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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Cancer Educ. Author manuscript; available in PMC Jun 1, 2013.
Published in final edited form as:
PMCID: PMC3352971
Brief Report: Ultraviolet Radiation Exposure, Considering Acculturation Among Hispanics (Project URECAH)
Carolyn J. Heckman and Jessye Cohen-Filipic
Carolyn J. Heckman, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA;
C. J. Heckman ; Carolyn.Heckman/at/
Very few studies have examined acculturation of Hispanics as it relates to skin cancer prevention attitudes and behaviors. This pilot study used the Abbreviated Acculturation Rating Scale for Mexican Americans-II to classify 14– 25-year-old Hispanics as traditional, bicultural, or acculturated. More acculturated individuals reported significantly higher perceived benefits of ultraviolet radiation exposure and lower worry about skin damage than traditional individuals. Bicultural individuals reported using sunscreen significantly more often than acculturated individuals. These preliminary data suggest that more acculturated Hispanic young adults may demonstrate riskier skin cancer-related attitudes and behaviors than others.
Keywords: Hispanics, Skin cancer, Prevention, Acculturation
Hispanics have the highest rates of cutaneous and ocular melanomas among US minority groups, and their cutaneous melanoma rates are increasing [1]. Hispanics tend to be diagnosed with cutaneous melanomas at a younger age yet later in the course of their disease and have higher mortality rates than white individuals [1].
Several studies have found that skin cancer prevention behaviors such as seeking shade, and wearing protection such as sunscreen, sunglasses, and clothing are lower among minority groups including Hispanics than among whites (e.g., [2]), even when skin color or skin sensitivity to ultraviolet radiation (UV) is controlled for in statistical analyses. One study found that whereas white Hispanic (WH) high school students were more likely to tan deeply and use indoor tanning booths than white non-Hispanics (WNH), WH were also less likely to use skin protection strategies [3]. Despite these behaviors, WH believed that they are at lower risk of developing skin cancer than WNH did [3]. Regarding exposure behaviors, national studies of Hispanic adults have found that 20% reported having had a sunburn in the previous year [4], and 12% of Hispanic young adults reported having indoor tanned in the previous year [5], both definitive risk factors for melanoma.
The Operant Theory of Acculturation (OTA) posits that due to a variety of cultural consequences, health behaviors that have a low prevalence among low-acculturated minorities increase in prevalence with adaptation or acculturation to a new culture. In contrast, health behaviors that have a high prevalence among low-acculturated minorities decrease with acculturation [6]. Within the US currently, a paradox exists between ongoing prejudice and discrimination against those with naturally darker skin yet wide-spread preference for the appearance of tanned skin. Some individuals from Hispanic and Asian countries possess similar prejudices and in some cases bleach their skin, avoid the sun, or use protection such as parasols for this reason. These behaviors are uncommon among the general US population; thus, the OTA would posit that Hispanics may decrease such protective behaviors as they acculturate to the US.
Because the OTA pertains only to acculturation’s impact on the frequency of health behaviors, we utilized another theory to incorporate some additional variables that would potentially account for additional variability in behavioral frequency. The Health Belief Model (HBM) is an evidence-based theory that describes the health-related perceptions that predict health risk and protective behaviors, including skin cancer-related behaviors [7]. We have included the following variables from the HBM: perceived susceptibility to illness, perceived benefits of health behaviors, and health behaviors. According to the HBM, individuals who believe they are susceptible to skin cancer or photoaging and who believe that skin protection will benefit them by reducing their susceptibility, would be expected to be more likely to engage in skin protection behavior such as wearing sunscreen.
In the only series of skin cancer prevention studies focused on acculturation among Hispanics, Andreeva and colleagues found that a national sample of Hispanics with a higher level of acculturation were less likely to seek shade or wear sun protective clothing but more likely to report using sunscreen than less acculturated Hispanics (e.g.[8]). However, that study did not address UV exposure behavior. The purpose of the current study was to further assess the association of acculturation with skin cancer-related knowledge, attitudes, worry, and behaviors.
This pilot study was part of an educational collaboration between a high school science department and a cancer center in the suburbs of Philadelphia. The high school administration and the Institutional Review Board at the cancer center approved the study protocol. The design of the study was quantitative and cross-sectional.
Participants and Procedures
All Hispanic students in the high school were recruited and informed about the study by science teachers or science students affiliated with the study. Interested students attended a luncheon, read an information sheet, and completed surveys anonymously. Due to the low risk and anonymous nature of the study, written signed consent was waived by the IRB. We estimate that approximately 40% of the school’s Hispanic students participated in the study. Students then distributed to and collected materials from Hispanic family members and friends between the ages of 14 and 25 years using snowball sampling. Family and friends read an information sheet and completed the anonymous survey.
