Assessment of prevalence of sunscreen use and related practices among people living in Saudi Arabia: A cross‐sectional survey‐based study

The use of sunscreen significantly reduces the risk of skin cancer and helps maintain skin health; however, improper use can decrease its effectiveness. This study aimed to investigate the prevalence and factors associated with sunscreen use in Saudi Arabia as well as identifying areas of weakness in sunscreen practices.


| INTRODUC TI ON
Sunlight is composed of ultraviolet radiation (UVR) consisting of 95% long-wavelength (UVA) and 5% short-wavelength (UVB), each of which interact with the skin differently. 1 Although UVR exposure has many beneficial functions, chronic exposure can be harmful. 2In fact, UVR is the leading cause of all types of human skin cancer. 3Skin cancer cases are on the rise in Saudi Arabia due to excessive UVR exposure given the climate nature of the area, which is mostly sunny year-round. 4Of the main types of skin cancer, 5 basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are the most common in Saudi Arabia (51.4% and 22.5%, respectively).While, malignant melanoma represent 3.8% of malignant skin cancers in Saudi Arabia. 6nscreens, one of the main methods for protection against UVR, are chemical products that reduce UVR transmission, either absorbing UVR or acting as a physical barrier to scatter UVR. 7Indeed, several studies have reported the effectiveness of sunscreen use in the reduction of various types of skin cancer. 7However, not following the recommended guidelines for sunscreen application can give a false sense of protection which was documented by several observational studies. 7,8veral international survey-based studies have been conducted to measure the prevalence of sunscreen use, sun exposure habits and sunscreen related practices for the general population. 9,10wever, few studies have been done on a national scale in Saudi Arabia. 11Based on the emerged trend of skin cancer in Saudi Arabia, the aim of this survey-based study is to investigate the prevalence, as well as details related to sun exposure and sunscreen practices in individuals living in Saudi Arabia to aid the development of successful sunscreen awareness campaigns.

| Study design, setting, and participants
This cross-sectional study was conducted across all regions of Saudi Arabia.Individuals from the general population were eligible to participate if they were ≥18 years old.All participants were asked to provide informed consent before responding.Social media platforms such as WhatsApp and Twitter were utilized for questionnaire distribution from April 1, 2023, to June 6, 2023, and Google Forms was employed to create the questionnaire.
A validated English questionnaire from a previously published study 12 with minor modifications was adapted.The questionnaire was professionally translated to Arabic and validated by a pilot study prior to collecting data form participants.A non-probability convenience sampling technique was used to collect data from a readily available pool of participants.

| Outcome and independent variables
The primary objective of this study was to determine the prevalence of sunscreen utilization in a sample of the population in Saudi Arabia and the primary outcome variable was binary, asking participants whether they used sunscreen or not.The independent variables included various sociodemographic factors such as age, gender, marital status, monthly income, education attainment, nationality, and region.Additionally, skin-related questions were incorporated into the final model, such as the number of previous sunburns, personal history of skin cancer, family history of skin cancer, and skin type.To gain further insights into sun exposure habits and sunscreen related practices, the three groups of questions were analyzed separately, as presented in Figure 2 and Tables 4 and 5.

| Statistical analysis
For univariate analysis, descriptive characteristics were analyzed using appropriate statistical tests such as the chi-squared test, and Fisher's exact test.The main objective of this study was to determine the prevalence and attitude of sunscreen usage among a sample of the Saudi population.For multivariate analysis, binary logistic regression analysis was conducted to identify significant predictors and factors associated with sunscreen utilization.The assumptions of a linear relationship between the logit of the outcome and predictor variables, as well as multicollinearity, were assessed and met. 13All statistical tests were two-sided, and statistical significance was considered at a p < 0.05.The data analysis was performed using SAS statistical software version 9.4 (SAS Institute Inc., Cary, NC).

