Sun-protection Behaviors Among Active Members of the United States Lifesaving Association

J Clin Aesthet Dermatol. 2021;14(1):14–20.

by Clinton W. Enos, MD; Soquel Rey, BS; Jayne Slocum, BS; Lauren Green, MPH; and Edward Prodanovic, MD

Dr. Enos, Dr. Prodanovic, Mr. Rey, and Ms. Slocum are with the Department of Dermatology, Eastern Virginia Medical School in Norfolk, Virginia. Ms. Green is with the Healthcare Analytics and Delivery Science Institute, Eastern Virginia Medical School in Norfolk, Virginia.  

FUNDING: No funding was provided for this study.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this study.

ABSTRACT: Background. Ultraviolet radiation exposure is the most prominent modifiable risk factor for developing both melanoma and non-melanoma skin cancers.

Objective. We sought to elucidate sun-protective behaviors among active members of the United States Lifesaving Association (USLA), a nationwide nonprofit organization comprising beach lifeguards, and to identify positive and negative predictors of sun protective behaviors.

Methods. This was a pilot, cross-sectional survey study. All USLA lifeguards aged 18 years or older were invited to complete a 19-item survey. Data were collected anonymously at the 2018 USLA National Lifeguard Championships in Virginia Beach, Virginia. Participant characteristics and sun-protective behaviors (e.g., hat, sunglasses, protective clothing, sunscreen, and seeking shade) were surveyed. A composite score (0–10 points) was created based on sun-protective behaviors. Simple linear regression models were fit to assess the relationship between lifeguard characteristics and the sun-behavior composite score and a multiple linear regression model was used to assess their overall positive or negative effect on composite scores.

Results. A total of 215 USLA lifeguards completed the survey study; of these, 64.2% were male and the average age was 34.2 years. The most common sun-protective behavior was wearing sunglasses (85%), followed by applying sunscreen (65%), wearing a hat (46.7%), seeking shade (38.6%), and wearing protective clothing (34.0%). The overall average composite score was 7.5±1.9 points. In the multiple linear regression model, female sex (beta=-0.85; p=0.0012), desiring a tan (beta=-1.26; p=0.0008), and working more summer daytime hours (beta=-0.49; p=0.049) negatively impacted composite scores.

Conclusions. USLA beach lifeguards are subject to sun-exposure patterns and practiced sun-protective behaviors that potentially place them at higher risk for skin cancer.

KEYWORDS: Sun protection, sun-protective behaviors, UV radiation, lifeguarding, skin cancer, tanning

The most prominent modifiable risk factor for developing both melanoma and non-melanoma skin cancers is ultraviolet radiation exposure (UVR).^1,2 While an individual’s short-term and lifetime UVR varies based on a variety of factors, it is important to highlight populations with modifiable exposure. The United States Lifesaving Association (USLA) is a nationwide nonprofit organization comprised of beach lifeguards and water rescuers who are, by nature of their profession, exposed to increased amounts of UVR. There are no previous studies identifying beach lifeguards as an at-risk population. This pilot survey study therefore aimed to elucidate sun-protection behaviors among active members of the USLA and to identify positive and negative predictors of sun behaviors within this population. We hypothesized that younger age, employment in a region with seasonal beaches, and desiring a tan would negatively impact sun-protective behaviors. 

Methods

Study design. In this study with institutional review board exemption, anonymous survey data were collected during the summer 2018 Annual National Lifeguard Championships hosted by the USLA in Virginia Beach, Virginia. All USLA participating lifeguards aged 18 years or older were invited to complete a 19-item survey. Among the demographic variables collected, participating lifeguards were asked to include the first three digits of their home zip code to identify their region of residence. Region of origin was defined using the regions and divisions designated by the United States Census Bureau.³ Increased sun exposure from non-summer hours to summer hours was determined using lifeguard responses to questions 9 and 10 in the survey. A composite score, ranging from 0 to 10 points, was created using questions 12a through 12e in the survey, including responses related to sun-protective behaviors. The scored answers for wearing a hat, sunglasses, and protective clothing; using sunscreen; and seeking shade were as follows: never=0, sometimes=1, always=2. A maximum sun-behavior score of 10 would be indicative of always adopting protective sun habits. 

