Sun-protection behaviors among African Americans

Perceptions of Sun Protection, Skin Tone, Colorism, and Dermatologic Care Among South Asians in the USA

South Asians (SAs) are among the fastest growing populations in the USA. Colorism - the system of inequality that views lighter skin as more advantageous in society - is prevalent in SA culture. This study evaluates motivations of sun protection use, attitudes of colorism, and skin lightening (SL) practices among SA Americans. Two-hundred-four participants recruited from online forums and ResearchMatch completed a questionnaire. Over half (111/204) reported use of sunscreen, of which 39.6% (44/111) reported daily or frequent use. Nearly half of respondents (98/204) believed that they are not at risk for skin cancer, with 37.7% (77/204) reporting minimal knowledge of skin cancers and only 4.9% (10/204) receiving a total body skin exam. One-third (65/204) reported being more concerned about prevention of tanning than skin cancer. In total, 38.2% (78/204) of respondents reported use of SL products, of which 33.3% (26/78) reported hydroquinone-based products and 26.9% (21/78) were unaware of the ingredients in their SL product. Only 16.7% (13/78) consulted a medical professional before using SL products. While many agreed that SA culture places high importance on light skin with regards to beauty standards (82.3%, 168/204), less noted that lighter skin is more beautiful (37.0%, 74/204). SL users more strongly agreed with colorism attitudes than non-users. Limitations include a small sample size with younger participants. Dermatologists must be mindful of the cultural motivations for skin tone preferences, sun protection habits, and SL behaviors and provide culturally relevant education on sunscreen, skin cancer, and risks of SL for the SA community.

Developing skin cancer education materials for darker skin populations: crowdsourced design, message targeting, and acral lentiginous melanoma

Despite decreased susceptibility, darker skin individuals who develop melanoma have worse survival. This disparity in melanoma mortality is the largest for any cancer, and partly driven by a lack of patient education materials targeted to darker skin populations in whom acral lentiginous melanoma (ALM) is the most common subtype. To address this communication disparity, the current study reports a multi-phase design process that leverages crowdsourcing and message testing to develop ALM-focused patient education materials for darker skin populations. Crowdsourced design was utilized to develop a pool of designs (phase 1), the pool was narrowed and thematically analyzed (phase 2), and select designs were evaluated via a message experiment (N = 1877). For darker skin populations, designs that depicted people enhanced knowledge of ALM through message memorability. The current study engages melanoma disparities by providing ALM patient education materials for darker skin populations vetted via a multi-phase process.

An Exploration of the Use and Impact of Preventive Measures on Skin Cancer

Background: Skin cancer is the most common form of cancer, and both clinical and epidemiological data link cumulative solar dosages and the number of sunburns to skin cancer. Each year, more than 5.4 million new cases of skin cancer are diagnosed, incurring a significant health and financial burden. Recommended preventive measures for skin cancer include the use of sunscreen, sun avoidance, and protective clothing. This study used a national database to examine the association of preventive measures with the prevalence of skin cancer, specifically analyzing the preventive measures of sunscreen use, staying in the shade, and wearing long-sleeved shirts. The second aim was to determine which characteristics, if any, correlated with using prevention measures. Methods: This study analyzed data from the National Health and Nutritional Examination Survey 2015−2016 cycle to examine the association of three preventive measures (using sunscreen, staying in the shade, and wearing long-sleeved shirts) with skin cancer. Logistic regression and chi-square tests were utilized to examine the relationship between skin cancer and these prevention methods. Results: Sunscreen use (OR = 3.752; p < 0.05) was statistically associated with a lower prevalence of skin cancer, while wearing long-sleeved shirts (OR = 6.911; p = 0.064) and staying in the shade (OR = 0.646; p = 0.481) did not emerge as factors significantly associated with a lower prevalence after controlling for gender, race/ethnicity, marital status, income, health insurance, and general health. Additionally, men and individuals of color were less likely to use sunscreen. Conclusion: Sunscreen use was associated with a lower prevalence of skin cancer, while wearing long-sleeved shirts and staying in the shade was not significantly linked to lower rates of skin cancer, suggesting that these measures may not be as effective as sunscreen for preventing skin cancer. Men and individuals of color were significantly less likely to use sunscreen. These findings can help guide future education efforts and research regarding skin cancer prevention and suggest the need to develop male-oriented programs to mitigate the gender disparity in employing sun-protection measures.

