level, attitudes and behaviors additional questions of adolescents regarding sun effect in health

Questions on attitude

Berat-Skrapar

Durrës

Saranda

Tirana

There is nothing that can prevent skin cancer

 

 

 

 

Yes

56

47

41

39

No

94

103

109

111

Melanoma is the most dangerous type of skin cancer that can cause death

 

 

 

 

Yes

87

60

97

70

No

63

90

53

80

Frequent sunburns in childhood increase the risk of skin cancer in older age?

 

 

 

 

Yes

102

81

77

78

No

48

69

73

72

The number of moles in an individual is related to the risk of developing melanoma

 

 

 

 

Yes

69

62

66

84

No

81

88

84

66

My skin will age faster if I stay longer in the sun

 

 

 

 

Yes

73

52

88

81

No

77

98

62

69

I am aware that sun / UV exposure can cause skin cancer

 

 

 

 

Yes

88

111

99

91

No

62

39

41

59

A suntan makes me look more beautiful

 

 

 

 

Yes

79

100

45

82

No

71

50

105

68

A suntan makes me feel healthier

 

 

 

 

Yes

90

82

59

71

No

60

68

91

79

Solariums are a safe way to get skin tan

 

 

 

 

Yes

68

58

49

54

No

82

92

101

96

Tables 5 and 6 are part of five sections and describe the current evidence data on preventing skin cancer. This part of questionnaire describes the skin cancer prevention and highlights ting areas of research where more work is needed. The protection measures those adolescents use to protect their self from the sun and skin cancer are presented below.

Adolescents from the Berat-Skrapar district 63.3 % (95/150) wear sun glasses as protective measures from the sun, 80.6 % (121/150) stay inside, etc. In adolescents of Durrës district 79.3 % (119/150) wear sunglasses as protective measures from the sun, 58 % (87/150) stay inside, etc. In adolescents of Saranda district, 88 % (132/150) wear sunglasses as protective measures from the sun, 45.3 % (68/150) stay inside, etc. In adolescents of Tirana district, 78.7 % (118/150) wear sunglasses as protective measures from the sun, 36 % (54/150) stay inside, etc.

Table 5: Strategies and protected measures regarding exposed to the sun amongst adolescents

Strategies

Berat- Skrapar`

adolescents

Durrës` adolescents

Saranda` adolescents

Tirana` adolescents

Wear sunglasses

95

119

132

118

Stay inside

121

87

68

54

Stay under shade/ Stay mainly in the shade

100

91

95

96

Cover up with clothes/ Wear clothing covering most of

your body

97

85

79

67

Keep out of the sun between 11 a.m. and 3 p.m

126

95

84

74

Wear a hat outside

118

92

73

108

Related to sunscreen application attitude and practices among adolescents, most adolescents 28.3 % use sunscreen with a protective factor always, and almost always 21.2 % of them. Regarding the reapply of sunscreen, 8.5 % never reapply the sunscreen, 25.5 % reapply every 4 hours, 30.7 % reapply every 2 hours and 35.3 % reapply every hour. For the question Do you frequent UV lamps, sunbeds (solarium), 7.3 % frequent the UV lamps or sunbeds 3-4 times a year, 5.5 % frequent 1-2 times a month 1 % frequent 1 time per week. According to the time that adolescents had stayed on the beach during last holidays, 43.8 % had referred that stayed less than 15 days. Regarding the sunbathing attitude, 23.3 % did not use sunbathing because they think that is dangerous 23.7 % referred that while they are at the beach they stay in the shade or swim 26.2 % like sunbathing sometimes, and 26.8 % really like sunbathing and tanning all the time. We ask all adolescents what they think about skin tanning, 32.5 % think that the tanning makes them look better/ prettiest, 29.2 % think that their body skin looks healthier when they tan, and 27.8 % think that most of their friends want to be suntanned. Regarding the attitude towards sun protection 31.8 % declared that they were ashamed of applying sunscreen in front of their friends, 39.2 % declared that if they are wearing a blouse on the beach does not make them look good, and 29 % declared that their parents did not protect themselves from the sun, so they do not think that is necessary to protect their self from the sun.