Statistical analysis. All statistical analyses were performed in collaboration with the Eastern Virginia Medical School Healthcare Analytics and Delivery Science Institute. To test for violations of normalcy, univariate analyses were performed on all continuous variables. Continuous variables with normal distribution are presented as mean ± standard deviation values, while non-normal continuous variables are presented as median with interquartile range values. Descriptive statistics of categorical variables are summarized and presented as count (percentage) values. Associations between lifeguard characteristics and sun-protective behaviors were tested using Pearson’s chi-squared test or Fishers exact test where appropriate. Simple linear regression models were fit to assess the relationship between lifeguard lifestyle predictors and the sun-behavior composite score. Significant lifeguard lifestyle predictors were entered into a multiple linear regression model to assess their overall group effect on the composite score. All hypothesis testing was carried out at the 95% significance level, unless otherwise specified, with a p-value of less than 0.05 accepted as statistically significant. All statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, North Carolina).

Results

A total of 215 registered USLA lifeguards completed the survey study (Table 1), of which 138 (64.2%) were male and 77 (35.8%) were female. The average age of survey participants was 34.2±15.2 years. Lifeguards from the South region were the most heavily represented, followed by those from the Northeast, West, and Midwest respectively. The majority of participants identified as white (82.2%), with the next most represented group being Hispanic (9.8%), while 7.9% identified as a different ethnicity (e.g., Asian, African-American, other). More than 88% felt their skin tanned, and of these, roughly 54% felt they rarely or never burn; meanwhil, 90% of surveyed lifeguards reported at least one sunburn in the 12 months prior to the survey. Over 50% reported desiring a tan and about 23% had used a tanning booth in their lifetime. A family history of skin cancer was reported by nearly 40% of respondents, while roughly 10% of respondents reported a personal diagnosis of skin cancer.

The majority of respondents were seasonal lifeguards (74.2%). The reported hours spent outdoors notably increased during the summer months: while around 26% of lifeguards reported spending eight hours or more outside per day during non-summer months, this increased to more than 70% of lifeguards during the summer. A majority of respondents reported performed skin self-examinations (74.9%) and having been examined by a dermatologist (70.7%).

Respondents were asked to report their sun-protective behaviors over the past 12 months (Table 2). Sunscreen was always used by 65% of respondents, while sunglasses were always used by nearly 85%. The use of a hat or protective clothing and seeking shade were always practiced by less than half of the respondents (46.7%, 34.0%, and 38.6%, respectively). The most commonly used sun-protective factor (SPF) levels were 30 and 45 (38.2% and 35.9%, respectively).

Associations between patient characteristics and sun-protective behaviors (i.e., use of sunscreen, sunglasses, hat, protective clothing, seeking shade) were tested (Supplemental Table 1). The use of sunscreen was significantly associated with desiring a tan (p=0.0028), a family history of skin cancer (p=0.038), and performing skin self-examinations (p=0.037). The use of sunglasses was associated with increased daytime hours over the summer (p=0.032) and performing skin self-examinations (p=0.044). Hat use was associated with increased daytime hours over the summer (p=0.024), desiring a tan (p=0.037), and tanning booth use (p=0.010). The use of sun-protective clothing was associated with sex (p<0.0001), increased daytime hours over the summer (p=0.0023), desiring a tan (p=0.0005), and tanning booth use (p=0.0005). Seeking shade was associated with sex (p=0.0005), seasonal employment (p=0.0087), increased their daytime hours over the summer (p=0.037), desiring a tan (p<0.0001), and tanning booth use (p=0.0063).

Using the sun-protective behavior variables, a composite score for each respondent was generated, ranging from 0 to 10 points (see Methods); a greater composite score corresponded to increased adherence to sun-protective behaviors. The overall average composite score was 7.5±1.9 points. Linear regression was performed to identify patient characteristics as negative or positive predictors of sun behavior composite scores (Table 3). In univariate analyses, age (p=0.049) was a positive predictor of composite scores. Meanwhile, the variables of sex (p=0.0001), answers of “yes” and “neutral” to desiring a tan (p<0.0001 and (p=0.037), tanning booth use (p=0.0004), and increased summer daytime hours (p=0.011) were negative predictors for composite scores. When controlling for all variables, sex (p=0.0012), desiring a tan (p=0.0008), and increased summer daytime hours (p=0.049) each negatively impacted composite scores.