Photoprotection for Skin of Color

Photoprotection behaviors can mitigate skin damage caused by ultraviolet radiation, and common methods include seeking shade, avoiding sun exposure during peak daylight hours, wearing sun-protective clothing, applying sunscreen, and using sunglasses. While the role of sun protection in preventing sunburns, photoaging, and skin cancer is well established in fair-skinned populations, individuals with skin of color (SOC) are presumed to suffer fewer negative effects from solar radiation. Thus, the importance of photoprotection in this population is understudied and may be underestimated. In SOC populations, sun exposure is known to cause pigmentary disorders, photoaging, and basal cell carcinoma (BCC), highlighting the potential benefits of photoprotection. Although SOC populations tend to practice photoprotection by seeking shade and wearing sun-protective clothing, survey and interview-based studies have consistently found relatively low use of sunscreen among these populations. Common motivators for photoprotection in individuals with SOC include preventing sunburn and pigmentation, with the prevention of skin cancer being a less important reason. As a skin cancer risk behavior, indoor tanning is relatively rare in SOC populations, but its use may increase with acculturation to US norms. While more studies are necessary to clarify whether photoprotection behaviors may decrease skin cancer-related mortality in SOC populations, regular dermatologic care and counseling on photoprotection remain essential in patients with SOC for overall skin health.

Tips for addressing common conditions affecting pediatric and adolescent patients with skin of color

Pediatric and adolesent patients with skin of color are seen by dermatologists for common complaints such as acne, atopic dermatitis, and traction alopecia. Combining the understanding of cultural practices, empathetic patient communication, and social implications is useful in counseling and treating pediatric and adolescent patients with skin of color.

Does acral lentiginous melanoma subtype account for differences in patterns of care in Black patients?

BACKGROUND

Melanoma-specific outcomes for Black patients are worse when compared to non-Hispanic white (NHW) patients. We sought to evaluate whether acral lentiginous melanoma, seen more commonly in Black patients, was associated with racial disparities in outcomes METHODS: The National Cancer Database was analyzed for major subtypes of stage I-IV melanoma diagnosed from 2004 to 2016. The association between Black race and (Siegel et al., Jan) 1 acral melanoma diagnosis and (Bradford et al., Apr) 2 receipt of major amputation for surgical management of melanoma was evaluated using multivariable logistic regression.

RESULTS

251,864 patients were included (1453 Black). Black patients had increased odds of acral melanoma (odds ratio [OR] = 27.6, 95% CI]: 24.4, 31.2) compared to NHW patients. Black patients still had higher odds ratios of major amputation across all stages after adjusting for acral histology and other potential confounders CONCLUSIONS: Increased prevalence of acral melanoma in Black patients does not fully account for increased receipt of major amputation.

A characterization of sun protection attitudes and behaviors among children and adolescents in the United States

Children and adolescents may be vulnerable to increased ultraviolet radiation exposure and greater risk for subsequent sun-related pathologies. This study examined the demographic, geographic, and phenotypic factors influencing sun exposure and protective behaviors among children and adolescents living in the United States. A cross-sectional survey on perceived sun exposure and protective behaviors was administered at three sports medicine clinics in California, Colorado, and Hawaii. Responses were measured with a 5-item frequency scale: Never, Rarely (25% of the time or less), Sometimes (50% of the time), Often (75% of the time or more), and Always. Sun protective behavior was examined using univariate and multivariate analyses. In total, 860 surveys were collected (52% female, 48% male; mean age 12.7 years). Females reported significantly greater frequency of using sunscreen (p = 0.001), staying in the shade or using an umbrella while in the sun (p = 0.004), and tanning (p < 0.001). Age was inversely associated with sunscreen use frequency (p < 0.001); the percentage of participants who reported always wearing sunscreen decreased as age increased. Participants in Hawaii reported using sunscreen less frequently than those in California and Colorado (p < 0.001). These results identify high-risk populations such as males, older adolescents, and Hawaii's youth who may not be practicing frequent sun protective behaviors. While it is important for youth to stay active, they must also be reminded to adopt protective behaviors while outdoors to prevent unnecessary sun damage and lower the risk of sun exposure complications.

