According to the World Health Organization (WHO, 2021), the incidence of both non-melanoma and melanoma skin cancers has been increasing over the past decades. Currently, between 2 and 3 million non-melanoma skin cancers and 132 000 melanoma skin cancers occur globally each year, and one in every three cancers diagnosed is a skin cancer (WHO, 2021). Cancer Research UK (2021) explain that the majority of skin cancers are caused by ultraviolet radiation (UVR) through exposure to the sun and sunburn, meaning that skin cancers are largely preventable through behaviours such as using sunscreen, avoiding the midday sun and seeking shade, as well as sun-protective clothing.
Fernández-Morano et al (2017) suggest that adolescents should be considered a priority group for targeted interventions to improve sun protection behaviour, with UVR exposure during childhood and adolescence being of particular importance for skin cancer risk across the life span (Pettigrew et al, 2020). In addition, Berneburg and Surber (2009) suggest that adolescents are an important group to explore in terms of sun-protective behaviours; while parents are likely to protect their children from sun exposure when they are very young, when they move into adolescence they are less likely to be observed by their parents, and therefore need to take more responsibility for their own sun-protective behaviours. Therefore, it is important to study awareness of and attitudes towards the risks of the sun and sun-protective behaviours in adolescents. One useful approach for investigation is through qualitative research methods, for example focus groups, where adolescents can discuss their attitudes and opinions regarding these issues. Focus groups are advocated as being ideal for exploring participants' understanding and attitudes towards health-related topics (Wilkinson, 1998).
‘… adolescents should be considered a priority group for targeted interventions to improve sun protection behaviour, with [ultraviolet radiation] exposure during childhood and adolescence being of particular importance for skin cancer risk across the life span’
Most of the previous research on this topic has focused on exploring adolescents' awareness of and attitudes towards UVR exposure and UVR protection quantitatively, through questionnaires and surveys (Owen et al, 2018). A qualitative study that explored adolescents' (11–14-year olds) awareness and attitudes towards UVR exposure and sun protection was carried out by Williams et al (2013a). The authors collected data from 227 Caucasian adolescents at a British secondary school, using open-ended questionnaires and 10 focus groups. Williams et al (2013a) found that all their participants were aware of sun protection and felt that there were both advantages and disadvantages to the use of sunscreen, as well as advantages and disadvantages of UVR exposure. They had mixed attitudes towards the benefits of tanned skin.
Most research in the area of sun protection awareness among adolescents has focused on quantitative methods, and there is a lack of qualitative research on young people's att itudes towards and knowledge of ultraviolet radiation exposure
‘There is little research that explores [ultraviolet radiation] exposure or related knowledge and att itudes among youth-group members, who may face greater exposure than average adolescents or children because of the nature of their activities’
The Williams et al (2013a) study looked at adolescents in general; however, it has been found that males and females seem to have different concerns and attitudes in regards to behaviours related to UVR exposure and sun protection (Williams et al, 2012; Williams et al, 2013b). There is little research that explores UVR exposure or related knowledge and attitudes among youth-group members, who may face greater exposure than average adolescents or children because of the nature of their activities (Wright and Reeder, 2005; Moehrle, 2008). The present study aimed to qualitatively explore the knowledge and attitudes of adolescent members of Girlguiding (Guides and Rangers) – an all-female youth organisation providing an abundance of opportunities and learning across the UK (Girlguiding, 2019) – towards UVR exposure and UVR-related behaviours.
‘…while participants knew that [ultraviolet radiation] can have a negative impact on the skin, when asked specifically what it does, the participants expressed uncertainty’
Methods
Participants
A total of 10 participants were opportunistically recruited from a sample of two girlguiding units in the UK: Guides and Rangers (four from the Rangers unit and six from the Guides unit). Participants ranged in age from 12–18 years old.
Data collection and analysis
Data were collected using focus groups, which have been described as a particularly valuable way of eliciting children or adolescents' views on health-related matters (Heary and Hennessy, 2002). A focus group question schedule was developed, informed by findings from existing literature, and consisted of 15 open-ended questions (with the addition of prompts). Example questions included ‘What do you think UVR exposure means?’ and ‘How aware are you of the appearance risks associated with UVR exposure?’. A Dictaphone was used to record the focus groups, and all data were transcribed fully afterwards. Both focus groups were facilitated by the first author who, at the time of the research, volunteered at the Girlguiding groups targeted for recruitment.
