Introducción
Skin cancer has a high global incidence; in 2020, there were 201 new cases per 100,000 inhabitants
1
. In Peru, it is the second most frequent type of cancer (13.7%)
2
. It can be classified as melanoma or non-melanoma. Among the factors associated with the development of skin cancer, exposure to solar radiation, use of tanning beds, and other individual determinants such as skin phototype, number of moles or freckles, and family or personal history of cancer have been described. Exposure to ultraviolet (UV) radiation from the sun, classified into UVA (315 to 400 nm), UVB (280 to 315 nm), and UVC (100 to 280 nm) according to wavelength, is one of the main causes of skin cancer. It significantly influences the clinical-pathological variety of melanoma due to sun exposure
3-
7
; especially UVB, which directly damages DNA and increases mutation frequency related to burns and the etiology of various skin cancers
8
.
Photoprotection refers to measures that prevent UV radiation damage to the skin; these can be intrinsic, such as skin phototype, or involve external resources: shade, limiting sun exposure time, clothing, sunglasses, hats, and daily use of sunscreen
9
. Sunscreens work by containing an active ingredient that absorbs, reflects, or disperses solar radiation in the range of 290 to 400 nm
9
10
. They are effective in preventing actinic keratosis and squamous cell carcinoma, while for basal cell carcinoma, their effectiveness is less clear.
It is important to assess the level of knowledge about the use of sunscreens, as it leads to increased usage and prevention of skin cancer. In Mexico, most medical students (66%) report using sunscreen, especially at the beach (76.1%), but only 26.4% use it daily
11
; Similarly, in Colombia, usage was inadequate, more so among women, and knowledge levels were low
12
. In Peru, varying levels of knowledge about sunscreen have been reported among medical students in Lima, depending on the type of question, with usage reaching 38.1%. Associated factors include being male and recent training
13
.
Medical students, due to the nature of their studies and their potential role in promoting the use of sunscreens and preventing skin cancer, are the focus of this research, whose main objective is to study the level of knowledge and frequency of sunscreen use and subsequently assess the influence of factors such as gender, age, and level of studies.
Materials and Methods
Design
The study follows a quantitative approach, with an observational, descriptive, and cross-sectional design. It was conducted with medical students from the II, VI, VII, VIII, IX, X, XI, or XII cycles at the Universidad Privada Antenor Orrego in Trujillo, Peru. Data collection took place from June to July 2022. Participants received an email with a form, which they completed after providing informed consent.
As a selection criterion, students had to reside in Trujillo and be enrolled in the 2022 academic cycle. Students were grouped into cycle II (early level), VI (middle and final basic courses), and VII to XII (clinical courses).
Sample Size Calculation
The sample size was calculated using the formula for estimating a proportion, working with a finite population of 2,090 medical students. An expected frequency of 25%, based on a pilot study, was used with 95% confidence intervals and a precision of 5%. The total sample size was 287 participants, and a 5% increase was applied to account for potential losses, leading to a final sample size of 302.
Variables and Instruments
The considered variables were: Sunscreen use, with three levels of indicators: always, sometimes, and never. Knowledge of sunscreens, assessed through an eight-question survey: low (1-4 correct answers), medium (5-6 correct answers), and high (7-8 correct answers). Gender: male and female. Study cycle: Based on enrollment, three groups were considered: cycle II, cycle VI, and cycles VII to XII. Skin types: Oily, with excessive sebum accumulation; dry, with low oil levels; combination, intermediate between oily and dry; sensitive, with itching and/or pain, potentially causing facial redness
14
15
Phototypes based on the Fitzpatrick scale and images included in the survey: I (white skin, always burns, never tans), II (white skin, always burns, tans with difficulty), III (medium skin color, sometimes mild burns, average tanning), IV (light brown skin, rarely burns, tans easily), V (brown skin, never burns, tans very easily), VI (dark skin, highly pigmented, never burns, tans very easily)
16
For the study, a survey titled “Knowledge and Frequency of Sunscreen Use among Medical Students” was developed, consisting of a 16-question validated and expert-reviewed questionnaire. The first eight questions addressed generalities and frequency of use, while the remaining eight assessed knowledge. These were based on a survey applied in Peru
13
and another at a Colombian university
12
. Skin type was self-evaluated as per Rodríguez-Gambetta
13
and Durán-Ávila
17
The format is described in Table 1.
Data Analysis
The collected data were tabulated using SPSS 23, which generated frequency tables on sunscreen use according to gender, skin type, phototype, study cycle, and level of knowledge by gender and study cycle. The association between the level of knowledge and sunscreen use, as well as with gender and study cycle, was determined. Additionally, the association of sunscreen use with skin type, phototype, and family history of skin cancer was analyzed using the Chi-square test, with a significance level of p < 0.05.