Awareness about proper use of sunscreen in people of color: A Jordanian-based survey

INTRODUCTION

The use of sunscreen is an important preventive measure against skin cancer and treatment for other skin conditions. There is evidence pointing to lack awareness and misconceptions regarding use of Sunscreen. This is especially evident in populations with skin of color (POC).

METHODS

This is a cross-sectional study of 2000 individuals. A structured questionnaire was designed to collect data on general knowledge and use of sunscreen as well as reasons for stopping use of sunscreen.

RESULTS

The results of this study indicate a clear deficiency in the use and knowledge about sunscreen among Jordanians. Females are using sunscreen more than males. However, the use of sunscreen is inadequate in many aspects including timing of application, frequency of use, and amount used among other things. There is an obvious lack of knowledge about sunscreen as shown by lack of awareness about benefits of use in various times of the year, use in children, use for all skin types, and several misconceptions among other knowledge gaps. Main reasons for stopping sunscreen include side effects, cost, and being not suitable for skin. Awareness about sunscreen can be improved by proper counseling by healthcare professionals and utilization of various media platforms.

CONCLUSIONS

The use of sunscreen is inadequate in this population of color (POC). Lack of proper counseling, failure to read use instructions can contibute to inadequate use of sunscreen. Risks and benefits of sunscreen should be explained by medical professionals. The media should be more utilized to disseminate such knowledge.

Are the Fitzpatrick Skin Phototypes Valid for Cancer Risk Assessment in a Racially and Ethnically Diverse Sample of Women?

The Fitzpatrick Skin Phototypes (FSP) were developed to classify skin color and response to ultraviolet radiation. FSP are used clinically to assess risk for sunburn and skin cancer. Our aim was to determine the criterion-related validity of self-reported FSP when compared with skin color and sunburn history, controlling for age, race/ethnicity, and seasonality/geography. We performed a secondary analysis of data (N=466) from an observational study. The racial/ethnic composition of the sample was 45% White/White Hispanic (WWH), 40% Black/Black Hispanic (BBH), and 15% Other Identities. Outcome measures were self-reported FSP and sunburn history, as well as physiological measures of skin color (L* lightness/darkness, a* redness/greenness, b* yellowness/blueness). Correlation between FSP and L* was -.77 (95% CI -.81, -.73; P<.001). Although 60% of the variance in FSP was accounted for by L* values for the entire sample, only 5% of the variance was accounted for among BBH participants (r=-.23), and up to 30% for WWH/Other Identity participants (r=-.48 and -.52). Multiple regression analysis indicated L* and b* values, sunburn history, and race/ethnicity, but not geography/seasonality or a* values significantly and collectively accounted for 72% of the variance in FSP. While the criterion validity of FSP was established by the strong relationship between L* values and FSP for the entire sample, when examined at the level of individual racial/ethnic subgroups, criterion validity of FSP was not demonstrated. When self-reported FSP are used for clinical skin assessment and sun cancer screening, they provide a restricted range of options for people with darker skin that does not capture variations in their skin color. Inaccuracy of clinical data may lead to unequal treatment or inadequate cancer risk assessment.