| RE SULTS
A total of 2321 individuals participated in this study.General characteristics of study participants and their prevalence of sunscreen use are presented in Table 1.Nearly, around 75% of participants reported using sunscreen (in a regular or fluctuating manner), while the remaining never used it before, Table 1.The prevalence of sunscreen use based on skin characteristics of study participants are presented in Table 2.Such as, skin type according to the Fitzpatrick skin phenotype, history of sunburn, and history of skin cancer.
In addition, the association between subjects' characteristics and sunscreen use were also explored using a multivariate analysis, Table 3. Participants in all age groups were more likely to use sunscreen compared to participants >60 years old.For example, participants in the 31-40 age group were two times more likely to report using sunscreen than participants >60 age group (OR 2.56; 95% CI (1.14, 5.75); p-value = 0.02), Table 3.Furthermore, females were seven times more likely to report using sunscreen than male (OR 7.73; 95% CI (6.12, 9.75); p < 0.0001), Table 3.In terms of financial factors, unexpectedly, the lower the monthly income the more likelihood of sunscreen use in the current study.For instance, participants with monthly income <2000 SAR were more likely to report using sunscreen than participants with monthly income >20 000 SAR (OR 1.61; 95% CI (1.08, 2.41; p = 0.01), Table 3.Moreover, the association of sunscreen use with specific skin characteristics that could increase the risk of skin cancer were assessed.It was less likely for participants to report using sunscreen with no history of sunburn compared to acquiring one sunburn (OR 0.55; 95% CI (0.41, 0.75) p = 0.0001).Moreover, users with skin types 1, 2, 3, and 4 were more likely to report using sunscreen compared to skin type 6 (OR 2.47; 95% CI (1.34, 2.56) p = 0.04, OR 1.83; 95% CI (1.02, 3.3) p = 0.003, OR 2.37; 95% CI (1.34, 4.21) p = 0.04, OR 1.5; 95% CI (0.91, 2.47) p = 0.002, respectively), Table 3 and Figure 1.Lastly, participants from the northern region were less likely to report using sunscreen compared to participants from the western region OR 0.25; CI 5% (0.15,0.4), p < 0.0001, Table 3 and Figure 1.
In terms of sun exposure habits, in our cohort, participants would be exposed to the sun mainly for necessary transportation or activity (77.17%),Table 4.Most of them maintained a sun exposure   4. Furthermore, the most common reasons for using or not using sunscreen were illustrated in Figure 2.
For the last part, we explored sunscreen related practices among participants to assess if sunscreen is being used effectively.The focus was on factors that could affect the protection level of sunscreen, Table 5.For example, 47.14% of sunscreen users reported using less than quarter teaspoon, 43% of them applied it to only their face and hands and most of them (77.44%) reported that they do not reapply sunscreen, Table 5.Most sunscreen users in this study used sunscreen on sunny days and applied it less than 10 min before sun exposure, Table 5. Noticeably, broad spectrum and high sun protection factor (SPF) sunscreen were favorable by sunscreen users in this study.Lastly, most sunscreen users reported that sunscreen is not affordable, Table 5.

| DISCUSS ION
Effective sunscreen application is one of the powerful protective methods against sun exposure (UVR).In this study, the prevalence of sunscreen use is considerably high compared to a similar study in Saudi Arabia, which reported a prevalence of 23.7%. 11Other studies targeting populations in Qassim city and in Al-Kharj city found the prevalence of sunscreen use to be (8.3% and 38.7%, respectfully). 14wever, a similar prevalence to our study was observed in a study conducted in Riyadh city, among patients attending dermatology clinics (72%). 15One possible explanation of the high prevalence of sunscreen use in our study and other studies conducted after the year 2020, is the increase in health awareness post COVID-19 pandemic.
Noticeably, females are significantly more likely to report using sunscreen compared to males in this study, Table 3.A similar finding was reported by Al-Jasser group. 12This could be because sunscreen use can prevent skin wrinkles and dark spots, which are usually concerns of females more than males. 12,16In addition, a Saudi based study reported that females had significantly higher skin cancer knowledge compared to males. 17Interestingly, participants with low monthly income are more likely to report using sunscreen compared to higher monthly incomes, Table 3, possibly because a large portion of participants in this study are students since 50% of participants age between 18 and 30 years old, Table 1.In addition, participants from the northern region are less likely to report using sunscreen compared to participants from the Western region, Table 3, this could be due to the small sample size from the northern region, Table 1.
Remarkably, some skin characteristics of the participants in this study such as skin type and history of sunburn significantly influenced the prevalence of sunscreen use, Tables 2 and 3.
Epidemiological studies demonstrate that individuals with higher skin pigmentation are less prone to skin cancer compared with TA B L E 2 Skin characteristics of the participants and its association with sunscreen use (univariate analysis).individuals with lower skin pigmentation. 18In reference to the Fitzpatrick skin phenotype scale used in this study, 19 skin type 6 has the highest skin pigmentation and skin type 1 has the lowest skin pigmentation, Tables 2 and 3.Moreover, individuals with past sunburns and lighter skin are at a higher risk of developing melanoma, the most aggressive form of skin cancer. 20Thus, the finding in our study that participants with lighter-skin complexion (skin type 1-3) and a history of more than one sunburn are more likely to report using sunscreen is considered a good practice, Figure 1, Tables 2 and 3.This finding is consistent with findings from a previous study in which participants with a history of more than one sunburns were more likely to report using sunscreen among a population of mostly skin type 3 or 4. 12 Interestingly, in this study and other similar studies on Saudi population, the association between the history of personal or family skin cancer and the prevalence of sunscreen use are not significant. 15Furthermore, Al-Atif found that despite knowing that unprotected sun exposure is a risk factor for skin cancer, sunscreen use was considerably low (36%). 21This could be due to the low prevalence (3.8%)rate of malignant skin cancer in Saudi Arabia. 6Meanwhile it is also important to note that most participants in this study are younger than 60 years old, Table 1, which is not a common age for skin cancer diagnosis.
Sun exposure habits such as, the time and amount of sun exposure, can greatly influence the incidence of skin cancer.In fact, the amount of sun exposure is directly proportional to the increased risk of UVR damage such as skin cancer. 22Sun exposure habits of the study participants in the current study are shown in Table 4. Consistent with other local studies, the main reason for sun exposure in this study is due to necessity. 12Data from Table 4 assessing the amount and frequency of sun exposure (natural and artificial) reflects healthy sun exposure habits.This suggests that participants have a decent level of knowledge regarding the harmful effects of chronic sun exposure.A similar high level of awareness regarding sun exposure was also found by Alghamdi et al. 11 However, a study conducted in Riyadh city found F I G U R E 1 Association between sunscreen use and sociodemographic factors.