Ethical Considerations
The study adhered to the Declaration of Helsinki
18
and followed the International Ethical Guidelines for Biomedical Research and Human Experimentation by the World Health Organization. All participants gave informed consent prior to participation. The study received approval from the Bioethics Research Committee of the Universidad Privada Antenor Orrego, with Resolution N° 0264-2022-UPAO. Data confidentiality was maintained by coding the responses.
Results
In the population of medical students studied, 64.2% were female, with an average age of 21 for men and 20.6 for women (Table 2).
To assess the level of knowledge, students were divided into three groups: cycle II, VI, and advanced cycles (VII-XII), and by gender. The highest percentage (57.5%) had a high level of knowledge, particularly among students in advanced cycles. Sunscreen use, according to cycles and gender, showed that 28.8% always use sunscreen, with higher use among women (Table 3).
Regarding the frequency of correct answers, question 2 had the highest percentage of correct responses, while question 8 had the lowest (Table 4).
The association between the level of knowledge and sunscreen use was significant across the total population, as well as among men and women, using the Chi-square test. Additionally, phototype significantly influenced sunscreen use, with the lightest phototype (I) showing the highest usage (Table 5).
Some complementary aspects of the surveys were also highlighted. The most frequent skin type (55%) was combination skin, and the most common skin phototype was type III, with 58.6%. Only 4.3% reported a family history of skin cancer. The most common reason for not using sunscreen (54.3%) was its oily consistency. The primary factors for choosing sunscreens were skin type and the sun protection factor (SPF). The most frequent condition for applying sunscreen was outdoor activities on sunny days (Table 6).
Discussion
Population and Sample
This study involved 302 medical students from a private university in Trujillo, with a predominance of females (64.2%), reflecting the gender distribution in the medical school. Students from early, mid, and advanced cycles were represented, and the average age increased with each cycle. Most respondents were 20 years old, accounting for 22.2% of the sample. The students participated voluntarily by answering the questionnaire that was sent to them virtually. The level of knowledge among medical students at this private university in Trujillo was similar to that reported for medical students in Santo Domingo
19
, and the population of Chiclayo, Peru (57%)
20
;However, it was higher in the advanced knowledge level compared to Ica, Peru (18%)
21
, where medium-level knowledge was predominant. The acceptable quality of knowledge may be attributed to medical students' interest and the good information on photoexposure and photoprotection provided by current media outlets.
This study shows a higher level of knowledge among female students (60.3%) compared to males (48.1%), in contrast to university students in Santo Domingo
19
where males had higher knowledge levels (31.0%) compared to females (17.0%). These results suggest that knowledge levels may vary by gender depending on different contexts.
Only 28.8% of students always use sunscreen, 46.4% sometimes use it, and 24.4% never use it. This percentage is lower than that reported in Santo Domingo (47%)
19
, Pakistan (33,1%)
22
and the United States (33%)
23
and is similar to the rates observed among Venezuelan athletes
24
.
Sunscreen use was higher among females, similar to findings in Pakistan. These results highlight the need for greater awareness among medical students about the importance of sunscreen use.
Sunscreen use was significantly associated with the level of knowledge, and knowledge levels were related to study cycles. However, sunscreen use was not associated with advanced study cycles, which may indicate the influence of other factors requiring further investigation. In Ica, Peru
21
, , no relationship was found between knowledge levels and attitudes. A systematic review involving 10,400 athletes found that despite knowing the risks of skin cancer from UV exposure, they did not adequately use sunscreens
25
. This suggests that knowledge alone is insufficient; attitudes must also be addressed.
The most frequent skin type in this study was combination skin, similar to findings among Colombian students
12
. The most common skin phototype, according to Fitzpatrick, was type III (58.6%), similar to reports from Chiclayo, Peru (43.7%)
20
, Ica, Perú (40,5%)
21
and Pakistan
22
. In another study of merchants in Chiclayo, Peru, phototype IV (48.8%) was the most common, followed by phototype III (24.7%)
26
. In Spain and Italy, phototype II (36.7%) was most common, followed by phototype III (27%) in medical students, as indicated by a survey
17
. Phototype significantly influences sunscreen use, with phototype I (the lightest) having the highest usage rate, which aligns with reports from Venezuelan athletes
24
. The Fitzpatrick scale, based on skin color and sun sensitivity, predicts the risk of photosensitivity, with types I to III being at higher risk for skin cancer
23
. Further research on skin phototypes is needed to recommend sunscreens that protect not only against UVB but also UVA and visible light
27
.
