INTRODUCTION

The deleterious effects of solar ultraviolet (UV) radiation on human health are increasing, particularly due to thinning of the ozone layer.1,2 Although all humans are at risk of skin cancer, the risk is higher among those with light skin, with prolonged exposure to the sun, and with histories of sunburn in childhood.3 Heavy UV rays are associated with skin cancers, particularly melanoma.4 The most important factor in terms of protection against skin cancer, irrespective of skin type, is sun protection at early ages. Exposure to the sun is particularly common in childhood, and maternal and paternal behaviors constitute a model for children. Parental behaviors in terms of protection from or avoidance of the sun are important in protecting their children against harmful rays and promoting appropriate habits at an early age.5,6

However, parents may not be aware of the importance of their behavior on this subject. The number of studies on the subject in Turkey is limited, and knowledge levels in the country are low.7 This study aimed to draw attention to the increasing prevalence of skin cancers to increase parental knowledge levels regarding solar protection and skin cancers and awareness of protective practices.

METHODS

This cross-sectional study was performed in Turkey between March and October 2022. Biological parents of children between the ages of 0 and 18 years who live in Turkey and could read Turkish were included. The authors collected data via an online questionnaire constructed using Google Forms that was sent to WhatsApp and Facebook groups (Arastiran Anneler, 17 thousand members; Doktor Anneler, 14 thousand members). Participants were included using the snowball sampling method. The questionnaire started with explaining how long the study would take, who the researchers were, the purpose and content of the study, and their informed consent. Ethical committee approval was obtained before the data collection commenced (OMUKAEK 2021/445). A needed sample size of 384 was calculated with 95% reliability and 50% probability.

The questionnaire was produced by the authors based on a review of the relevant literature. It was compulsory to complete all questionnaire items, so there were no missing data. The first part contained questions about parental characteristics, solar protection behaviors, skin cancer risk perception, and checking oneself for skin cancer. The second part investigated the children’s characteristics, behaviors aimed at protecting the child against the sun, skin cancer risk perception in terms of the child, and examining the child’s skin. The Fitzpatrick scale was used for skin color typing. Fitzpatrick skin types I, II, and III were grouped as “light skin” and IV, V, and VI as “dark skin.”8 The Skin Cancer and Sun Knowledge (SCSK) scale was provided in the third section of the survey.

Skin Cancer and Sun Knowledge Scale

The SCSK scale consists of 25 items intended to evaluate knowledge concerning solar protection, tanning, skin cancer, signs of the disease, and risk factors for it. These consist of 15 true-false items and 10 multiple-choice questions. Each correct item response is scored 1, and each incorrect answer is scored 0. Possible scores on the scale range between 0 and 25. Higher scores indicate higher levels of knowledge. The SCSK scale was developed by Day et al,9 and the Turkish validity and reliability study was conducted by Haney et al.10

Statistical Analysis

The authors analyzed the data using IBM SPSS Statistics version 21.0 (IBM Corp). Findings were expressed as number, percentage, mean, and SD. The χ2 test was used in the comparison of categorical variables. Continuous variables were evaluated using normality of distribution tests and graphics. The independent-samples t test was used to compare continuous variables between two groups, and analysis of variance among more than two groups. The least significant difference was used in post hoc analyses. Differences between groups were shown using superscript alphabetic characters. Multivariate logistic regression was performed using the stepwise method. Odds ratio and 95% CI values were given. P < .05 was considered statistically significant.

RESULTS

A total of 465 parents took part in the study, of whom 57.4% were 35 years or older, 60.2% were women, 65.8% were educated at the university level or above, 47.1% had income equal to their expenses, and 52.7% had two children. In addition, 83.2% of the participants were light-skinned, and 36.6% had experienced red or painful sunburns in the previous year. A family history of skin cancer was present in 11.4% of parents, 63.0% regarded themselves as being at low risk of skin cancer, and 13.8% had examined themselves from head to foot for skin cancer. In terms of sun protection, 37.8% of parents used sunscreen, 19.4% wore long-sleeved clothing, 21.5% wore headgear, 48.6% stayed in the shade or under sunshades, and 64.5% wore sunglasses (Table 1).

