A cross-sectional survey on knowledge, attitude, and practice of sunscreen usage among medical undergraduate students

INTRODUCTION

The solar spectrum includes ultraviolet (UV) radiation spanning 100-400 nm. Earth receives a mix of UVB (280-315 nm) and UVA (315-400 nm) radiation, while UVC (100-280 nm) is absorbed by the ozone layer.^[1] Prolonged and excessive sun exposure can cause deleterious effects on skin ranging from sunburn to even skin cancers.^[2] Sunscreens are an integral part of photoprotection and are used primarily in the prevention and management of sunburn, photoaging, photosensitive dermatoses, and skin cancers.^[3] Sunscreens contain active ingredients that either absorb UV radiation or serve as physical agents that scatter or reflect light.^[4] Due to the recent surge in the availability of wide range of sunscreens over the counter and the influence of social media, increased usage of sunscreens has been noted globally.^[5] The United States Food and Drug Administration recommends 2 mg/cm² of sunscreen application over the skin surface for its maximum benefit, but most consumers use only 20-50% of the same.^[6,7]

India is the world’s most populous country with a tropical climate. However, it has limited awareness of sun safety practices among its public. Indians use physical protective measures such as long sleeves, seeking shade, and using umbrellas than sunscreens.^[8] Several barriers may contribute to the issue, including a lack of knowledge about skin cancer risks, aversion to sunscreen, and limited access to dermatology consultation and photoprotection guidance.^[9]

Several studies, showed varying levels of knowledge and practices of sunscreen use among different populations; however, Indian studies are limited.^[10,11] To fill this lacuna, we carried out a cross-sectional, questionnaire-based survey to assess the knowledge, attitude, and practice of sunscreen usage among undergraduate students of various healthcare courses in a tertiary care center in North Kerala. We chose undergraduate students of healthcare courses for this study because their knowledge, attitude, and practices not only reflect current trends but also have a key role in educating and influencing society as they are the future healthcare providers.

MATERIALS AND METHODS

This was a descriptive cross-sectional questionnaire-based survey conducted in a tertiary care center in North Kerala. The study participants were undergraduate students of MBBS and other allied medical courses, including dental, nursing, and paramedical students of our campus. A sample size of 266 was derived based on the study conducted by Novitasari et al.^[7] Clearance from the institutional ethical committee was obtained. All students of the above-mentioned courses willing to enroll in the study after signing an informed consent were given a questionnaire along with a pro forma containing the demographic details of the students. The questionnaire was sourced from previous studies conducted in similar settings.^[7,11] There were a total of 21 multiple-choice questions, of which eight questions assessed knowledge about sunscreen and its application; three questions were related to attitude, and 10 questions were related to the practice of sunscreen use. The students were approached in their classroom without any prior notice and were given a brief explanation of the study and its objectives. They were asked to complete the questionnaire within 30 min.

RESULTS

DISCUSSION

The present study analyzed the knowledge, attitude, and practice of sunscreen use among undergraduate students from various healthcare-related courses in a health care institute in North Kerala. Females demonstrated significantly better knowledge compared to males (P = 0.026). This gender difference was consistent with findings from studies by Rajagopal et al., Agarwal et al., and Chapagain and Rauniar. It indicated that women have a greater awareness regarding skincare practices, including the use of sunscreen.^[5,10,12] This is probably because women are expected to be more concerned about physical appearance and skin care, whereas men view sunscreen as a mere beauty product and fail to recognize it as a preventive health measure. Educational campaigns aimed at changing these perceptions, particularly among men, could help to close this gap.

Significant differences in knowledge were observed among students from different courses (P = 0.0001). A higher proportion of MBBS students had better knowledge (60.1%), while paramedical and nursing students had relatively lower levels of knowledge (37.1% and 37.9%, respectively) about sunscreen use. This finding was in contrast to a study conducted by Awadh et al., where the knowledge of final-year paramedical students was significantly higher than the knowledge of final-year MBBS students (P < 0.0001).^[13]

Knowledge improved with the progression in the academic years, peaking in the 4^th year (61.4% had better knowledge). This trend aligns with findings from a study by Shanshal et al., where final year (6^th year) university students had better knowledge when compared to 1^st year, and this difference was statistically significant (P < 0.0001).^[2] These results highlight the importance of incorporating topics such as UV radiation risks and photo-protection early in the curriculum to build a solid foundation of knowledge.

The prevalence of sunscreen use was found to be 79.1% (470 respondents), with 44.1% (262 respondents) using it regularly. This is higher than the study by Chapagain and Rauniar, where 15.41% (35 out of 227 sunscreen users) applied sunscreen regularly.^[12] Among regular users, 69.1% had better knowledge about sunscreens, and this difference was statistically significant. This signifies that those with a better understanding of sunscreen are more likely to use it regularly, ensuring more effective protection against sun damage.