Table 6. Attitude and practices regarding sunscreen application among adolescents

Attitudes and Practices

Total number

Berat-Skrapar`

adolescents

Durrës`

adolescents

Saranda`

adolescents

Tirana`

adolescents

How often do you use sunscreens with protective factor?

Always

170

44

47

47

32

Almost always

127

28

35

35

29

Sometimes

77

25

8

8

36

Rarely

97

19

31

31

16

Never

124

29

29

29

37

Do you use sunscreen or sun oil with spf?

I do not use

234

74

63

63

34

Only during the summer at the beach time

277

69

59

53

96

Continuously in daily life

89

7

28

34

20

Do you reapply sunscreen

Never

51

23

6

6

16

Every 4 hours

153

39

22

76

16

Every 2 hours

184

48

46

22

68

Every hour

212

40

76

46

50

Do you frequent UV lamps, sunbeds (solarium)?

3- 4 times a year

44

10

16

11

7

1-2 times a month

33

4

11

16

2

1 time per week

6

0

1

2

3

Never

516

136

122

120

138

How long do your beach holidays last?

Less than 15 days

263

76

71

56

60

15-30 days

206

34

52

71

49

more than 30 days

131

40

27

23

41

What is attitude about sunbathing?

I do not sunbathe because they are dangerous

140

10

40

60

30

While I am at the beach I stay in the shade or swim

142

48

60

28

6

I like sunbathing sometimes

157

42

28

22

65

I really like sunbathing and tanning

161

50

22

40

49

What do you think about skin tanning

I think the tanning makes me look better/ prettiest

195

72

48

64

11

The bodyskin looks healthier when I tan

175

33

64

38

40

Most of my friends want to be suntanned

167

45

38

48

36

Attitude towards sun protection

I am ashamed to apply sunscreen in front of my friends

191

42

36

93

20

Wearing a blouse on the beach does not make you look good.

235

39

93

28

75

My parents do not protect themselves from the sun, so I do not think it is necessary to protect myself from the sun.

174

69

21

29

55

In a multivariate regression analysis, we have evaluated the association between adolescent self-report knowledge, behavior, and attitudes towards sun protection. In table 7 we have presented all the questions that show a strong significant association.

Table 7: Association between adolescent knowledge, behavior, attitude and sun protection

Questions

p value

Do you use sunscreen or sun oil with spf?

p=0.02

Do you reapply sunscreen

p < 0.0001

There is nothing that can prevent skin cancer

p < 0.0001

Do you know what melanoma is?

p = 0.04

Sunscreens with a factor 15 or less cannot protect you

p = 0.035

One application of sunscreen protects you for at least 4 hours

P = 0.007

How long do your beach holidays last?

p < 0.0001

What is attitude about sunbathing?

p = 0.0096

What do you think about skin tanning

p < 0.0001

Melanoma is the most dangerous type of skin cancer that can cause death

p = 0.049

Where did you get the information about melanoma?

p < 0.0001

Family history of skin cancer

p = 0.017

Frequent sunburns in childhood increase the risk of skin cancer in older age?

p = 0.018

I am aware that sun / UV exposure can cause skin cancer

p = 0.0027

Does your skin burn when you go to the beach for sunbathing?

p = 0.0007

The sunlight is more harmful to dark skin than to light skin

p < 0.0001

The sunlight is harmful to your skin only when you have sunburn in summer

p = 0.0032

How often do you use sunscreens with protective factor?

p < 0.0001

A suntan makes me feel healthier

p = 0.0007

Did you have controlled your mole?

p < 0.0001

Sunlight is stronger and harmful from 11:00 to 16:00

p = 0.027

Sunscreen provide protection from UV rays

p = 0.016

Solariums are a safe way to get skin tan

p < 0.0001

Do you reapply sunscreen

p < 0.0001

Discussion
Human exposure to solar ultraviolet radiation has important public health implications. Evidence of harm associated with overexposure to UV has been demonstrated in many studies [11,12,19]. Skin cancer and malignant melanoma are among the most commonly diagnosed cancer in the United States and affects the quality of life, and they can be disfiguring or even deadly most cases are preventable [3,6,7,20]. Unprotected UVR exposure has been reported as the single most important environmental risk factor. This study was carried out to evaluate the high school adolescent’s knowledge, attitude, behaviors, and sun protection measures regarding the sun protection. This cross-sectional study in four districts shows a relative level of knowledge among our adolescents regarding the harmful of UV and the problems that cause in the skin. We selected four different districts based on some characteristics.