The data were analysed using inductive thematic analysis, which is a method for identifying, analysing and reporting patterns within data (Braun and Clarke, 2006). A realist theoretical approach was taken for analysis, with the researcher treating participants responses as a reflection of reality in terms of their knowledge and awareness. Each focus group occurred in a quiet room adjacent to the Girlguiding groups' usual meeting rooms (a familiar setting to them, in an attempt to normalise the focus group as much as possible, to encourage honest and open discussion), and both focus groups lasted approximately 50 minutes. After the focus group, participants were debriefed verbally and received a written debrief sheet, which included contact information for questions and resources for further information.
Ethical approval and consent
The study received ethical approval from the Stafforshire University ethics committee, and the ethical guidelines from the British Psychological Society (BPS, 2009) and the British Educational Research Association (BERA, 2011) were used to inform ethical practice throughout. A two-step consent collection occurred in accordance with the BPS (2014) Code of Human Research Ethics, which suggests good ethical practice includes seeking written permission for participation from parents/guardians, as well as the child participating.
Results
Following thematic analysis of the data, four themes were identified that captured the Girlguiding members' attitudes towards the sun risks and sun protective behaviours:
- Uncertainty about the specifics
- The importance of the influence of others
- Tanned appearance is positive
- The importance of increased education.
Participant pseudonyms were used for anonymity for the supporting quotes.
Uncertainty about the specifics
Despite some knowledge and awareness of what UVR is and its associated risks, participants expressed uncertainty about the specifics. Participants were aware, for example, that UVR exposure could be damaging to their skin and could have a negative impact on their appearance and health, particularly in relation to the skin cancer risk.
‘Despite some knowledge and awareness of what [ultraviolet radiation] is and its associated risks, participants expressed uncertainty about the specifics’
‘It can cause cancer from too much exposure’.
(Blair, 17)
‘Skin cancer!’ (is a health risk associated with UVR)
(Lily, 12)
There was uncertainty among the participants regarding the accuracy of their knowledge surrounding skin cancer, with some asking the facilitator questions to clarify their understanding.
‘Isn't melanoma a kind of skin cancer… I think you can get it removed maybe it's less harmful than another type? I don't know I might be wrong?’
(Mia, 17)
‘You don't really hear about skin cancer a lot. Is it even common?’
(Olive, 13)
Similarly, while participants knew that UVR can have a negative impact on the skin, when asked specifically what it does, the participants expressed uncertainty.
‘I learnt at school kind of thing, but I don't remember it at all really.’
(Mia, 17)
‘I know it does something to your skin, but I don't know what’
(Millie, 16)
Several participants expressed the belief that people are at greater risk of danger and damage from UVR exposure when they have insufficient knowledge of the risks.
‘Without the education of it you're more at risk of being harmed by it … you can't reduce your risk if you don't know what the risk is.’
(Blair, 17)
‘People need to be aware that using a tanning bed is actually more harmful than the sun.’
(Skye, 14)
‘There are loads of people that don't actually know what the sun can do.’
(Millie, 16)
Despite some knowledge and awareness of the benefits, several participants admitted to not always participating in safe UVR protection behaviours.
‘It's like we all know about dangers and how not to add to our risk but sometimes you just do you know, because you don't always think about it in the moment.’
(Blair, 17)
‘I can't lie, sometimes I can't be bothered.’
(Mia, 17)
The importance of the influence of others
This theme highlights the importance of the influence of others on the UVR-related knowledge, attitudes and behaviours of the participants. Parents, particularly mothers, were talked about as being especially influential in terms of participants sunscreen use.
‘My mum keeps making us top up on sun cream especially on holiday and cause my sisters got really sensitive skin she burns really easily.’
(Amy, 18)
‘My mum checks what the temperature's gonna be all day and then puts the highest one on that she thinks, so like if its 24 degrees she'll use 50, but if it's only like 20 she'll maybe only use 30.’
(Faith, 12)
‘My mum always prompts me to put sun cream on anyway though, even if I couldn't be bothered I will.’
(Blair, 17)
As well as their parents, some of the participants highlighted the impact peers could potentially have on UVR protection behaviours. Jess (14) and Skye (14) gave an example of how those who followed the advice from their school with regards to sun safety, were the recipients of negativity and bullying.
‘The school advise you to bring a hat and sun cream but not very many people did.’
(Jess, 14)
‘Yeah and the ones that did sometimes got bullied for using it.’
(Skye, 14)
Participants were mixed as to who they considered responsible for giving them information and advice about the risks of the sun and the importance of sun protective-related behaviours. Some talked about their parents as their primary source of information for knowledge and advice regarding sunburn and protection, whereas others also reported school as a source of knowledge. Participants suggested that there might be a tension between schools and parents, with some schools perhaps expecting parents to teach children about sun protection when they are young, but others suggesting that parents believe schools should be where in-depth learning about the risks of UVR should take place.
