Open Journal of Nursing, 2011, 1, 43-50 OJN
doi:10.4236/ojn.2011.13006 Published Online December 2011 (
Published Online December 2011 in SciR es.
Current patterns of the sun protection measures adopted by
nurses and the risk factors influencing their compliance
Hero Brokalaki1, Evridiki Patelarou2*, Constantine Vardavas3, Ioannis S. Elefsiniotis1,
Konstantinos A. Giakoumidakis1, Eirini Brokalaki4
1Faculty of Nursing, University of Athens, Athens, Greece;
2University Hospital of Heraklion, Crete, Greece;
3Department of Social Medicine, Faculty of Medicine, University of Crete, Crete, Greece;
4Department of Dermatology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany.
Email: *
Received 21 August 2011; revised 22 September 2011; accepted 12 October 2011.
The incidence of skin cancer is increasing worldwide.
Included in high risk group are people who have light
common phenotypic factors (hair, skin, eyes), have
high number of naevi, report previous sunburns and
have a family history of skin cancer. Protecting the
skin from the sun by wearing protective clothing,
using sunscreen and avoiding sun exposure are rec-
ommended among primary preventive activities. The
purpose of this study was to describe the current
patterns of sun protection measures adopted by
nurses and to examine the association between com-
pliance with sun protection measures and the main
risk factors of melanoma. This cross sectional study
was conducted in 2007 during the Annual Greek Na-
tiona l Co nf erence of N urs ing. Nu rse s mo st co mmo nly
chose to use sunscreen, to wear glasses, to use an
umbrella or to seek for shade in order to protect
themselves against sun exposure. Finally, phenotypic
factors, previous sunburns and common naevi pres-
ence were found to affect nurses’ attitude towards
protective measures. This study poses the necessity of
targeting high risk groups for melanoma through
campaigns aiming to foster sun protection behav-
Keywords: Melanoma; Nursing; Prevention; Risk Fac-
tors; Skin Cancer
1.1. Literature Review
Melanoma and non-melanoma skin cancer consist the
most common types of cancer in white populations. The
incidence of cutaneous melanoma has increased rapidly
over the past decades, specifically 85% more than any
other major cancer [1-2]. The exact etiology of skin
cancer is unknown [3] with childhood and adolescent
years identified as key periods in the etiology of subse-
quent melanoma [4-5]. Exposure to ultraviolet (UV)
radiation has been linked with an increased risk of de-
veloping skin cancer [6-7]. UV exposure during child-
hood seems to be a main factor that induces mutations in
the melanocytes that are associated with an increased
induction of nevi and an increased risk for the develop-
ment of melanoma. Furthermore, intense intermittent
sunburns and sunburn history have been also strongly
implicated as key factors in the development of mela-
noma [8-9]. Individual phenotypic characteristics, in-
cluding skin, hair and eye colour are strongly related to
sensitivity to UV radiation. Persons with a light com-
plexion are considerably more photosensitive than per-
sons who have dark hair, iris and skin colour, respec-
tively. Research has indicated that increased sun expo-
sure is associated with an increased number of common
naevi in children [10-11]. Light-skinned children who
are exposed to sunlight increase their number of naevi
and the risk for developing melanoma later in life [12].
Other studies have also demonstrated that frequent
childhood sunburn and family skin cancer history are
also two other very important risk factors for the devel-
opment of malignant melanoma [13-14].
Overall, primary prevention of skin cancer is focused
on the reduction of exposure to major risk factors [15].
Key sunburn prevention messages have focused on get-
ting people to wear hats and long-sleeved clothes, and/or
stay in the shade during peak hours of the day. Sun-
screen has been recommended as an alternative means of
protection in situations where clothing may not be de-
sirable or appropriate [15-16]. Most current guidelines
on the primary prevention of skin cancer include protec-
H. Brokalaki et al. / Open Journal of Nursing 1 (2011) 43-50
Copyright © 2011 SciRes. OJN
tive clothing, correctly applied and reapplied sunscreen,
and the use of a hat.