Discussion

Here, we highlight USLA beach lifeguards as a population with increased ultraviolet radiation exposure and identify characteristics and behaviors that negatively impact sun-protective behaviors. In this study, the majority of lifeguards were seasonally employed, greatly increased the number of hours they spent outside during the summer, and self-identified their ethnicity as being white. Although epidemiological data on non-melanoma skin cancer is understudied, it is known that non-Hispanic whites are at greater risk for developing melanoma.^4,5 With this in mind, roughly 90% of responding lifeguards reported at least one sunburn in the past 12 months and more than 70% spent more than eight hours outdoors, while a majority also desired a tan. We indirectly asked the lifeguards to estimate their Fitzpatrick Skin Type; interestingly, the majority identified themselves as being types III and IV (40.2% “tan after initial burn;” 38.8% “rarely burns, usually tans”). This suggests that many lifeguards perceive their skin differently than their actual physiologic response to ultraviolet radiation.

Previous studies have found that young adult and pool lifeguard populations tend to have poor sun-protective habits and a higher prevalence of sunburn than that of the general population.^6,7 For instance, in a study of pool lifeguards in the United States, sunglass use was reported by 82.4%, sunscreen use was reported by 51.23%, shade use was reported by 17.2%, hat use was reported by 15.7%, and shirt use was reported by 15.0% of respondents, respectively.⁶ In the present study, sunglasses use was also the most frequently “always” used sun-protective behavior (84.7%), followed by sunscreen use (65.6%), hat use (46.7%), seeking shade (38.6%), and protective clothing use (34%). In our study, age was not a significant variable impacting these behaviors in an analysis of variance analysis (data not shown). 

Given that a subpopulation of beach lifeguards only work during summer months, we hypothesized that this group may behave differently and might be impacted by where they live geographically. Seasonal employment was associated with the use of a hat and seeking shade but did not impact overall behaviors. Likewise, there were no statistical differences in behaviors among geographic regions. However, a major limitation of this study was its population size; with a greater population represented, we suspect that geographic region might have more clearly impacted sun-protective behaviors.

Overall, sun behavior composite scores were significantly impacted by sex, desiring a tan, and increased daytime hours outdoors in the summer. Our findings of female sex negatively impacting sun-protective behaviors is contrary to a previous study of beachgoers⁸; however associations with tanning and female sex have been reported.⁹ The desire to tan has previously been shown to be driven by appearance.¹⁰ Recognizing that beach lifeguards have increased sun exposure by nature of their profession, it is important to take into account the large number of lifeguards who annually increase their ultraviolet radiation exposure for three to four months out of the year. This is potentially a two-hit risk in that there is increased sun exposure and an asymmetric spike in their exposure throughout the year. Of the respondents, 10% had been diagnosed with a skin cancer and nearly 40% had a family history of skin cancer; however, although 70% reported having had a skin exam prior to taking the survey, we did not ask whether they are routinely examined nor about their perception of the importance of being examined by a dermatologist.

Limitations to this study include its sample size, cross-sectional nature, and the fact that some of the questions are subject to respondent bias. We did not ask opinion- or motive-related questions to further understand behavior patterns. However, this is the first report to our knowledge highlighting this at-risk population.

Conclusions

USLA beach lifeguards are subject to sun exposure patterns and practiced sun-protective behaviors that potentially place them at higher risk for skin cancer. Our findings suggest opportunities for change among a population dedicated to helping others. In 2018, the USLA reported 78,890 water rescues and 7.7 million water-related interactions to prevent drownings.¹¹ USLA lifeguards are an important population to educate and encourage to undergo routine evaluation by a board-certified dermatologist. 

Acknowledgments

The authors would like to acknowledge Tom Gill of the Virginia Beach Lifesaving Service and Kay Smiley of the United States Lifesaving Association for their assistance with this study.

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