In the current study, the question with the highest percentage of correct answers in the knowledge section was about sunscreen’s ability to prevent tanning, with 90.2% of respondents answering correctly, which was in accordance with results reported by Agarwal et al.^[11] This indicates a strong understanding among participants that sunscreen helps protect the skin from UV radiation, which contributes to tanning. The majority of respondents (62.3%) believed that sunscreen should only be used during outdoor activities, while only 29% answered correctly, understanding that sunscreen should also be applied indoors. This suggests a gap in awareness regarding the importance of protecting the skin from UVA rays that can penetrate windows and other indoor environments. In a study, drivers found to have a higher prevalence of photo-damage, actinic keratoses, non-melanoma skin cancers, and melanoma in situ on the side of their body exposed to UV radiation from automobile windows.^[14]

Over half of the respondents (57.5%) knew that broad-spectrum sunscreen is ideal and 73.8% knew that sunscreen has to be applied 15 min before sun exposure. Most respondents applied an adequate amount of sunscreen, using at least half a teaspoon to cover their face and neck. This was reflected in their practices, as there was a statistically significant difference in knowledge levels between those who applied broad-spectrum sunscreen in the correct amount and at the proper time before sun exposure compared to those who did not (P = 0.0001).

Although most respondents (70%) knew that sunscreen has to be reapplied every 2 h while outdoors, 78.2% still made errors in reapplying it; in fact, 44.3% of respondents never reapplied sunscreen. This suggests that the practice of reapplying sunscreen is not only solely determined by knowledge but also could be influenced by other factors. Dislike of the feel or appearance of sunscreen (33.7%), cost (16.4%), and time constraints (15.3%) were the barriers identified in a survey conducted by Weig et al. assessing barriers to the use of sunscreen.^[15]

In our study, the most important consideration in choosing a sunscreen was SPF value (75.1%) followed by the type of skin. The knowledge regarding SPF was unsatisfactory. According to data, the majority of respondents (57.4%) applied sunscreen with SPF 50. This practice reflects their knowledge about SPF, as most respondents (74.3%) considered SPF 50 is required for Indian skin. An SPF 15 sunscreen absorbs 93.3% of the UVB radiation, an SPF 30 sunscreen absorbs 96.7%, and an SPF 50 sunscreen absorbs approximately 98% of the UVB radiation that causes erythema.^[1] Thinner application of sunscreen can result in lower SPF and reduced protection against UV radiation. For instance, applying sunscreen with SPF 50 at a thickness of 1 mg/cm² reduces the SPF to 26, while sunscreen with SPF 100 applied at the same thickness drops to an SPF of 55.^[16] When applied in the right quantity, an SPF of 30 is generally considered adequate to protect the Indian skin from the harmful effects of UV radiation.

Media influenced the participants most regrading the use of sunscreen (59.9%) to use sunscreen, followed by friends (49.8%) and dermatologists (29.5%). Media raises awareness about the risks of sun exposure and promotes sunscreen products through platforms such as television, social media, magazines, and the Internet. While the media offers general advice, dermatologists provide tailored, evidence-based guidance addressing individual queries and concerns.

Proportion of respondents who believed sunscreen should be used in cloudy days (41.8%) is almost equal to those who considered against (42.9%). The World Health Organization states that up to 80% of UV rays can pass through clouds. Therefore, it is important to wear sunscreen even on cloudy days.^[17] In this study, the main reason why respondents avoided sunscreen was its cost (38.2%). This is evident from the finding that alternate methods of photo-protection such as umbrellas, hats, and shades was used by 73.4% of respondents in the absence of sunscreen.

LIMITATION

As this study was solely conducted on medical and paramedical undergraduate students, its results cannot be generalized to the broader population. Future studies should include a larger, more diverse sample from various geographic regions, including both sexes, different ages, and educational backgrounds. In addition, since it used a questionnaire survey method, recall bias could be a potential limitation.

CONCLUSION

In our study, the prevalence of sunscreen use was high among medical undergraduates only, but small proportion used it regularly. Although the knowledge about sunscreen was good, many students were not applying it in practice. The primary barrier to sunscreen use was its high cost. Raising awareness about the importance of sunscreen and efforts to make it more affordable could improve sun protection practices in India. Integrating detailed discussions about different types of sunscreens, correct mode of application, and the importance of reapplication in medical education can probably be useful. Thus, increased awareness about sunscreen use among medical undergraduates can positively impact the public as they will become the future backbone of our healthcare system.