‘Risky sun tanning behaviours amongst Irish University students: A quantitative analysis’.
Caragh Flanneryᵃ*, Lee-Ann Burkeᵇ, Linda Graingerᶜ, Peter Williamsᶜ, Heather Gageᶜ
ᵃHealth Behavioural Change Research Group, National University of Ireland, Galway, ᵇ Department of Economics, University College Cork, Cork, Ireland, ᶜ School of Economics, University of Surrey, Guildford, UK.
Ms Caragh Flannery, Health Behavioural Change Research Group, National University of Ireland, Galway. , 021 4205514
Prof Heather Gage, School of Economics, University of Surrey, Guildford, UK. , Telephone 01483 686948
Dr Lee-Ann Burke, Department of Economics, University College Cork, Cork, Ireland. ,021 902464
Dr Linda Grainger, School of Economics, University of Surrey, Guildford, UK.
, Telephone 01483 686219
Mr Peter Williams, Department of Mathematics, University of Surrey, Guildford, UK. , Telephone 01483 689641
Research was conducted in University College Cork.
Acknowledgements: No external funding
Conflict of interest: None declared by any author
* Corresponding author:
Background
Despite its temperate maritime climate, research has indicated that Ireland has the third highest rate of malignant melanoma in the European Union[1].One in three people will develop skin cancer during their lifetime [1]; more than 800 new cases of melanoma were diagnosed between 2008 and 2010, and over 100 deaths occurred [2]. Because Ireland experiences relatively low levels of sunshine, the Irish population believe they are at less risk of developing skin cancer, and deliberate sunbathing behaviours are increasing [3]. Ireland’s population, however, is predominantly fair skinned and therefore has increased susceptibility to burning in the sun and risk of developing skin cancer [4,5]. With budget flights and package holidays on the increase, it has become much easier to reach sunny resorts, and this may lead to further increases in skin cancer in future years, particularly amongst younger people who tend to travel more, and to deliberately engage in risky sun tanning behaviours [6-8]. The study reported in this paper aimed to improve understanding of the factors associated withdeliberate tanning practices amongst younger people in Ireland to inform the design of preventive strategies that address this type risk taking behaviour.
Methods
The research adopted a quantitative approach. Self-reported sun exposure was investigated by means of a cross sectional survey of studentsat the University of Cork, in Ireland. A questionnaire was developed using selected items that had been used in previous studies of sun tanning behaviours [5,6,9,10], and that explored factors that relevant literature suggested might predispose young people to such activity.Items included in the questionnaire are shown in Table 1.
Table 1 goes here
The questionnaire was set up using ‘Survey Monkey’, an online facility for collecting questionnaire data [11]. An email inviting participants was sent by the Universities U-mail Moderator to a random sample of 10,000 students (from total roll of 18,820) in April 2010. Prior to data collection, a favourable ethical opinion was obtained from the Ethics Committee of the University College Cork, under the agreement that data collected were anonymous and confidential. Prior to the main mailing, a pilot study of 100 participants was conducted, after which minor refinements were made to the wording.
Analysis
The data were cleaned and transferred into STATA for analysis [12]. All questionnaires returned were complete but scattered missing items reduced the sample size for some variables.Associations between intentions to tan and risk behaviour were explored using Pearson’s correlation. Associations between the dichotomous deliberate tanning behaviour variable and participant characteristics and views were explored (chi-squared tests for categorical variables, Mann-Whitney U for continuous). A probit regression model with adjustment for gender and age, was run to identify the attitudes and external influencesthat were associated with deliberate sun tanning behaviour. Bivariate analysis was used to investigate the personal characteristics associated with attitudes and influencesthat were revealed in the regression modelling to be significantly related to deliberate tanning (Kruskal-Wallis H test for ordinal data,Spearman rank correlation for continuous). Finally comparisons between people who reported deliberate sun tanning and those who did not were made with respect to use of sun protection practices and awareness of sun exposure risks.
