Type of the Paper (Article Int. J. Occup. Safety Health, Volume 13, No 2 (2023), 199-205 https://www.nepjol.info/index.php/IJOSH 199 Original Article Evaluation of the knowledge of sun exposure and sun protective measures in healthcare workers Aryal E1, Shrestha PR2, Gautam S3 1 Associate Professor, Department of Dermatology, Kathmandu Medical College, Kathmandu, Nepal 2 Lecturer, Department of Dermatology, Kathmandu Medical College, Kathmandu, Nepal 3 Resident, Department of Dermatology, Kathmandu Medical College, Kathmandu, Nepal ABSTRACT Introduction: Solar ultraviolet (UV) radiation has a great impact on human life. The sun has always played an important role in Asian culture, so much so, that it is often prayed to as a God. Prolonged sun exposure can cause extensive and chronic harmful effects. Healthcare personnel is supposed to have good knowledge regarding sun protection as they play a key role in society disseminating knowledge to the general public. There are limited data regarding the knowledge of sun protection and sunscreen practice among health care workers. Methods: This descriptive cross-sectional study was carried out from June to October 2020 on healthcare workers (medical staff) in Kathmandu Medical College Teaching Hospital. A questionnaire was distributed to the target study population without disturbing or hampering the healthcare worker’s duty. Results: Out of a total of 264 participants in the study, 84 (31.8%) were male and 180 (68.2%) were female. The knowledge of proper terminology for SPF (Sun Protection Factor) was noted in 196 (74.2%) and 57 (21.6%) agreed that the value of SPF was related to age. No significant difference was noted regarding knowledge about the time of sun exposure for Vitamin D synthesis. No significant differences were found in practices of sunscreen use for purposes of fairness, or prevention of tanning, wrinkle, mole, and skin cancer. Conclusion: A higher level of education was associated with better knowledge and proper abiding practices regarding sunscreen use. As healthcare workers play a key role in distributing information in society, they should be targeted in education campaigns regarding sun exposure and sun protection measures; with these efforts focused more on nurses and medical officers. Keywords: Health personnel, Knowledge, Sunscreen, Ultraviolet Introduction Solar ultraviolet (UV) radiation has a great impact on human life. Sun has always been given importance in Asian culture to the extent that it is often considered of god, similar to the Greeks and Romans worshipping Apollo as the sun God and the god of light.1 Even today, UV radiation via sunlight has important public health implications in the form of both beneficial and deleterious effects. Sun exposure causes extensive intrinsic as well as extrinsic changes in the skin and has many acute and chronic harmful effects.2 Nowadays, there is an increasing awareness about the benefit Corresponding author: Dr. Eliz Aryal Associate Professor, Department of Dermatology, Kathmandu Medical College. Mobile No- +9779849214203. E-mail: eliz_aryal@yahoo.com ORCID ID: https://orcid.org/0000-0002- 3455-2095 Date of submission: 22.02.2022 Date of acceptance: 03.11.2022 Date of publication: 01.04.2023 Conflicts of interest: None Supporting agencies: None DOI: https://doi.org/10.3126/ijosh.v 13i2.43305 Copyright: This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License ISSN: 2091-0878 (Online) ISSN: 2738-9707 (Print) https://www.nepjol.info/index.php/IJOSH mailto:eliz_aryal@yahoo.com https://orcid.org/0000-0002-3455-2095 https://orcid.org/0000-0002-3455-2095 https://doi.org/10.3126/ijosh.v13i2.43305 https://doi.org/10.3126/ijosh.v13i2.43305 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ Aryal et al. Evaluation of the knowledge of sun exposure and sun protective measures in health care workers 200 of sunlight for the synthesis of vitamin D. Results of photo aging, such as pigmentation, sagging, wrinkling, and photo-carcinogenesis are caused by an alteration to DNA; which can be prevented with regular usage of sunscreen.2 During summer, the ultraviolet (UV) energy received on the earth's surface is made up of 3.5% ultraviolet B (UVB) and 96.5%ultraviolet A (UVA) radiation.4UVA penetrates up to the dermis whereas UVB affects the epidermis of the skin.3 Regular sunscreen usage can prevent photo- induced and photo-aggravated dermatoses. Food and Drug Administration have approved Sunscreen for use in the prevention of sunburn, photo-induced pigmentation, aging, and