Table 1. - COMPARISON OF SKIN CANCER AND SUN KNOWLEDGE SCALE SCORES BY PARENT SOCIODEMOGRAPHIC AND SUN PROTECTION CHARACTERISTICS Variable n (%) Mean ± SD P Age, y .000 ≤35 198 (42.6) 13.2 ± 4.5 >35 267 (57.4) 15.1 ± 3.6 Sex .000 Male 185 (39.8) 13.1 ± 4.4 Female 280 (60.2) 15.1 ± 3.6 Education level .000 High school or less 159 (34.2) 11.1 ± 3.8 University or advanced degree 306 (65.8) 16.0 ± 3.2 Economic status .000 Income < expenses 133 (28.6) 11.0 ± 3.9a Income = expenses 219 (47.1) 15.2 ± 3.3b Income > expenses 113 (24.3) 16.5 ± 3.3c No. of children .802 1 165 (35.5) 14.4 ± 4.3 2 245 (52.7) 14.4 ± 4.0 ≥3 55 (11.8) 14.0 ± 3.6 Parent skin type .002 Lighter-skinned 387 (83.2) 14.6 ± 4.0 Darker-skinned 78 (16.8) 13.0 ± 4.4 Family history of skin cancer .448 Yes 53 (11.4) 13.9 ± 4.7 No 412 (88.6) 14.4 ± 4.0 Perception of skin cancer risk .000 None 76 (16.3) 12.0 ± 3.9a Low 293 (63.0) 14.2 ± 4.1b Medium 79 (17.0) 16.3 ± 2.9c High 17 (3.70) 18.1 ± 2.6c Skin self-examination (head-to-toe) .127 Yes 64 (13.8) 15.0 ± 4.8 No 401 (86.2) 14.2 ± 4.0 Sunburn in the past 12 mo .282 No 295 (63.4) 14.2 ± 4.0 Yes 170 (36.6) 14.6 ± 4.3 Use of sunscreen .000 No 289 (62.2) 13.4 ± 4.2 Yes 176 (37.8) 15.9 ± 3.3 Wearing long-sleeved clothing .000 No 375 (80.6) 14.0 ± 4.1 Yes 90 (19.4) 15.7 ± 3.6 Wearing headgear .000 No 365 (78.5) 14.0 ± 4.2 Yes 100 (21.5) 15.5 ± 3.5 Seeking shade .000 No 239 (51.4) 12.8 ± 4.2 Yes 226 (48.6) 15.9 ± 3.3 Wearing sunglasses .000 No 165 (35.5) 13.3 ± 4.0 Yes 300 (64.5) 14.9 ± 4.0

The parents’ mean SCSK scale score was 14.3 ± 4.1. The SCSK scale scores were higher among parents older than 35 years (P = .000), mothers (P = .000), individuals educated at the university level or higher (P = .000), with income exceeding expenses (P = .000), light-skinned individuals (P = .002), and those who regarded themselves as being at a high risk of skin cancer (P = .000). The SCSK scale scores were also higher among parents who used sunscreen (P = .000), wore long-sleeved clothing (P = .000), wore headgear (P = .000), stayed in the shade or under sunshades (P = .000), and wore sunglasses (P = .000). No differences in mean SCSK scale scores were found by number of children, family history of skin cancer, skin self-examination, or presence of red or painful sunburn in the previous year (Table 1).

In terms of the children, 40.6% were aged 0 to 5 years, 58.1% were boys, and 89.7% were described as light-skinned. In addition, 20.2% of families regarded their children as having no risk of skin cancer, and 43.8% regarded their children as being at low risk. Only 14.6% of parents had examined their children from head to foot for skin cancer in the past year, and 42.4% of children had experienced red or painful sunburn in the previous year. Moreover, 38.5% of parents discussed sun protection with their children, and 16.3% reported that their children had received such information from physicians.