Factors that have been noted to predict differences in
regards to sun exposure patterns and compliance with
the use of protective measures include age, sex and edu-
cational status [17]. Young people have been identified
as a high risk group for skin damage that may lead to
skin cancer later in life [17]. Several studies sugg est that
the use of hats, protective clothing and seeking shade as
measure of sun protection increased with age [18]. A
recent study in Greece revealed also that younger age
groups were more likely to be exposed to sun whereas
females used sunscreen more commonly than males [19].
Similarly, a number of international studies have under-
lined that women and people with higher socio-eco-
nomic status are more likely to use sunscreen [18-26]. In
addition, people who perceived themselves as at risk for
skin cancer and those with sun-sensitive skin have been
found to adopt protective measures against sun exposure
more frequently than others [18,22,24,27].
1.2. The Purpose of This Study
The primary aim of this study was to describe the current
patterns of sun protection used by nurses in Greece, for
primary preventio n of skin cancer. Furthermore a secon-
dary aim of this study was to examine the possible asso-
ciation between compliance with sun protection meas-
ures and risk factors for the development of melanoma.
2.1. Sample and Sampling Procedure
This cross sectional study was conducted in May of
2007 during the Annual Greek National Conference of
Nursing. Based on the participation rates of previous
years’ conferences, it was estimated that 3000 nurses
would participate in the conference coming from differ-
ent areas of Greece and of different nursing specialties.
Out of the approximate 3000 nurses that participated in
the conference, one in six nurses (n = 500) were re-
quested to complete a questionnaire regarding risk fac-
tors and protective measures they use against sun expo-
sure. Out of the 500 nurses, 349 accepted to participate
(69.8% response rate) and completed the questionnaire
while due to missing data 45 of the questionnaires were
excluded from the analysis. As a result the final sample
of the study was 304 nurses. A cover letter explaining
the aim of the study was provided and an informed con-
sent form was obtained from each participant.The study
protocol was approved by the Ethical Committee of Na-
tional and Kapodi st ri an Universi ty of Athens.
2.2. Data Collection
The survey instrument was a questionnaire developed
for the purposes of this study and was based on the cur-
rent relevant literature. It was reviewed by two derma-
tologists, experts in the field and two nurses with a spe-
cialty in dermatology-nursing. The final questionnaire
was pretested as part of a pilot study conducted among
nursing students who accepted to participate as volun-
teers and all items were assessed for face validity by
health survey experts. The final questionnaire included
questions referent to the socio-demographic characteris-
tics of the participants, their years at work and their
educational level. In add ition to the above, the question-
naire also included questions regarding the nurses’ main
risk factors for skin cancer development and the protec-
tive measures against sun exposure that they usually
2.3. Data Analysis
The descriptive data is presented as mean ± standard
deviation for continuous variables and in percentages (n)
for categorical. Chi-squared tests (x2) were used during
the univariate comparisons while all reported analyses
are based on two sided tests, with statistical significance
noted at p < 0.05. To model the factors that influence the
adaptation of personal protective measures against sun
exposure, logistic regression models were applied so as
to provide odds ratios (OR) and 95% confidence inter-
vals (95% CI) after adjusting for age, gender and educa-
tional status. The statistical package Stata 10.0 was used
to perform the analysis.
Regarding the study populations characteristics, 85.2%
were female and 14.8% male and the average age was
33.9 6 years. As for their level of education, more than
80 % were of higher education (13% had a postgraduate
degree, 11% a degree from a university and 60% a de-
gree from a technological educational institute) while
16% were nurse assistants from secondary education.
Finally, almost half of the sample was married (59%)
and urban area residents (53%) (Table 1).
Regarding the nurses’ main risk factors for the devel-
opment of melanoma, 39% reported light skin colour
while the percentages for eye and hair light colour were
lower (28%, 18% respectively) as depicted in Table 2.
