Sunscreen use and availability among female collegiateathletes

Lauren E. Dubas, MD,a and Brian B. Adams, MD, MPHa,b

Cincinnati, Ohio

Depa

D

Stud

Su

Discl

A

Acce

876

Background: Each year more than 250,000 athletes participate on National Collegiate Athletic Association(NCAA) teams. The majority of outdoor NCAA athletes, however, do not use sunscreen on a daily basis.Previous research notes that sunscreen availability represents the main barrier to use among collegiateathletes.

Objective: We sought to explore the effect of sunscreen availability on its application among outdoorcollegiate athletes.

Methods: Participants (n = 83) on NCAA Division IA female golf teams were randomized to form treatmentand control groups. Treatment group players placed study-supplemented sunscreen in their golf bags andlocker rooms during the study period. Both groups completed self-administered surveys at the beginningand end of the 4-week investigation.

Results: The athletes for whom sunscreen was placed in the locker room and bags exhibited a statisticallygreater use of sunscreen at the end of the study compared with the control group (P = .01). Provision ofreadily available sunscreen in the locker room resulted in an average of 1.13 more days per week ofsunscreen use, after adjustment for baseline use (P = .008). In addition, players with ready access tosunscreen during competitions increased their reapplication, although not significantly, by nearly 20%(P = .10). Sunscreen reapplication during practice did not change for either group.

Limitations: Future investigations should target a larger population of both male and female outdoorcollegiate athletes.

Conclusions: The application of sunscreen increased significantly when athletes had easy access tosunscreen during practice and competition. These findings highlight a major opportunity to improve sun-protective behaviors among this vulnerable population. ( J Am Acad Dermatol 2012;67:876.e1-6.)

Key words: collegiate athletes; health behavior; outdoor sports; prevention; sun protection; sunscreen.

Abbreviations used:

NCAA: National Collegiate Athletic AssociationSPF: sun protection factorUV: ultraviolet

Skin cancer is the most commonly diagnosedform of malignancy in the United States. As theprevalence of melanoma and nonmelanoma

cancers dramatically increase, public health initia-tives continue to focus on prevention.1-3 Primarymethods of prevention include using broad-spectrum sunscreens, wearing protective clothing,seeking shade, and limiting exposure during peaksun hours.4 If implemented during early childhoodand adolescence, these preventive practices can

rtment of Dermatology, University of Cincinnati,a and Section of

ermatology, Veterans Affairs Medical Center, Cincinnati, Ohio.b

y sunscreen generously donated by Blue Lizard Australian

nscreen, Crown Laboratories.

osure: Dr Adams is on the advisory board of Mission

thleteCare. Dr Dubas has no conflicts of interest to declare.

pted for publication November 27, 2011.

.e1

decrease the carcinogenic effects of ultraviolet (UV)radiation.5-8

Among young populations at risk, outdoorcollegiate athletes represent a target group for skin

Reprint requests: Brian B. Adams, MD, MPH, Department of

Dermatology, University of Cincinnati, PO Box 670592,

Cincinnati, OH 45267-0592. E-mail: adamsbb@ucmail.uc.edu.

Published online February 10, 2012.

0190-9622/$36.00

� 2012 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2011.11.962

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VOLUME 67, NUMBER 5Dubas and Adams 876.e2

cancer prevention.9 Multiple factors place collegiateathletes at increased risk for sun exposure. Each yearmore than 250,000 National Collegiate AthleticAssociation (NCAA) participants experience largelevels of UV radiation during lengthy practices andmultiple-day tournaments.10,11 These competitiveoutings often take place during peak sun hours

CAPSULE SUMMARY

d The majority of outdoor NationalCollegiate Athletic Association (NCAA)Division IA athletes do not use sunscreenon a daily basis.

d Application of sunscreen increasessignificantly when athletes have readyaccess to sunscreen during practice andcompetition.

d More than 250,000 NCAA athletes standto benefit from increased sunscreenavailability, education, and ultravioletprotection.

without protective shade.In addition, sweating placesathletes at an even higherrisk, as sweat increases theintensity of UV radiation.12