In terms of protecting their children against skin cancer and the sun, 62.3% of parents reported applying sunscreen, 9.7% made children wear long-sleeved clothing, 60.0% made them wear headgear, 61.1% made their children stay in the shade or under sunshades, and 32.3% made them wear sunglasses (Table 2). The SCSK scale scores were higher among parents with children 6 years or older (P = .000), with dark-skinned children (P = .008), who regarded their children as at high risk of skin cancer (P = .000), who examined their children for skin cancer (P = .010), whose children had experienced a red or painful sunburn in the previous year (P = .000), who informed their children about skin cancer/sun protection (P = .000), and whose children were informed about such protection by a physician (P = .006). Parents who applied sunscreen to their children for sun protection (P = .000), who made them wear long-sleeved clothing (P = .000), who made them wear headgear (P = .003), who made them stay in the shade or under a sunshade (P = .000), and who made them wear sunglasses (P = .000) also registered higher SCSK scale scores (Table 2).

Table 2. - A COMPARISON OF SKIN CANCER AND SUN KNOWLEDGE SCALE SCORES BY CHILD CHARACTERISTICS AND PARENTAL PROTECTION MEASURES Variable n (%) Mean ± SD P Child age group, y .000 0-5 189 (40.6) 13.2 ± 4.4a 6-11 178 (38.3) 14.9 ± 3.9b 12-18 98 (21.1) 15.4 ± 3.3b Child sex .182 Male 270 (58.1) 14.1 ± 4.1 Female 195 (41.9) 14.6 ± 4.0 Child skin type .008 Light-skinned 417 (89.7) 14.2 ± 4.2 Dark-skinned 48 (10.3) 15.5 ± 3.2 Perception of the child’s risk of skin cancer .000 Not at all 94 (20.2) 12.2 ± 3.8a Low 250 (53.8) 14.8 ± 3.8b Moderate 106 (22.8) 14.5 ± 4.4b High 15 (3.20) 18.5 ± 2.4c Skin cancer examination of child .010 Yes 68 (14.6) 15.5 ± 4.4 No 397 (85.4) 14.1 ± 4.0 Child had red or painful sunburn in the previous year .000 No 268 (57.6) 15.2 ± 3.5 Yes 197 (42.4) 13.1 ± 4.5 Parent informed child about skin cancer or sun protection .000 Yes 179 (38.5) 15.6 ± 3.3 No 286 (61.5) 13.5 ± 4.3 Parent received information from a physician about skin cancer or sun protection for the child .006 Yes 76 (16.3) 15.5 ± 4.1 No 389 (83.7) 14.1 ± 4.1 Applying sunscreen to the child .000 No 222 (47.7) 13.6 ± 4.3 Yes 243 (52.3) 15.0 ± 3.8 Making the child wear long-sleeved clothing .000 No 420 (90.3) 14.1 ± 4.1 Yes 45 (9.70) 16.3 ± 3.1 Making the child wear headgear .003 No 186 (40.0) 13.6 ± 4.2 Yes 279 (60.0) 14.8 ± 4.0 Making the child stay in the shade or under a sunshade .000 No 181 (38.9) 13.3 ± 4.1 Yes 284 (61.1) 15.0 ± 4.0 Making the child wear sunglasses .000 No 315 (67.7) 13.7 ± 4.4 Yes 150 (32.3) 15.5 ± 3.1

A comparison of children by age group revealed significant variation in terms of perceptions of children’s risks of skin cancer, informing children about skin cancer, having them wear long-sleeved clothing and headgear, and making them wear sunglasses. Whereas parents with young children require children to wear long-sleeved clothes and headgear, parents with older children mostly inform their children about skin cancer and make them wear sunglasses (Table 3).