Correlates of sun protection behaviors in racially and ethnically diverse U.S. adults

Although skin cancer incidence is highest among non-Hispanic Whites, minority populations are often diagnosed with more advanced stage disease and are more likely to experience poor outcomes. Fewer people of color do not practice primary prevention of skin cancer according to recommendations, but public health education and interventions to promote sun protection behaviors have consistently targeted non-Hispanic Whites. This study examines performance of sun protection behaviors in a multiethnic sample and whether demographic, lifestyle and psychosocial predictors of these behaviors differ by race and ethnicity. In this study, a probability-based sample of 1742 adults completed an online survey in 2015. Main outcomes of interest included sunscreen use, wearing a sleeved shirt, and seeking shade. We stratified the sample into racial/ethnic groups (White, Black, Hispanic, Asian) and investigated demographic, lifestyle and psychosocial correlates of these behaviors in each group. Differences in adjusted estimates from each behavior-specific model were tested across strata. Racial/ethnic groups were significantly different in regards to sunscreen use and wearing a sleeved shirt, but similarly engaged in seeking shade. Results from multivariate ordered logistic regression models for each behavior revealed important demographic, lifestyle and psychosocial predictors and the importance of some demographic correlates varied between racial/ethnic groups. This study provides insight into the practice and correlates of skin cancer prevention among a multiethnic sample. Our findings suggest that targeting public health education efforts and interventions to promote sun protection in minority populations may be a beneficial approach to addressing heightened skin cancer morbidity and mortality in these groups.

Skin cancer knowledge, awareness, beliefs and preventive behaviors among black and hispanic men and women

Black and Hispanic populations perceive their skin cancer risk to be low and are less likely to use sun protection strategies. We conducted formative research to understand knowledge, awareness, beliefs, and behaviors among these groups. In 2017, eighteen focus groups were conducted with black and Hispanic respondents(18-44 years) in four US cities. Groups were segmented by participant characteristics associated with elevated or lower risk for skin cancer, by race/ethnicity, gender, and age. A professional moderator followed a semi-structured discussion guide, and focus group transcripts were analyzed using conventional content analysis and NVIVO 11 Software. Most participants perceived themselves to be at low skin cancer risk due to their "darker skin tone" and/or "lack of family history." Skin cancer signs and symptoms were more inconsistently reported by blacks than Hispanics. Few participants reported regular sun protection behaviors. Those who did used sunscreen, wore protective clothing, and had elevated risk based on sun sensitivity or UV exposure. While most participants recalled family discussions (as youth) about sunscreen and sun protection, the understood intent was to warn against "further skin darkening" or to "prevent aging," not to reduce sun burns or skin cancer risk. Tanning bed use was low across all segments, especially among black respondents. Tailored skin cancer prevention campaigns need to address misperceptions about risks and benefits of skin cancer prevention behaviors among black and Hispanic populations. Families, peer groups, and healthcare providers need to be engaged in the creation of educational interventions and messaging efforts that target these populations.

Effect of A Sun Protection Intervention on the Immune Response to Measles Booster Vaccination in Infants in Rural South Africa

The incidence of many serious childhood infections can be reduced by vaccination. High sun exposure at the time of vaccination has been associated with a reduced antigen-specific immune response. We hypothesized that providing sun protection advice and equipment to mothers of children who were waiting to be vaccinated would result in a more robust immunization response. We conducted a pilot study in 2015/2016 (data analyzed in 2017-2018) among 98 Black African children (~18 months of age) receiving the booster measles vaccination at two clinics in South Africa. Clinics were randomized to receive (or not) sun protection advice and equipment. We recorded demographic information on children and mothers and data on the child's usual sun exposure. At approximately 4 weeks' postmeasles vaccination, we measured measles immunoglobulin G levels in children. All children with blood results (n = 87, 89%) across both groups had antibody titers higher than 200 mIU mL^-1 which was considered the protective antibody concentration. There was no statistically significant difference in titers between groups: geometric difference in mean titers 1.13 mIU mL^-1 (95% CI 0.85, 1.51; P = 0.39) and 1.38 mIU mL^-1 (95% CI 0.90, 2.11, P = 0.14) for unadjusted and adjusted analyses, respectively. This study demonstrated that a sun protection intervention study could be performed in a developing-world pediatric vaccination setting. Although the sun protection intervention around the time of vaccination was not associated with a higher antibody level, given the potential importance of such an effect, a larger study should be considered.