Participants completed self-report pencil and paper measures. Participants could choose to receive information and surveys in either English or Spanish. Individuals who volunteered to participate completed the survey and returned it in an unmarked sealed envelope to teachers, students, or research staff affiliated with the study.
Demographics and Background
Participants completed demographic and background items including age, gender, race, and country of origin.
Abbreviated Acculturation Rating Scale for Mexican Americans (ARSMA-II) [9]
The 12-item ARSMA-II scale assesses Hispanic acculturation to the US. It consists of two subscales: a Mexican (Hispanic) Orientation Subscale (MOS) and an Anglo Orientation Subscale (AOS). The internal reliability of these scales in the current study was: MOS—six items, alpha=0.92; AOS—six items, alpha=0.85. The items are averaged within the subscales, with higher scores on MOS and lower scores on AOS representing Hispanic traditionalism, moderate scores representing biculturalism, and high scores on AOS with low scores on MOS representing acculturation to mainstream US culture. The MOS score was subtracted from the AOS score, and then cut scores were used to determine acculturation classification: (1) traditional≤−0.07, (2) bicultural>−0.07 and <1.19, and (3) acculturated≥1.19. We believe the ARSMA-II is generalizable beyond Mexican Americans because relevant items refer to “Spanish” rather than “Mexican” culture.
Exposure and Protection Knowledge
We used nine true/false items from Lazovich and colleagues [10] (e.g., There’s nothing people can do to prevent skin cancer) and items generated for this population and study (e.g., Hispanic/Latino people do not get skin cancer) to assess knowledge about UV exposure, protection, and skin cancer. The knowledge score equals the number of items answered correctly out of a possible nine, with higher scores indicating higher levels of knowledge.
Worry About Skin Damage
We assessed worry about skin damage with two five-point Likert items, one asking how often one worries about skin cancer (1=never, 5=always) and another asking about how often one worries about skin photo-aging (1=never, 5=always).
Constructs from the Health Belief Model
Perceived Susceptibility to Skin Cancer and Photo-aging
Perceived susceptibility was assessed for both skin cancer and premature aging using one item each with response options from 0 to 7 (i.e., “How likely is it that you will develop skin cancer?” or “How likely is it that your skin will age too soon (e.g., wrinkles, age spots, leathery skin)?”).
Benefits of Exposure and Protection
A five-point Likert-type eight-item scale, was used to measure the benefits of skin protection (four items, alpha=0.78, e.g., Spending less time in the sun is an easy way to protect my health) and the benefits of UVexposure (four items, alpha=0.74, e.g., I look better when I have a tan) [11]. Items from each subscale were summed.
Exposure and Protective Behaviors
Three items assessing self-reported UV protection behavior included frequency of sunscreen use with a sun protection factor (SPF) of 15 or greater, frequency of wearing protective clothing and hats while in the sun, and attempts to seek out shaded areas while outdoors, all scored on a five-point Likert scale ranging from 1=never to 5=always. These items were drawn from the literature (e.g., [12]). We also used an open-ended question asking participants the typical number of hours spent in the sun per week during the summer.
The sample consisted of 74 Hispanic participants, from a high school in the suburbs of Philadelphia, and their young adult family and friends. Participants ranged in age from 14 to 25 years with a mean age of 16.47 years (SD=1.94 years). The sample was 46% female. Only 8% of the sample identified themselves as being of a race other than white. Sixty percent of participants reported that they had spent most of their childhood in the USA. Twelve percent of participants reported spending most of their childhood in Mexico, and 27% reported they had spent most of their childhood in another country. These countries included El Salvador (10.8% of total sample), Brazil, Costa Rica, Guatemala, and the Dominican Republic. Eighty-one percent of the sample completed the survey in English, whereas 19% completed the survey in Spanish. The sample had the following skin cancer-related characteristics: sunburned in last year=35.1%, ever used sunless tanners=30.11%, knows someone with skin cancer=18.9%, sunbathes in summer= 14.9%, ever used a tanning bed=9.5%.
The mean scores, standard deviations, and possible ranges of the scales of interest are presented in Table 1. On the Abbreviated Acculturation Rating Scale for Mexican Americans II, 29.7% (n=22) of the sample was classified as traditional, 33.8% (n=25) was classified as bicultural, and 36.5% (n=27) was classified as acculturated.