Family history of skin cancer was very low, similar to reports from Lima, Peru
13
, Chiclayo, Peru
20
, Pakistan
22
, the United States
23
and Europe
17
, suggesting that this is not a significant factor.
Finally, regarding the questions on photoprotection knowledge, based on a Colombian university model
12
the question with the highest correct response rate was whether solar radiation causes skin cancer, similar to findings at that university. The question with the lowest accuracy was about the frequency of sunscreen reapplication outdoors, similar to results in Colombia. This highlights the importance of implementing photoprotection training programs not only for university students but also for the community to promote skin cancer prevention, aligning with findings at a Peruvian university
13
27
28
One limitation of this study was the convenience sampling method. The survey was only validated by expert judgment. The determination of skin phototype was self-reported by the participants in the survey, as it was not feasible to conduct dermatological examinations, a method also used by other authors
13
17
Table 1.
Other Characteristics of Medical Students from a University in Trujillo, Peru – 2022
| CHARACTERISTICS |
N° (%) |
| SKIN TYPE |
| Combination |
166 (55%) |
| Oily |
63 (20.9%) |
| Sensitive |
33 (10.9%) |
| Dry |
18 (6%) |
| Don’t know |
22 (7.3%) |
| SKIN PHOTOTYPE |
| I |
26 (8.6%) |
| II |
43 (14.2%) |
| III |
177 (58.6%) |
| IV |
52 (17.2%) |
| V |
3 (1%) |
| VI |
1 (0.3%) |
| FREQUENCY OF USE |
| Every 2 hours |
5 (1.7%) |
| Every 4 hours |
21 (7%) |
| Morning and night |
6 (2%) |
| Once a day |
89 (29.5%) |
| Occasionally |
181 (59.9%) |
| REASON FOR NOT USING SUNSCREEN |
| It is oily |
164 (54.3%) |
| It is expensive |
86 (28.5%) |
| It is unnecessary |
33 (10.9%) |
| It is ineffective |
3 (1%) |
| Allergic reaction |
16 (5.3%) |
| REASONS FOR CHOOSING SUNSCREEN |
| SPF |
125 (41.4%) |
| Skin type |
127 (42.1%) |
| Brand |
24 (7.9%) |
| Other |
13 (4.3%) |
| Price |
13 (4.3%) |
| CONDITIONS FOR SUNSCREEN USE |
| Outdoor activities on a sunny day |
78 (25.8%) |
| Outdoor activities on a cloudy day |
3 (1%) |
| For swimming, pool, or waterfall visits |
24 (7.9%) |
| Attending activities inside the hospital, reading rooms, or other activities |
5 (1.7%) |
| Attending any event at night |
0 (0%) |
| All of the above |
192 (63.6%) |
Table 2.
Knowledge and Frequency of Sunscreen Use Questionnaire for Medical Students
| Question |
Response Options |
| GENERAL INFORMATION |
| 1. What type of skin do you have? |
a) Oily b) Combination c) Dry d) Sensitive e) Reddened f) Acne-prone g) Mature h) Don’t know |
| 2. Skin phototype* |
a) I b) II c) III d) IV e) V f) VI |
| 3. Do you use sunscreen? |
a) Always b) Sometimes c) Never |
| 4. How often do you use sunscreen? |
a) Every 2 hours b) Every 4 hours c) Once a day d) Morning and night e) Occasionally |
| 5. What reason makes you avoid using sunscreen? |
a) It’s oily b) It’s ineffective c) Allergic reaction d) It’s expensive e) It’s unnecessary |
| 6. Do you have any first-degree relatives with skin cancer? |
a) Yes b) No |
| 7. Based on what criteria would you choose a sunscreen? |
a) Skin type b) SPF c) Price d) Brand e) Other |
| 8. Under what conditions should sunscreen be applied? |
Outdoor activities on a sunny day, Outdoor activities on a cloudy day, For swimming in pools, beaches, or waterfalls, Attending activities inside hospitals, reading rooms, or indoor facilities, Attending any event at night, All of the above |
| KNOWLEDGE |
| 1. Is sunscreen effective in preventing sunburn? |
a) Yes** b) No |
| 2. Is solar radiation the main cause of skin cancer? |
a) Yes** b) No |
| 3. Does a person of color also need to use sunscreen? |
a) Yes** b) No |
| 4. Is SPF 15 sunscreen better than SPF 30 sunscreen? |
a) Yes b) No** |
| 5. Is it necessary to use sunscreen on a cloudy day? |
a) Yes** b) No |
| 6. What does SPF stand for in sunscreen? |
a) Sun protection factor** b) Sun’s protection factor c) Filter protection factor d) Burn protection factor e) Tanning protection factor |
| 7. On a sunny day, when should sunscreen be applied before going outdoors? |
a) 5 minutes before b) 15 minutes before c) 30 minutes before** d) 45 minutes before e) It does not matter when f) Lack of information |
| 8. How often should sunscreen be reapplied when outdoors? |
a) Every hour b) Every two hours** c) Every six hours d) Follow product instructions e) Lack of information |
* Images of skin phototypes were provided to the respondents.