Parental use of sun protection for their children-does skin color matter?

BACKGROUND/OBJECTIVES

Excessive sun exposure during childhood is a risk factor for skin cancer. This study aimed to compare the frequency of ideal sun protection use between parents with lighter- and darker-skinned children and explore their attitudes and beliefs on sun safety and their choice of sun protection.

METHODS

Parents of children aged 6 months to 6 years completed self-administered questionnaires about sun protection practices for their children. Parents assessed their child's Fitzpatrick phototype and were divided into lighter- (Fitzpatrick phototype I-III) and darker-skinned (Fitzpatrick phototype IV-VI) groups. Sun safety guidelines from the Canadian Dermatology Association were used to qualify ideal sun protection.

RESULTS

A total of 183 parents were included. Overall, 31 parents (17%) used ideal sun protection for their children. As their children grew older, parents were less likely to use ideal sun protection (odds ratio = 0.69, 95% confidence interval = 0.53-0.90). Parents in the lighter-skinned group were more likely to use ideal sun protection for their children (odds ratio = 7.4, 95% confidence interval = 2.7-20.1), believe that sun exposure was harmful (odds ratio = 17.2, 95% confidence interval = 4.0-74.9), and perceive value in sun protection (odds ratio = 11.4, 95% confidence interval = 3.3-39.0); the darker-skinned group believed that darker skin tones provided more sun protection (odds ratio = 12.4, 95% confidence interval = 6.1-25.4).

CONCLUSION

Ideal parental sun protection efforts are overall low, particularly in parents of darker-skinned children. The identified attitudes toward and beliefs about sun safety may aid in delivery of future sun protection interventions, especially in multiracial populations.

'My child did not like using sun protection': practices and perceptions of child sun protection among rural black African mothers

BACKGROUND

Photodamage is partially mitigated by darker skin pigmentation, but immune suppression, photoaging and cataracts occur among individuals with all skin types.

METHODS

To assess practices and acceptability to Black African mothers of sun protection equipment for their children living in a rural area, participants were recruited at the time of their child's 18-month vaccinations. Mothers completed a baseline questionnaire on usual sun behaviours and sun protection practices. They were then provided with sun protection equipment and advice. A follow-up questionnaire was administered two weeks later.

RESULTS

Mothers reported that during the week prior to the baseline questionnaire, children spent on average less than 1 hour of time outdoors (most often spent in the shade). Most mothers (97%) liked the sun protection equipment. However, many (78 of 86) reported that their child did not like any of the sun protection equipment and two-thirds stated that the sun protection equipment was not easy to use.

CONCLUSIONS

Among Black Africans in rural northern South Africa, we found a mismatch between parental preferences and child acceptance for using sun protection when outdoors. A better understanding of the health risks of incidental excess sun exposure and potential benefits of sun protection is required among Black Africans.

Photoprotection in specific populations: Children and people of color

Improved education on appropriate photoprotection in children is vital. Photoprotection for these individuals should include seeking shade, the use of physical agents (clothing, hat, sunglasses), and application of sunscreens on exposed areas. Avoidance of the use of tanning beds is an important component of education for teenagers. Ultraviolet radiation exposure induces DNA damage and photoaging in all skin types, including people of color. The extent of such damage is inversely related to constitutive skin pigmentation. Therefore, personalized photoprotection recommendations concerning skin cancer risk factors, desired treatment outcomes, health needs (eg, vitamin D), and photoaging based on the needs and preferences of the patient are essential. It is clear that additional research is needed on optimal levels of protection against ultraviolet radiation for people of color.