Tirana is the capital city of Albania and almost 1 million people live here. Tirana capital city of Albania is among the wettest and sunniest cities in Europe, with 2,544 hours of sun per year. Durrës is the second city regarding the socioeconomic level and several populations. Also, this city is located on a flat plain along the Adriatic Sea Coast. Saranda is located on the Ionian Sea coast and has a typically Mediterranean climate with over 300 sunny days a year. Berat and Skrapar districts are located in the south of the country and are surrounded by mountains and hills. We have recruited an equal number of adolescents (150) for each district selected for this study. Based on the analyses of the self-reported questionnaires, males presented a predominance compared to females 52 % and 48 % respectively. On the other hand, females presented a good knowledge and attitude about protection from the sun versus males. We find a strong significance between them p=0.001. This finding is similar to another study carried out by Janjani et al, which showed a significant correlation between sex and the students’ knowledge and protection behavior [21]. Owen et al, found that the level of knowledge in males in the age group 16- 25 was lower than in other age groups [22] but, Terzi et al, found a good level of knowledge in patients in the 16-24 and 25-44 age groups and those pieces of knowledge were statistically significantly higher than in the 45-64 age group and those older than 65 years. Their finding was be explained by the fact that patients in the 16-24 age group who took part in our study had a higher level of education [23]. In our study, adolescents 17-20 years old presented a higher number of participants (67.2 %) compared to the age groups 14-16 years old (32.8 %). Also, in this age, we investigate good knowledge, attitudes, and behaviors related to protection from the sun. Related to the district analyses we find a strong association for the age groups' p-value of 0.0001. Most of the adolescents referred that living in urban areas 71.8 % and the higher number of adolescents were shown for grades school 11-12 without an association p-value of 0.051.

Regarding the type of skin and their personal information, 71 % of adolescents presented fair skin, and 67.8 % have at least 1 more burn during childhood. We found a correlation between the history of previous sunburn during childhood or skin type and knowledge level. We found varying levels of knowledge regarding the melanoma and effects of sunbathing or the number of moles in an individual is related to the risk of developing melanoma. Percentage regarding the knowledge and attitude of our adolescents were high compared to a study carried out on Greek adolescents. The results of this study show that the sun exposure knowledge of the Greek adolescents studied was insufficient and they reported risky behaviors in the summer months [11]. But the finding in our study was less compared to another study conducted by Benvenuto- Andrade et al in Brazil. They have administered a questionnaire to 724 students about ultraviolet radiation effects, opinions about tanning, total time of sun exposure per day, photoprotection, and activities in the sun and about 90 % were aware of the association between sun exposure and skin cancer, and mass media was the main source of information [24]. The knowledge level of the participants regarding sun exposure as a risk factor problem for causing skin cancer. We found that most adolescents had good knowledge about sun exposure as a cause of skin cancer and its impact on health. But we found a contrast regarding the knowledge of melanoma, so, most of them 61.5 % did not know what is. Our adolescents know the effect sun exposure may affect their health, but they do not know what melanoma is.

Kaptanoğlu et al, found in their study that 44.5 % of the participants stated that their sources of information on the ways of sun protection were television, magazines, and newspapers [25]. In our study, most of the adolescents have taken the information about melanoma from the internet 35.9 % and TV and radio 22.5 %. Only 1.5 % of adolescents have a family history of skin cancer.

Many studies present that people with white complexion show more protective behaviors against sunlight because they are more susceptible to sunlight [21,26]. In contrast to that, some studies suggest that the youth find tanned skin tones more attractive than pale skin. In the US, the incidence of skin tanning was higher among women, younger people, and those with brightly colored skin and it seems tanning is still prevalent despite the well-publicized risks [27,28].

However, in our study, the great majority of adolescents believed that tanning improved their appearance and that it was worth taking the risk. So, 51 % of adolescents think that a suntan makes them look more beautiful; 50.3 % think that suntan makes them feel healthier and 38.2 % think that solariums are a safe way to get skin tan. Avoiding the sun at midday was found as the most frequently used sun protection method in these adolescents. Because avoiding the sun at midday and staying in the shade as their sun avoidance behaviors rather than wearing more covering clothes for protection from the sun, wearing hats, and wearing sunglasses. This can be explained by the fact that physical methods such as wearing hats and sunglasses and using SPPs are more difficult to implement in practice. Similarly finding were found and in some other studies were the sun protection method most widely used by those who cared about protection from the sun was not going out in the sun between 10:00 and 16:00 hours [29,30].