Table 3. - A COMPARISON OF PARENTS’ PERCEPTIONS, ATTITUDES, AND PRACTICES TOWARD SUN PROTECTION BY CHILD AGE Variable 0–5 y, n (%) 6–11 y, n (%) 12–18 y, n (%) P Perception of the child’s risk of skin cancer .017 No risk 50 (26.5) 29 (16.3) 15 (15.3) Low 87 (46.0) 105 (59.0) 58 (59.2) Moderate 45 (23.8) 42 (23.6) 19 (19.4) High 7 (3.7) 2 (1.1) 6 (6.1) Head-to-toe skin cancer examination of the child .351 No 156 (82.5) 156 (87.6) 85 (86.7) Yes 33 (17.5) 22 (12.4) 13 (13.3) Child had red or painful sunburn in the previous year .145 No 99 (52.4) 111 (62.4) 58 (59.2) Yes 90 (47.6) 67 (37.6) 40 (40.8) Parent informed the child about skin cancer or sun protection .000 No 154 (81.5) 92 (51.7) 40 (40.8) Yes 35 (18.5) 86 (48.3) 58 (59.2) Parent received information from a physician about skin cancer or sun protection regarding the child .291 No 154 (81.5) 155 (87.1) 80 (81.6) Yes 35 (18.5) 23 (12.9) 18 (18.4) Making the child use sunscreen .881 No 89 (47.1) 84 (47.2) 49 (50.0) Yes 100 (52.9) 94 (52.8) 49 (50.0) Making the child wear long-sleeved clothing .047 No 164 (86.8) 168 (94.4) 88 (89.8) Yes 25 (13.2) 10 (5.6) 10 (10.2) Making the child wear headgear .009 No 63 (33.3) 72 (40.4) 51 (52.0) Yes 126 (66.7) 106 (59.6) 47 (48.0) Making the child stay in the shade or under a sunshade .339 No 68 (36.0) 69 (38.8) 44 (44.9) Yes 121 (64.0) 109 (61.2) 54 (55.1) Making the child wear sunglasses .000 No 144 (76.2) 120 (67.4) 51 (52.0) Yes 45 (23.8) 58 (32.6) 47 (48.0)

The factors affecting parental protective behaviors were evaluated using multivariate logistic regression analysis (stepwise method). The behaviors the parents impressed upon their children reflected their own behaviors. The factor most affecting the parental application of sunscreen to their children was their own use of sunscreen (odds ratio = 5.27, 95% CI = 3.46-8.02). The most significant factor affecting parents making their children wear long-sleeved clothing was their own use of such clothing (odds ratio = 3.22, 95% CI = 1.69-6.16). The most important factor affecting parents making their children wear headgear was also their own use of such headgear (odds ratio = 2.53, 95% CI = 1.53-4.18). The most important factor affecting parents making their children stay in the shade or under a sunshade was parents’ own exhibition of such behavior (odds ratio = 3.76, 95% CI = 2.53-5.61). Similarly, the most important factor affecting parents making their children wear sunglasses was their own use of sunglasses (odds ratio = 3.35, 95% CI = 2.10-5.35).

DISCUSSION

This study investigated the methods used by parents to protect themselves and their children from the sun and their attitudes and behaviors concerning harmful solar rays and skin cancer.

Despite regional climate differences, the number of sunny days in Turkey is higher than in many other countries.11 However, parental approaches to protecting both themselves and their children against the sun are limited. Studies have shown that although men spend more time outdoors, women are more aware of solar protection.9 Mothers’ mean total SCSK scale score in this study was 15.1 ± 3.6, compared with 13.1 ± 4.4 for fathers. Total SCSK scale scores were significantly higher in mothers, individuals educated to university level or higher, those whose income exceeded their expenses, light-skinned individuals, and those who perceived themselves to be at high risk of skin cancer. A study of university students in Turkey reported a higher level of knowledge among young women (15.28 ± 2.74) than in young men (14.19 ± 3.05).10 Scores in a study from Germany were 15.85 ± 3.20 for women and 14.33 ± 2.69 for men.12 The authors believe that this is because of social pressure on women to have light/fair skin and avoid wrinkles and sun spots to conform to cultural beauty standards.

Studies have shown that the parents of light-skinned children tend to use sun protection, particularly in the form of sunscreen, sunglasses, and protective clothing.13–15 However, the behavior of the parents in the present study, in which 9 of 10 children were light-skinned, is inconsistent with this finding.

Some parents in this study used sunscreen (37.8%), and 62.3% of children had sunscreen applied. The prevalence of sunscreen application to children in some previous studies ranges from 38.8% to 89%.16,17 One in 10 parents made their children wear long-sleeved clothing, compared with rates from other regions such as 75% in California and 92% in Paris.17,18 Parents may think that long-sleeved clothing will be uncomfortable for their children on hot sunny days and that they will be more comfortable wearing short-sleeved clothing. In the present study, the most important reason for the higher rate of long-sleeved clothing use among parents themselves (19.4%) may have been mothers covering themselves up for religious reasons.