Almost one th ird r eported the pre sence of mor e than five
common naevi (32%) while 62% reported sunbathing
during summer. Among nurses 38% reported previous
sunburns during childhood which consist one of the most
important risk factors for the development of skin cancer.
The majority of the population reported the use of sun-
glasses, umbrella or shade, and sunscreen to protect
themselves against sun exposure (85%, 83% & 81%
respectively) as seen in Table 3 . Regarding clothing as
H. Brokalaki et al. / Open Journal of Nursing 1 (2011) 43-50
Copyright © 2011 SciRes. OJN
Table 1. Socio-demographic characteristics of the study popu-
n (%)
Male 45 (14.8)
Female 259 (85.2)
20 - 29 63 (20.7)
30 - 39 102 (33.6)
40 - 49 98 (32.2)
>50 41 (13.5)
Marital status
Married 178 (58.6)
Unmarried 126 (41.4)
Educational status
Secondary 49 (16.1)
Technological 183 (60.2)
University 33 (10.9)
Postgraduate 39 (12.8)
Urban 162 (53.3)
Semi-urban 119 (39.1)
Rural 23 (7.6)
protective measure the use of a skirt or a trouser during
sun exposure was the most common (41%) while hat use
was a choice for the 28% of the population and sleeves’
use was preferred by the 11% of the population.
Females were found to use sunglasses and sunscreen
more than males and this finding was statistically sig-
nificant (p = 0.04 and p < 0.001, respectively). Age was
also found to affect the use of protective measures with
those aged between 30 - 50 found to use umbrella/shade
and clothing to protect themselves from sun exposure
more than those younger than 30 and older than 50 (p <
0.05) (Table 4). A multiple logistic regression analysis
was used to evaluate the effect of the having a risk factor
for skin cancer on the nursing staff’s compliance in the
use of protective measures against sun exposure. As seen
in Table 5, nurses with light eye colour were more likely
to use sunscreen with an odds ratio of 3.4 (95% CI: 1.4 -
8.3) while light skin colour was also associated with
increased use of sunscreen (OR 1.6 95% CI: 1.1 - 3.1)
and protective clothing including a hat, sleeves and skirt
Table 2. Risk factors for melanoma among Greek nurses.
n (%)
Eye color
Black/Brown 220 (72.4)
Blue/Grey/Green 84 (27.6)
Hair color
Black/Brown 248 (81.6)
Blond 56 (18.4)
Skin color
Light 118 (38.8)
Dark 186 (61.2)
Personal skin cancer history
Yes 2 (0.7)
No 302 (99.3)
Familial skin cancer history
Yes 15 (4.9)
No 289 (95.1)
Previous sunburn s during
Never 187 (61.5)
1 - 2 86 (28.3)
3 - 4 18 (5.9)
4+ 11 (3.6)
Common naevi
Less than 5 123 (40.5)
6 - 10 46 (15.1)
11 - 20 19 (6.3)
>20 36 (11.8)
I have never counted them 40 (13.2)
I don’t kn ow 40 (13.2)
Yes 188 (61.8)
No 116 (38.2)
or trousers with an OR of 1.3 (95% CI: 1.2 - 2.2), 2.7
(95% CI: 1.3 - 5.8) and 1.5 (95% CI: 1.0 - 2.4), respec-
tively. Those who reported previous sunburns were also
more likely to use an umbrella or to seek for shade (OR
3.1 95% CI: 1.4 - 6.8), to wear a hat 2.0 (95% CI: 1.2 -
3.3) and sleeves 2.4 (95% CI: 1.2 - 5.1) to protect them-
selves. On the other hand, the presence of common naevi
H. Brokalaki et al. / Open Journal of Nursing 1 (2011) 43-50
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Table 3. Protective measures against sun exposure among
greek nurses.