** Correct answers.
Table 3.
Population of Medical Students at a University in Trujillo, Peru – 2022
|
|
Males |
|
Females |
|
| Cycle |
Total number (%) |
Number |
Average age |
Number |
Average age |
| II |
75 (24.8 %) |
27 |
18.7 |
48 |
18.6 |
| VI |
108 (35.8 %) |
33 |
20.5 |
75 |
20.5 |
| VII |
33 (10.9 %) |
13 |
21.5 |
20 |
20.5 |
| VIII |
15 (5 %) |
6 |
21.3 |
9 |
21.8 |
| IX |
25 (8.3 %) |
11 |
23.6 |
14 |
22.9 |
| X |
16 (5.3%) |
7 |
23.9 |
9 |
22.4 |
| XI |
20 (6.6 %) |
7 |
23 |
13 |
22.9 |
| XII |
10 (3.3 %) |
4 |
23.5 |
6 |
23.2 |
| TOTAL |
302 (100 %) |
108 (35.8 %) |
|
194 (64.2 %) |
|
| Average |
|
|
21 |
|
20.6 |
Tabla 4.
Level of Knowledge and Use of Sunscreen by Gender and Academic Cycle among Medical Students at a University in Trujillo, Peru – 2022
| Knowledge level |
Academic cycle |
| II |
VI |
VII-XII |
Total |
| MALES |
| Low |
3 (11.1%) |
6 (17.6%) |
2 (4.3%) |
11 (10.2%) |
| Medium |
15 (55.6%) |
12 (35.3%) |
18 (38.3%) |
45 (41.7%) |
| High |
9 (33.3%) |
16 (47.1%) |
27 (57.4%) |
52 (48.1%) |
| FEMALES |
| Low |
1 (2.1%) |
5 (6.8%) |
1 (1.4%) |
7 (3.6%) |
| Medium |
25 (52.1%) |
24 (32.4%) |
21 (29.2%) |
70 (36.1%) |
| High |
22 (45.8%) |
45 (60.8%) |
50 (69.4%) |
117 (60.3%) |
| TOTAL |
| Low |
4 (5.3%) |
11 (10.2%) |
3 (2.5%) |
18 (6%) |
| Medium |
40 (53.3%) |
36 (33.3%) |
39 (32.8%) |
115 (38%) |
| High |
31 (41.3%) |
61 (56.5%) |
77 (64.7%) |
169 (56%) |
| SUNSCREEN USAGE LEVEL |
| MALES |
| Always |
5 (18.5%) |
8 (23.5%) |
7 (14.9%) |
20 (18.5%) |
| Sometimes |
9 (33.3%) |
10 (29.4%) |
28 (59.6%) |
47 (43.5%) |
| Never |
13 (48.2%) |
16 (47.1%) |
12 (25.5%) |
41 (38%) |
| FEMALES |
| Always |
15 (31.2%) |
30 (40.5%) |
22 (30.6%) |
67 (34.5%) |
| Sometimes |
26 (54.2%) |
29 (39.2%) |
38 (52.7%) |
93 (48%) |
| Never |
7 (14.6%) |
15 (20.3%) |
12 (16.7%) |
34 (17.5%) |
| TOTAL |
| Always |
20 (26.7%) |
38 (35.2%) |
29 (24.4%) |
87 (28.8%) |
| Sometimes |
35 (46.6%) |
39 (36.1%) |
66 (55.4%) |
140 (46.4%) |
| Never |
20 (26.7%) |
31 (28.7%) |
24 (20.2%) |
75 (24.8%) |
Knowledge level: Association with gender p=0.041, Association with academic cycle p=0.006.
Usage Level: Association with gender p=0.001, Association with academic cycle p=0.065.
Table 5.