Patterns of sunscreen use on the face and other exposed skin among US adults

BACKGROUND

Sunscreen is a common form of sun protection, but little is known about patterns of use.

OBJECTIVE

We sought to assess patterns of sunscreen use on the face and other exposed skin among US adults.

METHODS

Using cross-sectional data from the 2013 Summer ConsumerStyles survey (N = 4033), we calculated descriptive statistics and adjusted risk ratios to identify characteristics associated with regular sunscreen use (always/most of the time when outside on a warm sunny day for ≥1 hour).

RESULTS

Few adults regularly used sunscreen on the face (men: 18.1%, 95% confidence interval [CI] 15.8-20.6; women: 42.6%, 95% CI 39.5-46.7), other exposed skin (men: 19.9%, 95% CI 17.5-22.6; women: 34.4%, 95% CI 31.5-37.5), or both the face and other exposed skin (men: 14.3%, 95% CI 12.3-16.6; women: 29.9%, 95% CI 27.2-32.8). Regular use was associated with sun-sensitive skin, an annual household income ≥$60,000, and meeting aerobic activity guidelines (Ps < .05). Nearly 40% of users were unsure if their sunscreen provided broad-spectrum protection.

LIMITATIONS

Reliance on self-report and lack of information on sunscreen reapplication or other sun-safety practices are limitations.

CONCLUSION

Sunscreen use is low, especially among certain demographic groups. These findings can inform sun-safety interventions and the interpretation of surveillance data on sunscreen use.

Social determinants of racial and ethnic disparities in cutaneous melanoma outcomes

BACKGROUND

This article sought to elucidate how aspects of poverty and culture may contribute to race- and ethnicity-based disparities in cutaneous melanoma outcomes.

METHODS

We identified published studies addressing the social determinants of melanoma. Selected review articles included US-based studies comprised of patients representing adults, children, and adolescents.

RESULTS

African Americans and Hispanics diagnosed with cutaneous melanoma are more likely to present with more advanced stages of disease at diagnosis and have higher rates of mortality than their nonminority counterparts. These disparities may be a consequence of economic, social, and cultural barriers such as low income, public forms of health insurance, lower levels of education, lower levels of melanoma awareness and knowledge, and lower rates of participation in melanoma screening. No studies in the literature examined the potential impact of social injustice, English proficiency, immigrant status, and health literacy.

CONCLUSIONS

Substantial gaps exist in our knowledge of the pathways linking social determinants and race- and ethnicity-based disparities in melanoma. More studies are warranted to inform the development of effective interventions aimed at narrowing inequities and improving cutaneous melanoma outcomes among minority populations.

SunSmart: evaluation of a pilot school-based sun protection intervention in Hispanic early adolescents

The incidence of melanoma is rising among Hispanic populations in the United States. The purpose of this study is to evaluate the impact of a pilot sun safety educational intervention conducted from 2006 to 2012 on Hispanic early adolescents in a high ultraviolet environment. Nineteen schools with high Hispanic enrollment were recruited from urban neighborhoods in Los Angeles. The analytic sample was restricted to students identifying as Hispanic or Latino (n = 777). A mixed effects linear model was used to test mean changes from pre- to posttest on students' sun protection knowledge, attitudes and behaviors. Significant improvements were observed across several cognitive outcomes related to sun protection, including knowledge of and attitudes toward sun protection and self-efficacy to wear sunscreen. However, changes in sun protective behaviors were not achieved. Although some improvements were observed, future studies should identify the factors that motivate sun protection in this population and develop tailored prevention strategies, as improving the sun safe behaviors of Hispanic youths may aid in reducing the risk of melanoma in adulthood in this population.

The association between demographic and behavioral characteristics and sunburn among U.S. adults - National Health Interview Survey, 2010

OBJECTIVE

To examine the association between demographic and behavioral characteristics and sunburn among U.S. adults.

METHOD

We used 2010 National Health Interview Survey data (N=24,970) to conduct multivariable logistic regressions examining associations with having 1 or more sunburns in the past year and having 4 or more sunburns in the past year.