n (%)
Never/Rarely/Sometimes 52 (17.1)
Often/Always 252 (82.9)
Never/Rarely/Sometimes 47 (15.5)
Often/Always 257 (84.5)
Never/Rarely/Sometimes 218 (71.7)
Often/Always 86 (28.3)
Long sleeves
Never/Rarely/Sometimes 270 (88.8)
Often/Always 34 (11.2)
Skirt or trousers
Never/Rarely/Sometimes 180 (59.2)
Often/Always 124 (40.8)
Never/Rarely/Sometimes 59 (19.4)
Often/Always 245 (80.6)
was found to increase the likelihood of wearing a hat or
sleeves during sun exposure OR 1.1 (95% CI: 0.6 - 1.9)
and 1.7 (95% CI: 1.2 - 4.0). All the above correlations
were adjusted for age, gender and educational status, as
possible confounders.
Our study indicated an increased number of high risk
group nurses in Greece for the development of skin can-
cer, since almost 40% were of light skin colour and re-
ported prev ious sunburns during ch ildhood. Furthermore
the nurses commonly chose to use sunscreen, to wear
glasses, to use an umbrella or to seek shade in order to
protect themselves from sun exposure. Finally, our re-
sults revealed that main socio-demographic characteris-
tics such as gender and age and main risk factors in-
cluding light eye and skin color, previous sunburns and
the presence of common naevi robustly affect the atti-
tude of nurses towards the use of protective measures
against sun exposure. Similarly with other studies, sun-
screen was one of the most commonly used protective
measures [29-30] whereas females were more likely to
use sunscreen compared to males [31-33]. Mo reov er, our
results revealed that older ages were more compliant
with sun protection measures and this is in accordance
with the results of other studies which reported in creased
use of hats, protective clothing and seeking for shade as
protective measures among older ages [34-35].
Phenotypic factors and the number of common naevi
are very important independent risk factors for the oc-
currence of melanoma. A recent study performed in a
Greek sample observed that fair skin and intermittent
sun exposure during ch ildhood were positively related to
the risk of melanoma where as an elevated count of
common melanocytic nevi and the presence of clini-
cally atypical nevi consisted an independent risk factor
of melanoma [36]. Several constitutional characteristics
are highly inter-related, and possibly interact with each
other in determining individual sun exposure sensitivity
and, ultimately, melanoma cancer risk. Thus, the indi-
vidual characteristics and the reaction of unprotected
skin to mid-day summer sunlight are often analysed as
risk factors and important confounders, respectively, in
epidemiological studies on skin cancer and melanoma.
Clearly hair and eye colours cannot be considered di-
rectly in a causal relationship with melanoma and are
likely to be risk factors by virtue of their correlation with
skin phenotype [37].
Sunburn is an inflammatory reaction that arises fol-
lowing acute ex posure of the skin to sun ex posure and is
as a biological marker of high dose of ultraviolet radia-
tion penetrating to the melanocytes at the base of the
epidermis [38]. The number of participants that reported
previous sunburns was high (38.5%) while recent studies
have also revealed that the percentages of children and
adolescents who report sunburn during summer is actu-
ally high [39-40]. Numerous common naevi might indi-
cate a greater genetic tendency to form melanoma. Al-
though no major gene conferring an increasing risk has
been identified (except for CDKN2A and CDK4 in
melanoma-prone families) the possibility that some of
the genes associated with naevi may play a direct role in
melanoma progression cannot be excluded. In addition,
multiple naevi might indicate that previous exposure to
environmental agents, such as increased sun exposure,
has occurred, thereby independently causing both a large
number of naevi and an increased risk of melanoma
formations [37]. The melanoma risk of melanoma is
strongly related to the number of naevi, which are in-
creased in individuals with high levels of sun exposure.
Thus, naevi may lie in the causal pathway between sun
exposure and melanoma and in this case, the adjustment
for naevi would not be appropriate because it would de-
crease the true association [41].
Although there are a number of factors that predict
solar protective behaviour in this sample, there are rela-
H. Brokalaki et al. / Open Journal of Nursing 1 (2011) 43-50
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Table 4. Main socio-demographic characteristics and protective measures compliance.