Knowledge about Sunscreen among Medical Students at a University in Trujillo, Peru – 2022
| Question |
Correct |
Incorrect |
| 1. Effective in preventing burns |
287 (95%) |
15 (5%) |
| 2. Solar radiation causes cancer |
293 (97%) |
9 (3%) |
| 3. People of color require sunscreen |
291 (96.4%) |
11 (3.9%) |
| 4. SPF comparison |
259 (85.8%) |
43 (14.2%) |
| 5. Use of sunscreen on cloudy days |
269 (89.1%) |
33 (10.9%) |
| 6. Meaning of SPF |
26 (86.4%) |
41 (13.6%) |
| 7. Time of application on a sunny day |
169 (56%) |
133 (44%) |
| 8. Frequency of reapplication outdoors |
122 (40.4%) |
180 (59.6%) |
SPF: Sun Protection Factor
Table 6.
Other Factors and Sunscreen Use among Medical Students at a University in Trujillo, Peru – 2022
| Sunscreen use |
Always |
Sometimes |
Never |
Total |
P |
| SKIN TYPE |
| Combination |
40 (24.1%) |
86 (51.8%) |
40 (24.1%) |
166 (100%) |
0.054 |
| Oily |
21 (33.3%) |
24 (38.1%) |
18 (28.6%) |
63 (100%) |
|
| Sensitive |
15 (45.5%) |
14 (42.4%) |
4 (12.1%) |
33 (100%) |
|
| Dry |
6 (33.33%) |
9 (50%) |
3 (16.67%) |
18 (100%) |
|
| Don’t know |
5 (22.73%) |
7 (31.82%) |
10 (45.45%) |
22 (100%) |
|
| SKIN PHOTOTYPE |
| I |
12 (46.15%) |
7 (26.92%) |
7 (26.92%) |
26 (100%) |
0.005 |
| II |
18 (41.86%) |
21 (48.84%) |
4 (9.30%) |
43 (100%) |
|
| III |
42 (27.73%) |
93 (52.54%) |
42 (23.73%) |
177 (100%) |
|
| IV |
14 (26.92%) |
18 (34.62%) |
20 (38.46%) |
52 (100%) |
|
| V |
1 (33.33%) |
1 (33.33%) |
1 (33.33%) |
3 (100%) |
|
| VI |
0 |
0 |
1 (100%) |
1 (100%) |
|
| FAMILY HISTORY OF SKIN CANCER |
| Yes |
5 (38.46%) |
5 (38.46%) |
3 (23.08%) |
13 (100%) |
0.726 |
| No |
82 (28.38%) |
135 (46.71%) |
72 (24.91%) |
289 (100%) |
|
| HISTORY OF SKIN CANCER |
| Yes |
0 |
0 |
1 (100%) |
1 (100%) |
1.000 |
| No |
87 (28.08%) |
140 (45.19%) |
74 (23.87%) |
309 (100%) |
|
| LEVEL OF KNOWLEDGE - WOMEN |
| High |
48 (40.7%) |
57 (48.3%) |
13 (11%) |
118 |
0.021 |
| Medium |
17 (24.6%) |
32 (46.4%) |
20 (30%) |
69 |
|
| Low |
2 (28.6%) |
4 (57.1%) |
1 (14.3%) |
7 |
|
| Total |
67 |
93 |
34 |
194 |
|
| TOTAL |
| High |
61 (36.1%) |
79 (46.7%) |
29 (17.2%) |
169 |
0.001 |
| Medium |
21 (18.3%) |
56 (48.7%) |
38 (33%) |
115 |
|
| Low |
5 (27.8%) |
5 (27.8%) |
8 (44.4%) |
18 |
|
| Total |
87 |
140 |
75 |
302 |
|
Conclusions
Se concluye que en los estudiantes de medicina de una universidad peruana, el nivel de conocimiento sobre el uso de protector solar fue alto en 56 % de los encuestados, mayor en las mujeres, aumenta significativamente con los ciclos de estudios y favorece el uso del protector solar. El 28,7 % de los estudiantes de medicina siempre usaban protector solar. Los factores que guardan relación con el uso del protector solar son el género femenino, el fototipo y el nivel de conocimiento.
Additional Information
Conflict of Interest Declaration: The authors declared no conflicts of interest.
Author Contributions:
All authors have participated in the various stages of the research and approved the final version of the article.
Funding: Self-funded by the authors.
Received: February 11, 2024
Accepted: September 12, 2024
Corresponding Author Information
Correspondence: Luciana Ximena Yep-Romero
Email: jjhuamans@gmail.com
Published article by the Journal of the Faculty of Human Medicine of the Ricardo Palma University. This is an open-access article distributed under the terms of the Creative Commons License: Creative Commons Attribution 4.0 International, CC BY 4.0
, which allows non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial use, please contact revista.medicina@urp.edu.pe.
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