Results
Characteristics of respondents
A total 833 responses were received from the random sample of 10,000 students (8.33%); age range 17-57 years, (mean 22, standard deviation 5.34), 75% female. A low number of respondents (11%) were risky drinkers, 15% were current smokers. There were 532 (63.9%) respondents stating they intended to get a tan next summer and 389 (46.7%) reporting they had deliberately tanned in the previous summer. There was a high positive correlation between intentions to tan and deliberate tanning behaviour (r =0.622; p<0.001).
Characteristics of participants reporting deliberate tanning behaviours
Women were significantly more likely than men to state they had deliberately tanned the previous summer(Table 2). Dark (rather than fair) complexion increased the likelihood of reporting tanning behaviour; being a current smoker or a risky drinker did not. Those who had deliberately tanned were significantly more likely to agree to each of the attitude questions and to be influenced by peers and media pressure(Table 2).
Table 2 goes here
Associations between deliberate sun tanning behaviour and respondents’ attitudes and external influences: results of probit regression modelling
Women were significantly more likely than men to engage in deliberate sun tanning behaviour, and that age (within this sample of young people) was not a significant influence(Table 3). Being a woman, rather than a man, increased the probability of deliberate tanning by 33.8%. Respondents that agreed with the statement ‘I enjoy tanning’ were significantly more likely to reportdeliberate tanning behaviour than those who neither agreed nor disagreed, and this indifferent group were significantly more likely to deliberately tan than those disagreeing. Agreement with the statement ‘it is worth getting a little burnt to get a tan’ was marginally associated with reporting deliberate tanning behaviour. Amongst the two external influences, respondents agreeing with the statement ‘I try to get a tan because my friends get a tan’ were significantly more likely to engage in deliberate sun tanning, but celebrity pressure was not a factor(Table 3).
Table 3 goes here
Personal characteristics and attitudes
Exploration ofthepersonal characteristics associated with the attitudes and influences linked with deliberate tanning revealed that enjoying tanning was significantly associated with being female (p=0.01), having a dark (rather than fair) complexion (p=0.001) and younger age (p=0.003). Thinking it was worth getting a little burnt to get a tan was also associated with younger age (p<0.0001), and marginally with having a dark complexion (p=0.06) and being a current smoker (p=0.06). Agreeing that ‘I try to get a tan because my friends get a tan’ was associated withyounger age (p=0.026), female (p=0.202) and current smoking status (p=0.017).
Awareness and sun protection practices
Respondents who did not deliberately tan (compared to those that did) reported use of the higherSPF (p=0.001), and higher proportions stayed inside (69.6% vs. 59.9%, p=0.004) and covered up (82.5% vs. 71.9%, p=0.001) in the sun.Neither self-reported skin checking (reported by around 60% of respondents) nor the number of sources of information accessed on skin risks (mean of 3), were significantly different between students who deliberately tan and those who did not. Television advertisements were the most frequently reported source while school and college was the least reported source of information. The mean number of sun burns over the last two years was similar for those who deliberate exposed themselves to the sun and those who did not (median 2; p<0.005).
Discussion
In the context of rising concerns about skin cancer in Ireland, this study investigated the factors associated with deliberate sun tanning behaviouramongst university students. Womenand students with a dark complexion were likely to report engaging in deliberate tanning. Enjoying tanning, thinking it is worth getting burnt to get a tan and being influenced by peer pressure also predicted deliberate tanning behaviours. Each of these attitudes were more prevalent amongst the younger students in the sample, the latter two were also associated with smoking.
These findings are consistent with other research that indicates, within the general population, that risky sun exposure practices are associated with cosmetic motives, especially amongst women, and social acceptance [6,13]. High proportions (70%) of women have been reported as deliberately seeking a tan, with almost 50% using oils to help do so [9]. Body image is an important factor influencing both men and women to engage in sun tanning activities, and most people (50 - 70%) have been found to agree that a suntan makes them feel more attractive [5,9]. Pale, yet healthy skin colour is no longer deemed desirable [14],and almost half (46%) of Irish individuals have stated that a tan made them feel healthier [5,10].