Table 1
Table 1
Scale means, standard deviations, and ranges
A one-way analysis of variance (ANOVA) was used to test for differences in worry about skin cancer as a result of UVexposure among the three acculturation groups (traditional, bicultural, and acculturated). Worry about skin cancer differed significantly across the three groups, F (2, 71)=6.40, p=0.003. Tukey post hoc comparisons of the three groups indicated that the traditional group (M=2.64, 95% CI [2.21, 3.06]) had significantly higher worry about skin cancer than the bicultural group (M=2.00, 95% CI [1.62, 2.38]), p=0.044 or the acculturated group (M=1.74, 95% CI [1.42, 2.06]), p=0.002.
A one-way ANOVA was used to test for differences in worry about photo-aging as a result of UV exposure among the three acculturation groups. Worry about photo-aging differed significantly across the three groups, F (2, 71)= 4.87, p=0.01. Tukey post hoc comparisons of the three groups indicated that the traditional group (M=3.18, 95% CI [2.66, 3.71]) had significantly higher worry about skin photo-aging than the acculturated group (M=2.04, 95% CI [1.54, 2.53]), p=0.007.
A one-way ANOVA was used to test for differences in perceived benefits of UV exposure among the three acculturation groups. Perceived benefits of UV exposure differed significantly across the three groups, F (2, 71)=4.07, p= 0.021. Tukey post hoc comparisons of the three groups indicated that the acculturated group (M=12.59, 95% CI [11.11, 14.08]) had significantly higher levels of perceived benefits of UV exposure than the traditional group (M=9.64, 95% CI [7.91, 11.36]), p=0.018.
A one-way ANOVA was used to test for differences in the use of sunscreen of at least SPF 15 among the three acculturation groups. Use of sunscreen of at least SPF 15 differed significantly across the three groups, F (2, 70)=3.993, p< 0.023. Tukey post hoc comparisons of the three groups indicate that the bicultural group (M=3.36, 95% CI [2.79, 3.93]) reported using sunscreen of at least SPF 15 significantly more often than the acculturated group (M=2.40, 95% CI [1.96, 2.85]), p=0.020.
One-way ANOVAs were used to test for differences in knowledge, perceived susceptibility to premature photo-aging, perceived benefits of skin protection, hours per week outside in the sun during the summer, and use of protective clothing or shade among the three acculturation groups. No significant differences were found among the groups for these variables. Because perceived skin cancer susceptibility was highly skewed, we dichotomized this variable. Based on a chi-square analysis, perceived skin cancer susceptibility did not differ significantly across the groups.
Our findings are consistent with prior literature demonstrating risky skin cancer-related attitudes and behaviors among US Hispanics (e.g., [2]). We found that acculturation was positively associated with perceived benefits of UV exposure in that the acculturated group reported higher perceived benefits of UV exposure than the traditional group. We found that acculturation was negatively associated with adequate sunscreen use (among acculturated vs. biculturals) as well as worry about skin cancer (among traditional vs. either of the other groups) and worry about photo-aging (among traditional vs. acculturated). We did not find significant associations between acculturation and knowledge or the other attitudinal or behavioral variables; however, this may be due to the small sample size.
These findings are generally not consistent with the Operant Theory of Acculturation, which posits that engagement in health behaviors changes over time with acculturation and will increase or decrease depending on the frequency of the behavior in the prior and current locales. In Hispanic countries where lighter skin is preferred, skin protection is popular. In the USA, UV exposure is popular, and UV protection is not. Prior studies found acculturation among US Hispanics to be associated with lower levels of use of shade and protective clothing but higher levels of sunscreen use (e.g., [8]). Thus, we might have expected skin cancer prevention attitudes and behaviors (other than sunscreen use) to decrease with acculturation and most skin cancer risk attitudes and behaviors to increase with acculturation.
That acculturation was associated with lower skin cancer prevention-oriented attitudes and behaviors and higher risk attitudes and behaviors is worrisome given the existing cancer disparities in terms of adult Hispanics’ (particularly individuals with low SES) being more likely to be diagnosed with more severe melanoma earlier than their white counterparts as well as to die from melanoma [1, 13].
Strengths of the study are that it addresses an understudied issue related to cancer disparities and is theoretically-based. Limitations are the small self-selected convenience sample, which precluded comparisons among Hispanic subgroups, the use of some single item and very brief measures, and the fact that SES was not assessed.
A recent policy update by the American Medical Association and a recent review article noted the need for the skin cancer prevention field to target specific population sub-groups such as communities of color to help decrease the overall burden of skin cancer in the US [14, 15].
Contributor Information
Carolyn J. Heckman, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA.
Jessye Cohen-Filipic, Portland VA Medical Center, 3810 SW U.S. Veterans Hospital Road, Portland, OR 97239, USA ; JessyeCohen/at/
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