Tabl e 5. Adjusted† odds ration (OR) and 95% confidence intervals (CI) for compliance with the protective measures and melanoma
risk factors.
†Adjusted for age, ge nd er, educational status.
Shade or umbrella Sunglasses Hat Sleeves Skirt or trousers Sunscreen
n (%) p-value n (%) p-value n (%) p-value n (%) p-valuen (%) p-value n (%) p-value
Male 37 (14.7) 34 (13.2) 14 (16.28)6 (17.7)17 (13.7) 27 (11.0)
Female 215 (85.3) 0.90 223 (86.8) 0.04 72 (83.72)0.65 28 (82.4)0.62 107 (86.3) 0.66 218 (89.0)<0.001
20 - 29 45 (17.9) 53 (20.6) 8 (9.3) 4 (11.8)17 (13.7) 52 (21.2)
30 - 39 87 (34.5) 90 (35.0) 31 (36.0)14 (41.2)49 (39.5) 81 (33.1)
40 - 49 85 (33.8) 83 (32.3) 29 (33.7)15 (44.1)49 (39.5) 76 (31.0)
>50 35 (13.9)
31 (12.1)
18 (20.9)
1 (2.94)
9 (7.26)
36 (14.7)
1st level 187 (74.2) 193(75.1) 61 (71.0)27 (79.4)101 (81.5) 180 (73.5)
2nd level 65 (25.8) 0.06 64 (24.9) 0.24 25 (29.1)0.17 7 (20.6)0.65 23 (18.6) 0.08 65 (26.5)0.02
Urban 141 (56.0) 138 (53.7) 52 (60.5)16 (47.1)59 (47.6) 134 (54.7)
Semi-urban 96 (38.1) 98 (38.1) 29 (33.7)14 (41.2)57 (46.0) 93 (38.0)
Rural 15 (6.0)
21 (8.2)
5 (5.81)
4 (11.76)
8 (6.5)
18 (7.4)
Shade or umbrella Sunglasses Hat Sleeves Skirt or trousers Sunscreen
Eye color
Dark reference reference reference reference reference reference
Light 0.44 (0.23 - 1.00) 0.46 (0.23 - 1.00)1.29 (0.73 - 2.25)0.81 (0.35 - 1.90)0.74 (0.43 - 1.25) 3.37 (1.36 - 8.33)
Skin color
Dark reference reference reference reference re ference re ference
Light 1.09 (0.58 - 2.07) 0.21 (0.10 - 1.03)1.32 (1.18 - 2.23)2.74 (1.29 - 5.81)1.48 (1.00 - 2.39) 1.62 (1.10 - 3.14)
Hair color
Dark reference reference reference reference re ference re ference
Light 0.51 (0.06 - 4.27) 0.40 (0.17 - 1.91)0.29 (0.08 - 1.08)0.22 (0.05 - 1.09)0.57 (0.16 - 2.11) 0.75 (0.09 - 6.40)
Familial skin cancer history
No re ference reference ref erence refe rence refe rence re ference
Yes 0.24 (0.08 - 0.71) 0.52 (0.15 - 1.75)1.46 (0.47 - 4.50)1.18 (0.25 - 5.54)0.86 (0.29 - 2.49) 0.78 (0.23 - 2.68)
Previous sunburns during childhoo d
No re ference reference ref erence refe rence refe rence re ference
Yes 3.11 (1.44 - 6.76) 1.10 (0.51 - 1.91)1.96 (1.15 - 3.32)2.41 (1.15 - 5.06)0.78 (0.48 - 1.27) 1.32 (1.07 - 2.51)
Common naevi
No re ference reference ref erence refe rence refe rence re ference
Yes 0.77 (0.37 - 1.57) 1.14 (0.54 - 2.42)1.12 (1.05 - 1.88)1.67 (1.21 - 3.97)0.70 (0.40 - 1.22) 1.00 (0.48 - 2.09)
H. Brokalaki et al. / Open Journal of Nursing 1 (2011) 43-50
Copyright © 2011 SciRes. OJN
tively few modifiable factors that can be addressed. For
example, factors such as gender and age are not amena-
ble to intervention; however, the identification of these
factors can assist in ensuring that subsequent interven-
tion strategies are effectively targeted. On the whole,
those people who are included in high risk groups are
more likely to adapt personal protective measures [32,35]
most probably due to the fact that they perceive them-
selves as at risk for the development of skin cancer [34]
and they are aware of the danger. Therefore, it is impor-
tant that preventive programs in this area are based on
reference to behavioural data that assesses a range of sun
protective measures in conjunction with knowledge and
attitudinal parameters [42].