RESULTS

Overall, 37.1% of adults experienced sunburn in the past year. The adjusted prevalence of sunburn was particularly common among adults aged 18-29years (52.0%), those who repeatedly burn or freckle after 2weeks in the sun (45.9%), whites (44.3%), indoor tanners (44.1%), those with a family history of melanoma (43.9%), and those who are US-born (39.5%). Physical activity, alcohol consumption, and overweight/obesity were positively associated with sunburn (all P<0.001); sun protection behaviors were not significantly associated with sunburn (P=0.35). Among those who were sunburned in the past year, 12.1% experienced 4 or more sunburns.

CONCLUSION

Sunburn is common, particularly among younger adults, those with a more sun-sensitive skin type, whites, those with a family history of melanoma, the highly physically active, and indoor tanners. Efforts are needed to facilitate sun-safety during outdoor recreation, improve the consistency of sun protection practices, and prevent sunburn, particularly among these subgroups.

A critical evaluation of the UK SunSmart campaign and its relevance to Black and minority ethnic communities

Skin cancer is the most common cancer in the United Kingdom and is rising to epidemic proportions. While the majority of skin cancers are treatable, malignant melanoma kills over 2,000 people in the United Kingdom each year, with all skin cancers killing a total of more than 2,500 people annually. SunSmart, the United Kingdom’s major skin cancer public health initiative, was implemented to raise awareness about sun exposure and to promote sun safety behaviours. However, it has failed to curb the incidence and mortality rates. Furthermore, while Australia has the highest skin cancer incidence rates globally, the mortality rates are lower than those in the United Kingdom. There has also been a growing amount of evidence demonstrating ethnic disparities in skin cancer survival rates. Even though incidence rates of skin cancer among Black and minority ethnic (BME) groups are significantly lower, it is often diagnosed late, resulting in higher mortality rates. This, coupled with climate change and the proportion of BME groups expected to rise in the United Kingdom from 8% to 20% by 2051, raises public health concerns. This article aims to critically analyse the UK SunSmart campaign’s success in addressing skin cancer in the population and in particular its relevance to BME communities. It also compares this approach with the Australian campaign. This article demonstrates that Australia’s campaign has been more successful than the United Kingdom’s due to their more comprehensive application of health promotion and public health principles.

Polytobacco use and multiple-product smoking among a random community sample of African-American adults

OBJECTIVES

Little is known about polytobacco use among African-American adults. This study is the first to explore this among a random, statewide, community sample of African-American adults.

SETTING

Community-based sampling obtained a random, household-probability sample of African-American adults from California, surveyed door to door in randomly selected census tracts statewide.

PARTICIPANTS

Participants were a statewide, random-household sample of N=2118 African-American adults from California who completed a survey on past 30-day smoking of cigarettes, blunts, bidis, kreteks, cigarillos, marijuana and cigars.

RESULTS

Almost half (49.3%) of the African-American cigarette-smokers and 14.9% of the cigarette non-smokers had smoked at least one non-cigarette product in the past 30 days. Smokers had a substantial prevalence of smoking cigarillos (28.7%) and blunts (27.7%). Logistic regressions revealed that the odds of smoking most of the non-cigarette products were higher for cigarette smokers and men, inversely related to age, and unrelated to socioeconomic status. However, smoking of blunts, bidis and kreteks was not predicted by cigarette smoking.

CONCLUSIONS

Smoking of cigarillos (eg, Phillies, Black & Mild) and blunts may be prevalent among African-American cigarette-smokers and non-smokers alike, but such products are not examined in most population-level smoking research. Smoking of these products should be included in surveillance studies, in cancer prevention programmes and in healthcare provider-assessment of smoking, and addressed in smoking cessation programmes as well.

A qualitative study exploring barriers related to use of footwear in rural highland ethiopia: implications for neglected tropical disease control

Background

The role of footwear in protection against a range of Neglected Tropical Diseases (NTDs) is gaining increasing attention. Better understanding of the behaviors that influence use of footwear will lead to improved ability to measure shoe use and will be important for those implementing footwear programs.