Three of five parents in this study made their children wear headgear. Equivalent figures between 29% and 96% have been reported in other studies.17,18 The use of headgear in this study was considerable, and this was the most important form of solar protection. The analysis also showed that 61.1% of parents sought shade for their children or kept them under sunshades, and 48.6% engaged in such behavior for themselves. Rates of seeking shade in the literature vary widely, from 7% to 69%.2,19 Remaining in the shade is a highly protective method and one implemented by the great majority of participants.

Although two of three parents used sunglasses themselves, only one in three made their children wear them. The use of sunglasses varies widely in previous studies, from 8% to 63%.17,18 These authors posit that mothers and fathers regard sunglasses not only as a form of solar protection but also as a fashion accessory, which may have increased the level of parental use. Görig et al19 reported less widespread use of shade-seeking and sunglasses in their study conducted in Germany.

One in three parents, and almost half of the children, had experienced a red or painful sunburn in the previous year. The risk of melanoma is reported to increase with the number of lifetime sunburn events, and the presence of painful sunburns in childhood doubles the probability of melanoma in adulthood.20 The prevalence of melanoma is increasing rapidly in such countries as Australia, New Zealand, and the US.21 High rates of sunburn among children are therefore a cause for concern.20,21 Prevalence rates of sunburn of 21.8% in Germans and 35% in Danes have been reported.19,22 Even levels in developed countries are considerable; it seems all countries could improve solar protection among children. Further, solar protection is not by itself sufficient for preventing skin cancer.10 As with many types of cancer, the course and treatment of skin cancer are much improved when it is detected early. However, only one parent in eight in this study reported examining themselves and their children for signs of skin cancer. Although 15% of parents who examined themselves were diagnosed with skin lesions without progression to melanoma in one study, the incidence of melanoma was significantly lower than in the control group.23

One parent in eight had been educated about skin cancer by a physician. In a survey study from Germany, 81% of participants obtained information from a physician, and 34% over the internet.24 Healthcare workers represent the most reliable source of information. Both family physicians and pediatricians should regard every examination as an opportunity from this perspective and should inform families, children, and adolescents capable of understanding them about means of solar protection and dermatologic signs and symptoms requiring further evaluation.

Three of five participants in this study regarded their own risk of skin cancer as low, and more than half regarded their children as being at low risk, with one in five believing their children were not at risk. Hall et al25 reported that three of four adults regarded themselves as having a high risk of skin cancer in the future. A study from Europe reported that 46% of participants were concerned about skin cancer.26 The participants in the present study were thus less worried about skin cancer than individuals living in the US and Europe.25,26 This may be attributable to public health campaigns run in these countries, both in schools and in the media, to inform their populations about skin cancers and to raise awareness of solar protection, and to insufficient development of such campaigns in Turkey.

Bruce and Cowan27 found that giving healthcare workers information about protecting their children against skin cancer increased their levels of knowledge. Almost all the participants in that study reported encouraging their children to use sunscreen and supporting changes in their behavior. However, only one in three reported that they were likely to use sunscreen or solar protection themselves. Although appropriate parental education is important, parental behavior is particularly motivating and exemplary for children. In their 2019 study, Pérez and Bashline28 reported that although monitoring by physicians is particularly important for high-risk children, attitudes and behaviors exhibited by parents/role models are a more important risk factor among low-risk children.28

The measures adopted for protection by parents were consistent with the measures they applied to their children in this study. It appears to be of crucial importance to reinforce the parental role model with information and education, given what an important factor it is in encouraging children to engage in solar protection.29

Limitations

This study should be considered in terms of the evaluation of parental attitudes toward skin cancer and sun protection in Turkey. However, parents were contacted via social media, and only a specific parent group (those using social media) was thus enrolled. The results are limited by the high levels of education and income and the predominantly fair skin types of the children and parents. This study was conducted online due to the COVID-19 pandemic. It was based on self-report and may therefore contain response bias. It also may contain recall bias regarding the sun protection behavior of parents and their children. Parents may also have stated that they did apply solar protection strategies that they knew to be correct when they did not actually use them (to attract a desired social reaction).

This study provides descriptive information for parents and their children; future studies with a balanced distribution of participants with different skin types, a balanced distribution of individuals with lower and higher economic status, and in-person studies with large samples are required.

CONCLUSIONS

The results o