‘They don't see it as a risk that they need to teach us about because your parents should have… you do learn it from your parents when you go on holiday or when we're younger growing up they try and get it to stick with you.’
(Amy, 18)
Tanned appearance is positive
For many of the participants, having tanned skin was considered a positive.
‘Tanned skin seemed to be considered to be a societal expectation for many of the participants, and it was talked about as being a “social norm”.’
‘You get more attention if you're tanned.’
(Faith, 12)
‘It makes you feel better about yourself.’
(Millie, 16)
Tanned skin seemed to be considered to be a societal expectation for many of the participants, and it was talked about as being a ‘social norm’.
‘It's becoming like a social norm that you want to have a tan or that you should have a tan.’
(Amy, 18)
Participants talked, in particular, about how social media was influential in perpetuating this image. Several explained that a tanned complexion is seen on a variety of celebrities and influencers, as well as on social media channels such as Instagram and YouTube.
‘Social media cultivates everything like from your body type and body image and skin tone too like all these social influencers and celebrities are all tanned and flawless.’
(Blair, 17)
‘On Instagram and YouTube there's always people with tans and talking about holidays and “this will look good with a tan” and say they didn't tan enough on holiday and they want to be darker.’
(Jess, 14)
Despite most participants expressing the view that tanned skin was positive, several were keen to emphasise that they preferred to stay pale.
‘I don't want to look like everyone else, I like being pale, it suits who I am, I stay inside to stay pale.’
(Ruby, 16)
Sunless tanning
There was an awareness of different products that attempt to replicate a tanned complexion without the risks of UVR, known as sunless tanning (also referred to as self-tan or fake tan). Participants were aware that sunless tanner was healthier for the skin, in comparison to UVR exposure.
‘Fake tan is not as harmful as natural real tanning to your skin.’
(Amy, 18)
‘Products like self-tan are a lot more accessible than sun beds ‘cause that's… expensive… and you have to be a certain age … whereas anyone can just go in to Boots and buy self-tan.’
(Mia, 17)
However, for some, the use of these products appeared less desirable than the alternative.
‘Fake tan, a lot of the time, does look artificial … it goes streaky or patchy or orange.’
(Mia, 17)
The importance of increased education
The participants emphasised the importance of increased education in terms of the risks associated with the sun, not only for themselves, but for other young people. In particular, it was emphasised that more education was needed about the risks of UVR exposure, especially from sunbeds.
‘People need to be aware that using a tanning bed is actually more harmful than the sun.’
(Skye, 14)
The participants made a number of suggestions for how Girlguiding groups could be used as a particularly effective platform for increasing education on this topic. One suggestion was for the units to design and deliver activities that make learning about the risks of the sun and sun protective behaviours more fun and engaging. This was thought to be particularly applicable for the younger Girlguiding groups (Rainbows: 5–7-year olds and Brownies: 7–10-year olds).
‘The younger ones might not understand as much but their parents should, even if they just get more interested in putting sun cream on ‘cause they see it as good or fun.’
(Millie, 16)
‘Maybe with Rainbows or Brownies turn it into a game and make it fun but still have facts.’
(Faith, 12)
The participants also suggested how advice and talks from experts could be particularly beneficial in increasing knowledge about the risks and the importance of protective behaviours.
‘Maybe people could come in and have talks… if we got a teaching session or like it was all explained… that would be good.’
(Olive, 13)
Discussion
The findings of this study indicate that the participants did have some awareness of the risks of the sun and particularly of the importance of using sunscreen as a protective behaviour. However, awareness and knowledge were limited, with some uncertainty about the specifics. Attitudes such as not wanting to wear sunscreen despite knowing its importance, and the positive image of a tanned appearance are a concern, especially given the uncertainty of knowledge, which could be vulnerable to change. The influence of others on their knowledge and attitudes was highlighted, especially the importance of family members and schools providing information about the risks and appropriate UVR-related behaviours. Participants had suggestions for how the gaps in the knowledge and awareness of young people on this topic could be addressed and particularly how the Girlguiding association could draw on strategies to help improve the knowledge and attitudes of adolescent girls, who may be more vulnerable to the risks given the outdoor nature of many of their activities.