Methodology/Principal Findings

Using the PRECEDE-PROCEED model we assessed social, behavioral, environmental, educational and ecological needs influencing whether and when children wear shoes in a rural highland Ethiopian community endemic for podoconiosis. Information was gathered from 242 respondents using focus groups, semi-structured interviews and extended case studies. Shoe-wearing norms were said to be changing, with going barefoot increasingly seen as ‘shameful’. Shoes were thought to confer dignity as well as protection against injury and cold. However, many practical and social barriers prevented the desire to wear shoes from being translated into practice. Limited financial resources meant that people were neither able to purchase more than one pair of shoes to ensure their longevity nor afford shoes of the preferred quality. As a result of this limited access, shoes were typically preserved for special occasions and might not be provided for children until they reached a certain age. While some barriers (for example fit of shoe and fear of labeling through use of a certain type of shoe) may be applicable only to certain diseases, underlying structural level barriers related to poverty (for example price, quality, unsuitability for daily activities and low risk perception) are likely to be relevant to a range of NTDs.

Conclusions/Significance

Using well established conceptual models of health behavior adoption, we identified several barriers to shoe wearing that are amenable to intervention and which we anticipate will be of benefit to those considering NTD prevention through shoe distribution.

Consistently wearing shoes may help in preventing onset or progression of a wide range of Neglected Tropical Diseases (NTDs). This study assessed the factors that influenced shoe wearing behaviors among people living in a rural community in highland Ethiopia. In this community, a substantial proportion of people are at risk for podoconiosis, a debilitating lower leg condition that can be prevented by wearing shoes. We conducted semi-structured individual interviews, focus group discussions and extended case studies among 242 adults and systematically analyzed the information. We found that shoe wearing is intermittent, and that different factors such as cost and ability to use the shoes for certain activities (such as farming) influenced consistent shoe wearing for most people. Some factors (such as shoe size, fear of stigma) were more relevant for podoconiosis patients. Social norms were found to be increasingly supportive of shoe wearing, and children exhibited greater desire to wear shoes than adults. These findings have relevance for preventing development and progression of a variety of NTDs in a range of settings.

Photoprotective habits of patients with cutaneous lupus erythematosus

BACKGROUND

Previous studies have suggested that patients with cutaneous lupus erythematosus (CLE) are deficient in sunscreen use. Use of other photoprotective methods by patients with CLE has not been assessed to our knowledge.

OBJECTIVE

We sought to identify demographic and clinical characteristics of patients with CLE who have the lowest overall sun-protection habits scores, and who are least likely to practice 5 individual photoprotective methods (ie, shade, sunscreen, long sleeves, hat, and sunglasses).

METHODS

A total of 105 patients with CLE at the University of Texas Southwestern Medical Center in Dallas completed a survey to evaluate their photoprotective practices. Additional information including demographics and clinical indicators related to CLE was collected from the patients.

RESULTS

Patients with medium and dark skin (ie, Fitzpatrick skin types III-VI) and patients aged 31 to 50 years were the least likely CLE subgroups to practice overall photoprotection, as indicated by low sun-protection habits scores (P = .001 and P = .04, respectively). In terms of individual photoprotective methods, male patients with CLE were deficient in sunscreen use, but were more likely to wear hats than female patients with CLE. Sunscreen and sunglasses use was also significantly more infrequent in dark-skinned patients than those with Fitzpatrick skin types I to IV. Patients with CLE between the ages of 41 and 50 years were least likely to wear hats.

LIMITATIONS

This study was subject to reporter bias and did not cover barriers to and knowledge of photoprotection.

CONCLUSION

Cultural customs and misconceptions shared by those from the general population have a significant influence on the photoprotective habits of this CLE population. These need to be addressed to improve photoprotection rates in these at-risk individuals.