Related to sunscreen application attitude and practices among adolescents, most adolescents use always (28.3 %) and almost always (21.2 %) sunscreen with a protective factor. 39 % of adolescents do not use sunscreen or sun oil with SPF, 46.2 % use sunscreen only during the summer at the beach time and 14.8 % use sunscreen continuously in daily life. In our study, the use of SPPs was found to be significantly higher in those who had parents with a higher level of education, and in those with higher economic levels, those living in cities, and those with a higher level of knowledge of the harmful effects of sunlight and the ways of protection. Some reports about the rate of using SPPs show significant increases in those populations that have higher levels of education and high monthly income, especially women [31,32] Those facts are similar to our findings. According to the reapply of sunscreen, 8.5 % never reapply the sunscreen, 25.5 % reapply every 4 hours, 30.7 % reapply every 2 hours and 35.3 % reapply every hour. Regarding the sunbathing attitude, 23.3 % did not use sunbathing because they think that is dangerous 23.7 % referred that while they are at the beach they stay in the shade or swim 26.2 % like sunbathing sometimes, and 26.8 % like sunbathing and tanning all the time. Regarding the attitude towards sun protection 31.8 % declared that they were ashamed of applying sunscreen in front of their friends, 39.2 % declared that if they are wearing a blouse on the beach does not make them look good, and 29 % declared that their parents did not protect themselves from the sun, so they do not think that is necessary to protect their self from the sun.

In this study, adolescents referred to good knowledge and attitude regarding the effect of sun exposure on health. But the protective effects of sunscreen, with an overall poor to intermediate understanding among our participants. The participants were aware of the ability of a sunscreen to prevent skin cancer and aging [33- 36]. Furthermore, female students were significantly more aware of the protection offered by sunscreen against sunburn and skin aging and were compelled to utilize sunscreen due to their knowledge more than their male colleagues. A possible explanation for this could be the more image-conscious and appearance-focused nature of women compared with men [36]. Also, based on a multivariate regression analysis, we have evaluated the association between adolescent self-report knowledge, behavior, and attitudes towards sun protection. Most of our questions show a strong significance. So, we found an association between the use of sunscreen or sun oil with SPF p=0.02; reapply of sunscreen p < 0.0001; nothing that can prevent skin cancer p < 0.0001; One application of sunscreen protects you for at least 4 hours p = 0.007; Melanoma is the most dangerous type of skin cancer that can cause death p = 0.049, etc. All our finding regarding the association of the questions is given in table 7.

Conclusion
In this study, the adolescents presented relative knowledge regarding the sun effect and especially for the sun protection behavior. Meantime the attitudes and general knowledge about sun protection were significantly different among male and female adolescents. These results emphasize the need for the promotion of protective habits in our adolescents and the importance of engaging all responsible government especially staff involved in the school curricula in developing campaigns directed at this issue to achieve effective long-lasting results. Adolescents are aware of the effects of ultraviolet radiation on the skin, but campaigns have not successfully changed their sun exposure habits. Given the lack of awareness regarding the protective effects of sunscreen against skin cancer and aging, adolescents should be educated with the help of awareness campaigns and initiatives. Adolescents constitute an important audience for protection programs. Furthermore, the sun exposure and sun protection habits acquired during adolescence may have a significant impact on skin cancer incidence in the future.

Limitations
Questionnaires in this study are the instruments usually used to investigate health-related behaviors; they can be used in population studies and to assess the impact of interventions that have been implemented in the target population (adolescents). Related to our study, we have evaluated some limitations. Knowledge and attitude regarding sunscreen use were self-reported by the adolescents for a consequence we could not verify their refer. Almost half of the questionnaires were filled during the hot months of April to September which may not reflect sunscreen use attitudes and practices throughout the year, especially for the district that are not near the beach. Also, we do not arrive at recorded the frequency of sunscreen use per day by the adolescents so we think that this may be explored in future studies.

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