The study did indicate that some participants had ambivalent attitudes towards the use of sun protection, specifically because of perceived negative aspects associated with using it, and had positive attitudes towards UVR exposure, in terms of having tanned skin. Several participants talked about social media and celebrities as perpetuating society's positive attitudes towards tanned skin. A previous study exploring Girlguides' thoughts and feelings about their appearance, found that young people reported having a positive body image and feeling about their bodies; however, they also identified areas that made them feel more negatively about their appearance, including social media and the media (Owen and Griffiths, 2018). This echoes the present study's findings about the influence of social media and participants' views on having a tan and supports previous research specifically with regards to UVR exposure. For example, McWhirter and Hoffman-Goetz (2015) found that exposure to photos of people with tanned skin in traditional media (for example television and magazines) was correlated with significantly larger pro-tan attitudes, positive beliefs about tanning, frequency of tanning, and other behaviours linked to UVR exposure. The tripartite influence model is a socio-cultural theory of body image, which proposes that exposure to media leads to the internalisation of the ideals that define beauty, and according to this model, people make comparisons of their own appearance to the media ideals and subsequently experience body dissatisfaction (Keery et al, 2004). Findings indicate activities designed to encourage Girlguiding members to challenge the beauty ‘ideals’ that circulate on and are perpetuated by social media hold potential. Participants who articulated satisfaction with their non-tanned appearance could be encouraged to facilitate these activities and support others, especially given body comparisons with peers have been found to have a significant impact on the body image concerns of adolescent girls (Carey et al, 2014).
Fernández-Morano et al (2017) found adolescents' favourable attitudes towards sunbathing and sun tanning have the most influence on inadequate habits of sun exposure and deficient measures of sun protection. Thus, it is important to educate young people about the impact of exposing their skin to UVR, and the importance of using sun protection, as well as encouraging alternative ways of achieving a tan that are not associated with UV risk, ie through sunless tanning products. Participants' negative views on the aesthetics of these products need to be further explored and findings indicate that interventions teaching adolescent girls how to more effectively apply these products could have merit.
Participants discussed the influence of others on their attitudes to UVR exposure, and specifically their sun protection behaviours. In particular, they talked about how parents were a major influence on whether they used sun protection, which support previous research. Mewse et al (2011) found that parental authoritativeness was positively associated with the use of sun protection, even after the effects of other familial and peer variables were controlled. Interestingly, Mewse et al (2011) found that UVR exposure, in terms of sunbathing, was not associated with parental authoritativeness, but was instead associated with friends' behaviour. This links to some of the findings in the present study in regards to the participants' sun protective behaviours. For example, the participants talked about how people who brought sun protection into school were bullied about it, suggesting that this may discourage people from carrying out this health protective behaviour in school time.
The participants provided recommendations of how they felt that schools and Girlguiding could incorporate UVR-safety at several levels, from local Girlguiding unit meetings to the national Girlguiding programme, including expert talks on the risks and designing fun activities to engage and educate adolescents and younger girls on this topic. Girlguiding emphasises the importance of their sessions being led by the Girlguides (Girlguiding, 2021), which means that new additions to their programme should involve decisions that members themselves have participated in. The findings of the present study are an ideal example of where this could be possible.
Limitations and suggestions for future research
Although this study had several strengths, particularly in terms of the rich data obtained from an under-researched group, there were limitations. All the participants were white British, which limits the transferability of the findings to adolescents of other ethnicities. Information regarding the skin type of the participants was also not known and research indicates that skin type can impact attitudes towards UVR risks. Stapleton and Turrisi (2008), found that those with a darker skin type expressed more favourable attitudes towards sunbed tanning. It would be of interest to capture information about participant skin types in future studies to explore its potential impact on attitudes.
Conclusions
This study explored Girlguiding members' awareness of and attitudes towards the sun and sun-protection behaviours. While participants did have some awareness of the risks and of the importance of sun protective behaviours, awareness and knowledge were limited, with some uncertainty about the specifics. The influence of others on their knowledge and attitudes was highlighted, especially that of family members, in particular mothers, and schools. Potential conflicting expectations between school and parents in terms of the responsibility for providing information about the risks were highlighted. The Girlguides themselves had suggestions for how Girlguiding groups could be used as effective platforms for increasing education with regards to this topic and suggestions are made in this paper for potential strategies that could be implemented in an effort to challenge the positive image of having a tanned appearance that appears entrenched.
KEY POINTS
- Adolescent females were aware of the need for sun protection and the health and appearance risks of sun exposure but were uncertain about the specifics.
- Some participants had ambivalent attitudes towards the use of sun protection (specifically because of perceived negative aspects associated with using it), and had positive attitudes towards sun exposure, in terms of having tanned skin.
- The study emphasises the need for interventions in schools as well as outside groups such as Girlguiding, to educate young people about sun protection behaviours.
- The Girlguides themselves had suggestions for health promotion ideas, including parental involvement, as well as focusing more on making activities and ultraviolet radiation protective behaviours more fun.
REFLECTIVE QUESTIONS
- Is there anything you could do in your day-to-day discussions with young people that might positively impact the way they view sun protection?
- How might you encourage conversations around sun protective behaviours, such as sunbathing or using sunbeds, to try and help young people see the importance of protecting their skin?