Primary prevention campaigns are recommended so as
to increase the awareness of population regarding the
risk factors for melanoma, the potential harm of overex-
posure to the sun and th e importance of comp liance with
the suggested preventive measures. Furthermore, such
kind of campaigns should primarily focus to children
and adolescents as a recent study performed to a Greek
sample of adolescents showed that small percentages of
the sample (38%) knew that melanoma was a type of
skin cancer where as half of them were unaware of what
melanoma was [43]. The same study reported that half of
the adolescents did not wear a sunhat or stayed in the
shade and either did not use a sunscreen properly or use
one with insufficient sun protection factor [43]. More-
over, preventive campaigns should take into account th at
several studies have reported a diagnostic peak for
melanoma diagnosis during the summer months most
probably due to the change in clothing habits, the in-
creased visibility of the skin and sustained sunburns due
to recent sun exposure. As a result, such findings suggest
that preventive campaigns should emphasize and pro-
mote a better skin awareness among population espe-
cially during summer period.
However, the relationship between knowledge, sun
protective behaviour and the mediating effect of sun
protective attitudes and attitudes towards tanning and
sunbathing are still not fully understood. Sunscreen can
effectively reduce sunburn rates and the development of
solar keratosis [16] and has been recommended as a cen-
tral part of sun protection since public health campaigns
first started. A long-term, coordinated multi-level ap-
proach to increase sun protection that uses a range of
strategies needs to be developed over the next few years.
Messages need to be specifically targeted for at-risk
groups (especially by age, gender and skin type), and
approaches need to be refreshed and updated regularly,
particularly to capture young markets. Reduction of the
prevalence of sunbu rn cu rren tly o b ser ved in child r en and
adolescents is of great priority. A reduction in sunburn
rates may be best facilitated by the increased use of pro -
tective clothing, hats and seeking shade. Melanoma
needs to remain on the social agenda through a variety of
mechanisms, and innovative new strategies are needed to
achieve or maintain high levels of awareness and sun
protecti ve beh aviour [1 7].
In conclusion, this study poses the necessity of target-
ing those individuals at risk of melanoma through cam-
paigns which should be implemented in a wide scale in
Greece. These campaigns should organize future preven-
tive strategies aiming to foster sun protection behaviours
whereas further studies with a multivariate design aim-
ing to extract confounding factors of sun protective be-
haviour and interactions between knowledge, attitudes
and behaviours seem necessary.
The study design allowed u s to perform the analysis to a
representative sample of nurses. Additionally, this study
adds important information to the limited body of
knowledge regarding the relationship between the ad-
herence to protective behavioural measures and high risk
groups for the development of skin cancer. On the other
hand, there are a number of limitatio ns within our study.
Firstly, this is a study conducted among nurses, a study
population who might be more informed about skin
cancer risk factors and as a result be more willing to
adapt personal protective measures as previous knowl-
edge about the d anger of sun exposure is associated with
increased sun protection, and therefore our results may
not be generalisable to the general population. Finally,
the participants self reported assessment of the number
of common naevi they have, might have affected the
estimates as studies have revealed great heterogeneity
among the methods of counting naevi: self-assessment,
the interviewer’s and trained clinician’s examination [37].
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