carcinoma of the skin.4 The mechanism by which sunscreens inhibit the transmission of UV radiation into the skin is by absorbing, reflecting, or scattering such radiation.4 Sunscreens have been recommended as preventive and protective measures against sunlight, with the efficacy increasing with a higher sun protection factor.4 Health care personnel supposedly have good knowledge regarding sun protection and they play a key role in society disseminating knowledge to the general public. There are limited data regarding the knowledge of sun protection and sunscreen practice in health care workers. Our study aimed to determine the knowledge of healthcare workers regarding the solar spectrum, sunscreen, the relation of Vitamin D with sun exposure, the practice of using sunscreen and other sun protection methods. Methods This descriptive cross-sectional study was carried out from October 2020 to July 2021 on healthcare workers (medical staff) in Kathmandu Medical College Teaching Hospital after taking ethical approval from IRC. Non-medical hospital staff and health workers with less than one year of experience in healthcare practice were excluded from our study. All health workers working in the hospital who voluntarily agreed to participate were included. Participants were informed about the purpose of the study and its methodology. The questionnaire was self-designed and pilot testing was done on 15 participants to calculate the approximate time to complete it and to determine the clarity of the questionnaire. Feedback was taken for further improvement and modification of the questionnaire. The researcher distributed the self- administered questionnaire to the target study population without disturbing or hampering the healthcare worker’s duty. A researcher was available to clarify any issue and questionnaires were collected soon after responses were collected. The questionnaire consisted of three sections. The first section consisted of demographic variables including age, gender, education, and medical post. The second section consisted of knowledge regarding the sun, SPF, vitamin D, and sunscreen and the third section consisted of questions regarding the practice of sun protective measures. Data were entered and analyzed by SPSS version 20. Analytical statistics was applied using the chi- square test for testing the difference or association between two categorical variables, similarly, descriptive statistics were applied to calculate frequency and percentage. Results The participants in the survey aged between 24-67 years with a mean age of 34.74±7.839. Out of a total of 264 participants in the study, 84 (31.8%) were male and 180 (68.2%) were female. In our study, the healthcare workers participating were nursing staff 41(15.5%), Medical officers 81(30.7%), and consultant doctors, 142(53.8%). Among them, 89(33.7%) health workers had skin problems at some point in their lives. The number of participants who knew about the different spectra of ultraviolet radiation was 175 (66.3%). (Table 1). Regarding the level of knowledge about sunscreen 212 (80.3%) agreed that sunscreen is expensive, (significant p<0.005). Out of 264 participants, only 196 (74.2%) knew the proper terminology for SPF (Sun Protection Factor) and only 59 (21.6%) agree that the value of SPF is related to age. Similarly, 120 (45.4%) participants knew about the difference between physical and chemical sunscreen and it was not significant. (Table 2). Aryal et al. Evaluation of the knowledge of sun exposure and sun protective measures in health care workers 201 Table 1: Socio-Demographics data of participants Variables N (%) Gender Male Female 84(31.8) 180(68.2) Education qualification Nursing Medical Officer Consultant 41(15.5) 81(30.7) 142(53.8) Age range 20-29 30-39 40-49 50-59 > 60 81(30.7%) 120(45.5%) 52(19.7%) 5(1.9%) 6(2.3%) Underlying skin condition Yes No 89(33.7) 172(65.2) Table 2: Health worker level of knowledge regarding Sunscreen Variables Nursing N (%) Medical officer, N (%) Consultant N (%) p- value Sunscreen is expensive Agree Disagree Don’t know 36 (13.6) 3 (1.1) 2 (0.7) 74 (28) 5 (1.8) 2 (0.7) 102 (38.6) 14 (5.3) 26 (9.8) 0.002 Meaning of SPF Sun protection factor Sun prevention factor Sun protection formula Sun Prevention formula Don’t know 27 (10.2) 4 (1.5) 5 (1.8) 2 (0.73) 3 (1.1) 58 (21.9) 2 (0.75) 13 (4.9) 2 (0.75) 6 (2.2) 111 (42) 10 (3.7) 4 (1.5) 2 (0.75) 15 (5.6) 0.023 Value of SPF is related to age Agree Disagree Don’t know 28 (10.6) 3 (1.1) 10 (3.7) 48 (18.1) 20 (7.5) 13 (4.9) 77 (29) 36 (13) 29 (10) 0.132 Difference between physical and chemical sunscreen Yes No 17 (6.4) 24 (9) 35 (13.2) 46 (17.4) 68 (25.7) 74 (28) 0.681 Out of the total participants, 214 (81%) agreed that there is a relationship between sunlight and vitamin D synthesis , and it was significant. No significant difference was noted regarding knowledge about the time of sunscreen exposure for vitamin D synthesis. Around 95 (45.5%) recommended that 20-30 minutes/week of sun exposure is required for vitamin D synthesis. Similarly, regarding vitamin D deficiency, 90(34%) agreed that regular use of sunscreen can cause vitamin D deficiency. (Table 3) Regarding the knowledge about sunlight, only 172 (65.1%) were aware of different spectra of UV light. Similarly, 96 (36.3%) knew that skin condition gets aggravated by exposure to Ultra Violet radiation. Regarding outdoor activities among the three groups, Consultants, 52( 19.6%) were more likely to spend lesser time outdoors and avoided sunlight exposure during peak hours. (Table 4) Table 3: Health worker level of knowledge regarding vitamin D and Sunscreen Variables Nursing N (%) Medical officer N(%) Consultant N(%) P- value View on the relationship between sunlight and vitamin D Agree Disagree Don’t know 37 (14) 2 (0.75) 2 (0.75) 75 (28.4) 1 (0.3) 5 (1.8) 107 (40.5) 24 (9) 11 (4.1) 0.020 Is the area of sunlight exposure related to vitamin D synthesis Yes No 28(10.6) 13 (4.9) 60 (22.7) 21 (7.5) 98 (37.1) 44 (16.6) 0.003 The exposure time required for vitamin D synthesis 20-30min/week 40-60min/week 60-90min/week 17 (6.4) 13 (4.5) 11 (4.1) 21 (7.9) 40 (15.1) 20 (7.5) 57 (21.5) 29 (10.9) 56 (21.2) <0.001 View on sunscreen use and vitamin D deficiency Agree Disagree Don’t know 15 (5.6) 23 (8.7) 3 (1.1) 18 (6.8) 47 (17.8) 16 (6.06) 57 (21.5) 49 (18.5) 36 (13.6) 0.001 Table 4: Healthcare worker level of knowledge regarding sunlight Variables Nursing N(%) Medical officer N(%) Consultant N(%) p- value Know about the different spectra of UV light Yes No 27 (10.2) 14 (5.3) 50 (18.9) 31 (11.7) 98 (37.1) 44 (16.6) 0.541 Do you think skin condition is aggravated by UV light Yes No 13 (4.9) 28 (10.6) 33 (12.5) 48 (18.1) 50 (18.9) 92 (34.8) 0.567 Is sun exposure bad for the skin Agree Disagree Don’t know 26 (9.8) 15 (5.6) 0 (0) 64 (24.2) 13 (4.9) 4 (1.5) 98 (37.1) 33 (12.5) 11 (4.1) 0.048 Hours of outdoor activity you do in a week <15hr/week 15-30hr/week >30hr/week 26 (9.8) 15 (5.6) 0 (0) 45 (17) 29 (10.9) 7 (2.6) 87 (32.9) 41 (15.5) 14 (5.3) 0.249 Avoid sunlight during peak hour Always Sometimes Rarely Never 15 (5.6) 26 (9.8) 0 (0) 0 (0) 20 (7.5) 57 (21.5) 1 (0.37) 3 (1.1) 52 (19.6) 57 (21.5) 26 (9.8) 7 (2.6) <0.001 According to the participants, 89 (33.7%) used coin size volume of sunscreen regularly and among them, 45 (17%) were consultant doctors. Regarding the sunscreen application time, 91(34.4%) used it in the morning, while 51(19.3%) used sunscreen whenever they go out in sun. Reapplication of sunscreen was done only by 73 (27.6%) participants. Most of the participants i.e. 124 (46.5%) used SPF of 30-50 and a majority of participants (62.1%), applied sunscreen only on the face followed by face and neck by 128( 48-4%) and arm 32 (12.1%). (Table 5). No significant differences were found in the level of practice of sunscreen for precaution of fairness, or prevention of tanning, wrinkle, mole, and skin cancer. The most common reason for sunscreen application was to prevent sunburn 132(50%) and was significant. Apart from sunscreen other sun protection methods reported were the use of an umbrella 149 (56.4%), wearing sunglass 125(47.3%), and wearing full sleeves 106(40%) which were not significant. (Table 6). Table 5: Practice of sunscreen by healthcare workers. Table 6. The practice of sun protection measures by Healthcare workers. Discussion Healthcare workers are considered to be well- educated and knowledgeable. Higher education level was known to be associated with increased use of sunscreen and other sun protection measures as they are aware of sun radiation damage to the skin.5 In our study, there were more female participants due to nursing female healthcare workers. Among the three groups in our study, the knowledge about UV radiation, sunscreen, physical and chemical sunscreen and SPF (Sun Protection Factor) was found more in consultant doctors and was statistically significant. The subgroup among the healthcare professions that had a lower knowledge also had a lower education level. A similar outcome was found in other