Protective behavior of people exposed to extreme levels of ultraviolet (UV) radiation (tropics, high mountain altitudes, marine environment, etc.) has been poorly studied,[1-5] even though these populations are implicitly at high risk of skin cancer. Pleasure craft captains in the tropics are numerous (160,000 per year in Martinique, French West Indies). To prepare a prevention campaign for this population, current sun-protection behaviors of professional skippers sailing in Martinique and the behavior of their passengers should be explored.
A preliminary inquiry, conducted on Martinique Island, sought to determine professional skippers' sun-protection knowledge and behavior. Fifty-two skippers (mean age: 41 years) completed a questionnaire; 39 (75 %) had a simple sunburn over the last 6 months and 3 (6%) severe sunburn; 54 (64%) declared achieving sun protection by wearing clothes during >90% of the day. Only 17% had used sun protection >90% of the time.
From September 2010 to January 2011, 53 consecutive professional pleasure craft skippers in Martinique were interviewed with an anonymous, self-administered, print questionnaire, while in the waiting room of the Maritime Affairs Outpatient-Consultation Health Service, where they are convoked annually for a systematic physical examination. The questionnaire, comprising 32 items, collected the sociodemographic and skin characteristics (phototype in four of the six groups of Fitzpatrick classification, dermatological history).
Estimation of their sun-protection knowledge was summarized by regrouping the responses pertaining to the following two questions: “In your opinion, what is the recommended frequency of sunscreen application? Every hour, Every 2 hours, Every 4 hours, Every 8 hours” and “Sunscreen protects against the sun better than clothes. What is your opinion? Yes, No, I don't know.” Knowledge was considered good, when both questions were answered correctly (“every 2 hours” and “no,” respectively); intermediate, for one correct response; and poor, for no correct answers.
Behavior was assessed by estimations of photoprotection and sunburns; simple sunburn was defined as erythema and severe sunburn as “blisters” or the need for analgesics or medical care. The number of sunburns over the last 6 months and on the last sailing day, coupled with the duration of exposure to sun with appropriate photoprotection (sunscreen or clothing) were compiled. Passengers' sun-protection behavior observed by the skippers was limited to the existence of sunburns, simple or severe, and the sun-protection methods, if any, used, adapted or not adapted, to their exposure.
Fifty-two skippers (45 men and 7 women; mean age: 41 years) completed the questionnaire (1 refused). The majority had been boat captains for >10 years. More than half (56%) of them had never undergone medical screening for skin cancer or nevus monitoring; only one had experienced a previous skin cancer. Skin types were distributed as follows: 10% I and II, 46% III, 31% IV, and 13% V and VI.
Among them, 38 and 54% had good or intermediate sun-protection knowledge. Reported sun-protection behavior showed that 75% had had a simple sunburn over the last 6 months and 6% severe sunburn; sunscreen use is detailed in Table 1. Thirty-four (64%) skippers declared achieving sun protection by wearing clothes during >90% of daytime and 14 (27%) did so for 50% of daytime; clothing consisted of wearing long-sleeved shirts for 9%, short-sleeved shirts for 40%, shorts or bermudas for 47%, and long pants for 5%. Finally, 17% of the skippers had used sun protection >90% of the time exposed to the sun and had suffered no sunburn over the last 6 months.
|Experience of sunburns|
|Experienced a simple sunburn in the last 6 months||39 (75)|
|Experienced severe sunburns over the last 6 months||3 (6)|
|Experienced simple sunburns on the last sailing day||8 (15)|
|Experienced severe sunburns on the last sailing day||0|
|Use of sunscreen|
|90%–100% of time in sun||13 (25)|
|50% of time in sun||13 (25)|
|Number of sunscreen tubes used over the last 6 months|
|Sun-protection factor used|
|Number of sunscreen applications on the last sailing day||34 (65)|
|Use of protective clothing|
|90%–100% of time in sun||34 (65)|
|50% of time in sun||14 (27)|
|Overall sun-protection behavior|
Almost all skippers reported severe sunburns of at least one of their passengers over the last 6 months; 90% of them recommended sun protection at the beginning of the cruises and half of them had spontaneously intervened at least once with advice for passengers not having adequate sun protection.
This is the second study concerning sun-protection knowledge and behavior of professionals with extreme UV exposure. Although the majority of professional skippers consulting at the Maritime Affairs Health Service in Martinique had quite good sun-protection knowledge, behaviors left room for improvement.
This study has some limitations, such as its small sample size; however, because of systematic annual convocations of skippers, it is believed that this sample is quite representative of professional skippers (nonprofessional skippers were not investigated). The absence of a question concerning the wearing of sunglasses is also a limitation.
The 75% simple sunburn rate over the last 6 months in this environment is similar to the 87% sunburn rate during the previous year among French adults who had visited a high UV-index country for >1 month.[4, 5] Moreover, this frequency is not much higher than that estimated by French dermatologists (50% during the last 6 months, for all French territories combined), perhaps a more exact estimation by the latter.
The frequency of severe sunburns (6%) reflected the intense, natural UV irradiation, in a context where the absence of protective care for as little as 15–30 minutes may be sufficient to cause severe sunburn. In addition, the frequency of sunscreen application, recommended every 2 hours, is probably not suited to the sea in the tropics. That aspect remains to be evaluated, as do situations involving the impact of ocean bathing or sweating on decreasing efficacy.
Moreover, the sun-protection factor (SPF) of 50, deemed sufficient in most cases, is perhaps not adequate in this environment, as shown by the results of a study comparing SPF50 and SPF85 at high mountain elevations. Furthermore, promotion of regular skin-cancer screening for these maritime professionals, similar to that for mountain guides routinely exposed to high UV radiation, appears necessary. The frequency of passengers with severe sunburns observed by skippers is still unclear, because of the methodology used and the questions asked. However, severe sunburns are real for these passengers. Sun-exposure prevention among pleasure craft passengers in the tropics appears crucial, and the results of this study showed the interest and involvement of sailboat captains in the subject. Thus, a sun-exposure prevention campaign targeting boatmen in this region is essential and is in preparation, actively involving the professional skippers.
The authors thank Mrs J. Jacobson for editorial assistance.
Declaration of Interests
The authors state that they have no conflicts of interest.