Frequency and percentage N (%)
What is the reason for sun exposure?
For necessity such as that approximately 80% of their participants did not know the harmful association between sun exposure and skin cancer. 23 terms of reasons behind sunscreen usage, the determining factor for sunscreen use is to maintain light skin complexation, Figure 2, which is consistent with other Saudi studies. 12,17This indicates that in the Saudi community preventing skin darkening is a major motive for sunscreen use.The major factors for not buying and using sunscreen are inconvenience and high prices.Conversely, high sunscreen prices did not prevent dermatology patients, in a Saudi study, from buying sunscreens. 15This could be because dermatology patients have the opportunity to be educated about the importance of regular use of sunscreen.
There are several factors that can affect the degree of sunscreen protection against sun rays (UVR).UVR is composed of UVA and UVB both have detrimental effects on the skin with chronic exposure. 1us, an effective sunscreen should have protection against both UVA and UVB (broad-spectrum) and with sufficient SPF. 7Data represented in Table 5 reflect a good sunscreen related practice in regard to using a broad-spectrum coverage.In contrast, Al-Jasser et al study, reported that only 28% of them used broad-spectrum sunscreens. 12The data related to sunscreen SPF in this study is consistent with the current recommendation of using an SPF of 30 or more to provide the optimal protection which reflects good practice, Table 5. 16 Similarly, majority of sunscreen users (72%) in al Al-Robaee study used an SPF >30. 17 Table 5 also displays some sunscreen related practices that needs attention and improvement.For full sunscreen protection, sunscreen should be applied 15-30 min before sun exposure, on both cloudy and sunny days as UV rays are still reaching the skin even with the clouds present, and with an amount of approximately one to two tablespoon to cover the whole face and neck. 7Furthermore, sunscreen should be reapplied 2-3 h as it was shown to decrease its effectiveness with time and can be removed with excessive sweating and after water immersion. 7,24To maximize the benefit of sunscreen these recommendations should be followed, however, most participants in this study that use sunscreen do not follow these recommendations, Table 5. Consistently with other Saudi studies, 62% of participants in Al-Jasser study did not reapply sunscreen 12 and 79% of participants in Alamri study lacked the knowledge about sunscreen reapplication. 23I G U R E 2 Reasons for using or not using sunscreen among participants.N = number of participations; % = percentage of participation.
TA B L E 5 Sunscreen related practices.

Frequency and percentage N (%)
In which weather conditions do you use sunscreen?

Odds ratio (OR) Using sunscreen vs. never used sunscreen 95% Confidence interval p-value
TA B L E 3 Multivariate analysis of subjects' characteristics associated with sunscreen use.