studies.6 In our research, we assessed the relationship between vitamin D syntheses with sun exposure. It was found that 81.8% of healthcare workers agree that there is a relationship between vitamin D and sunlight, while 186 (70%) believe that sunlight exposure is related to vitamin D synthesis, which is similar to a study by Kaymalet al. 7 The study done by Neale et al. also supported the theoretical risk of sunscreens may affect vitamin D levels.8 Young et al. concluded that high UVA-PF sunscreen enables significantly higher vitamin D Variables Nursing N (%) Medical Officer N (%) Consultant N (%) p- value The volume of sunscreen applied Pea size Coin size Double coin size 11 (4.1) 16 (6.06) 0 (0) 29 (10.9) 28 (10) 6 (2.2) 35 (13.2) 45 (17) 7 (2.6) 0.118 Time of application Morning Afternoon Going out Twice a day 16 (6.06) 3 (1.1) 7 (2.6) 1 (0.3) 22 (8.3) 7 (2.6) 30 (11.3) 5 (1.8) 53 (20) 11 (4.1) 14 (5.3) 10 (3.7) 0.001 Reapplication Yes No 7 (2.6) 34 (12.8) 30 (11.3) 51 (19.3) 36 (13.6) 106 (40) 0.044 Use sunscreen indoor Yes No 13 (4.9) 27 (10) 28 (10.6) 53 (20) 50 (18.9) 92 (34.8) 0.235 SPF use 15-29 30-50 >50 5 (1.8) 22 (8.3) 1 (0.3) 20 (7.5) 37 (14) 8 (3.03) 15 (5.6) 65 (24) 9 (3.4) 0.007 Area of application Face Neck Arm Other parts 25 (9.4) 19 (7.1) 5 (1.8) 0 (0) 57 (21.5) 32 (12.1) 2 (0.75) 2 (0.75) 82 (31) 77 (29.1) 25 (9.4) 0 (0) 0.172 0.091 0.004 Variables Nursing N (%) Medical officer N (%) Consultant N (%) p- value Reason for use of sunscreen Fairness Prevent tanning Prevent sunburn Prevent wrinkle Prevent early aging Prevent mole Prevent skin cancer 11 (4.1) 18 (6.8) 17 (6.4) 12 (4.5) 10 (3.7) 5 (1.8) 4 (1.5) 25 (9.4) 33 (12.5) 50 (18.9) 38 (14) 28 (10.6) 22 (8.3) 24 (9) 7 (10.2) 44 (16.6) 65 (24.6) 54 (20.4) 49 (18.5) 37 (14) 30 (11.3) 0.128 0.178 0.036 0.150 0.447 0.144 <0.01 Other sun protection measure used Umbrella Hat Sunglasses Full sleeves 15 (5.6) 13 (4.9) 18 (6.8) 17 (6.4) 48 (18.1) 33 (12.5) 47 (17) 41 (15.5) 86 (32) 50 (18.9) 60 (22) 48 (18.1) 0.233 0.567 0.068 0.047 203 Aryal et al. Evaluation of the knowledge of sun exposure and sun protective measures in health care workers 204 synthesis than a low UVA-PF sunscreen because the former, by default, transmits more UVB than the latter. Sunscreens (sun protection factor, SPF 15) applied at a sufficient thickness to inhibit sunburn during a week-long holiday with a very high UV index still allow a highly significant improvement of serum 25-hydroxyvitamin D3 concentration. An SPF 15 formulation with high UVA protection enables better vitamin D synthesis than a low UVA protection product. The former allows more UVB transmission.9 In this study, 87 (32.9%) participants avoided sunlight during peak hours, this may be due to indoor working hours. Similarly, Kaymak et al. found ‘not going out at peak times’ to be the most commonly adopted method with a figure of 45.3% and 53.0% in males and females.10 The outcome of this study shows that consultants were more likely to be familiar with the sun’s detrimental effects on skin and take protective measures, including sunscreen application. A Greek study found the use of sunglasses (83.4%) as the most common sun protection measure in Mediterranean inhabitants, followed by protective clothing (57.8%),11 in contrast to our study where other sun protection measures were less adopted. This can be due to a lack of knowledge, social and cultural norms, and economical barriers. Using an umbrella was the least adopted method of sun protection in Turkey,11 similar to that of our study. In Saudi Arabia, 95% of respondents reported wearing long-sleeved cloth and a head cover, clearly influenced by customs and traditional dressing practices.12 Surprisingly, our study found that the knowledge about the relation of sun exposure with skin cancer is very low (21.9%), as opposed to many international studies, where the knowledge about sun exposure and its relation with skin cancer as well as adapted measures of sun protection was very high. For example, 85% in Australia, 92 % in Canada and the United States, and 92.5% in Malta where as 55.5% in India reportedly were more aware.13,14 No significant difference was found among the three study groups (consultant, nursing, and medical officer) regarding the reason for using sunscreen. This is similar to the result of a study by Ergin et al.15 Conclusion A higher level of education was associated with better knowledge and behavior toward sunscreen and the solar spectrum. 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