With the growth of fake tanning lotions, a bronzed appearance can be achieved without incurring the risks of sun exposure. Spray tan products, however, may themselves be viewed as unsafe [15]. Evidence suggests that spray tan users are predominantly young and female, and that they are more likely to suffer burns from the sun exposure than those who do not use the products [16,17]. This confirms that cosmetic and self image motives are not the only reasons underlying tanning behaviours, but that sun exposure is an enjoyable activity, and one that has been shown to have a positive effect on mood [18].
Previous research has shown that individuals may be aware of the risks of sun exposure but very few are willing to change their behaviour [6,19]. In this study, students reported accessing information about sun risks from various sources, but the majority still engaged in deliberate sun exposure or stated an intention to do so. Only 3% reported not using protective sun creams, although those who stated they deliberately tanned used lower SPF than those who did not. Theoretical approaches within economics and psychology seek to explain individual decision making about health-related risky behaviours. Behavioural economics is predicated on the empirical observation that individuals do not always act in a rational way, and in their own long term best interests, because they discount future risks and are influenced by factors that give more immediate gratification [20,21]. Accordingly, awareness of the risks of sun exposure has not been found to be a deterrent to deliberate sun tanning behaviours, or a motivation to use sun protection creams[8,13].Psychological theories similarly predict that people continue to engage in risky behaviours such as smoking and sun tanning because they do not believe they are susceptible to adverse effects [22,23].
The Irish Cancer Society recommends that multiple strategies should be implemented in Irish primary, secondary and third level education to tackle deliberate sun exposure behaviours and to ensure that bad sun exposure habits are not passed from childhood to adulthood [24]. Such strategies could improve sun protection practices, highlight the risks associated with sun exposure and incorporate sun safety into everyday life [25]. Effective communication is, however, difficult and needs to be carefully tailored to the audience. The results of this study suggest that impressionable younger students, and those who engage in other risky taking activities such as smoking, particularly need to be targeted. Appearance-based programmes, such as photo aging and wrinkles, and illustrations of skin damage have been used in hot sunny climates such as Southern California for this purpose [9]. Furthermore the use of skin cancer and surgery scarsimagery may provide an effective awareness method to highlight the risks associated with UV exposure. An intervention focussed on physical damage from the sun recorded a reduction in tanning indicating that appearance-based approaches can result in behaviour change [26].
The study has several limitations. A random sampling method was used to select the students from the University population to receive the questionnaire. No comparison of those invited to participate and either the whole student body, or respondents, is possible, so selection bias and response bias cannot be investigated. The response rate was low (8.33%), although this might be considered acceptable for online methods [27]. Mail methods, or approaches involving personal contact, can generate better responses, but were not feasible on cost or resource grounds. Another limitation is that the questionnaire did not include items to assess knowledge and understanding of sun risks amongst respondents, so deficiencies in this area were not uncovered.Moreover the definition of risky drinking (consumes alcohol on more than 2 days per week) may not accurately identify risky drinkers. The number of days that alcohol is consumed is only one dimension in screening for alcohol misuse [28].
Conclusion
Deliberate sun tanning is a form of strongly motivated risk taking as much in a sun-limited country like Ireland as in hotter sun-rich climates, and is most prevalent in younger women. These risk taking behaviours need to be addressed by public policy that targets the attitudes and influencesaround sun tanning of the vulnerable group, in conjunction with educational campaignsthat focus on the adverse effects of sun damage on the skin, and the full risks to health of sun burns. With peer pressure a significant influence on sun tanning behaviours, strategies for resisting this, and taking adequate protection when exposed to the sun, need to be offered. More research is needed to identify effective behaviour change approaches.
Compliance with Ethical Standards:
Funding:No external funding.
Conflict of Interest: None declared by any author.
(In case animals were involved) Ethical approval: This article does not contain any studies with animals performed by any of the authors.
(And/or in case humans were involved) Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
(In case humans are involved) Informed consent: Informed consent was obtained from all individual participants included in the study.
Acknowledgements: The authors thank two anonymous reviewers for helpful comments on an earlier draft of the paper.
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