Lastly, a majority of outdoorNCAA athletes do not usesunscreen on a daily basis.In one study, 85% of sun-exposed outdoor NCAA ath-letes reported no sunscreenuse in the previous 7 days.Athletes attributed the lowapplication of sunscreen pri-marily to its unavailability.13

Collegiate athletic pro-grams, however, do little tosupport proper sun protec-

tion. Modifying NCAA practice and competitionschedules may aid in decreasing an athlete’s durationand intensity of UVexposure, but this would requirecoordination of several hundred unique collegiateathletic programs. Thus, NCAA schedules are un-likely to undergo a wholesale change. Therefore, anathlete’s use of sunscreen remains the easiest andmost effective method of skin cancer risk reduc-tion.14 This study seeks to examine the effect ofsunscreen availability on sunscreen applicationamong collegiate athletes.

METHODSStudy population

The study population included female athletes onNCAADivision I golf teams from 10Midwest regionalcolleges: Ohio (5), Kentucky (1), Indiana (3), andIllinois (1). The study targeted women’s golf teamsfor two main reasons. First, collegiate golfers en-counter intense levels of UV radiation exposureduring competition.15 Most golf tournaments takeplace during peak sun months (August, September,May, and June) and peak sun hours (10 AM-4 PM).Second, tournaments take up to 10 hours to com-plete, wherein players experience lengthy periods ofUV radiation.

Survey and sunscreen distribution methodsAll of the recruited golf teams (10) agreed to

participate in this 4-week study. Each team’s head

coach provided permission for survey distribution.A computer algorithm randomized the 10 teamsinto two groups (treatment and control) and pro-vided each player with a numeric code to protectconfidentiality. Treatment group participants com-pleted surveys and received sunscreen for thestudy month. Control group participants only com-

pleted surveys. Both groupscompleted the same surveyon two separate occasionsduring the first and lastweeks of September.

All subjects in the treat-ment group were providedsunscreen when they sub-mitted their completed firstsurvey. Each of the treatmentteams received one (1-gal-lon) tub of sun-protectionfactor (SPF) 301 sunscreenlotion. A research assistantpositioned the sunscreentub at the entrance of eachtreatment group team’slocker room during an initial

site visit. In addition, each treatment participantreceived 5 tubes of SPF 301 sunscreen. Written andverbal directions informed players to use the lockerroom tub of sunscreen daily and to keep at least onetube of sunscreen in their golf bag at all times. Thestudy, however, did not require players to use theprovided sunscreen. Participants in both groupscould use any form of sunscreen during the studymonth.

Each survey contained a detachable cover sheetexplaining the voluntary nature and requirementsof the study. Completion of the survey impliedinformed consent. To ensure anonymity, eachplayer received a study number to be placed onboth surveys. In addition, a research assistantdocumented the high temperature and cloud levelfor all practice and competition days for bothstudy groups. The Medical Institutional ReviewBoard of the University of Cincinnati approved thestudy.

Survey questionsThe survey administered consisted of 6 ques-

tions covering the topics of skin type, age, schoolyear, and sunscreen use. The questions containedmultiple-choice answers and one of the questionsalso required the participant to provide a shortwritten response. Recent validation of self-reportedsunscreen use supports the implementation of thissurvey. This survey method of data collection

Please answer the following questions as accurately as possible:

1.) Circle the best description of your skin type:

a) Always burns, never tans; very fair skin toneb) Usually burns, tans with difficulty; fair skin tonec) Sometimes burns, often tans; fair to medium skin toned) Rarely burns, always tans; medium skin tonee) Very rarely burns, tans very easily; olive/dark skin tonef) Never burns, deeply pigmented; very dark skin tone

2.) How old are you?

17 18 19 20 21 22

other:______

3.) What is your current college year?

1 2 3 4 5 Graduate/5+

4.) In the past month, I have used sunscreen an average of (circle below) times per week during practice/competition.

0 1 2 3 4 5 6 7

5.) During practice I have reapplied sunscreen?

Yes No

6.) During competition I have reapplied sunscreen?

Yes No

If you circled anything less than 7 days, why didn’t you use sunscreen every day?

Study Questionnaire.

J AM ACAD DERMATOL

NOVEMBER 2012876.e3 Dubas and Adams

provides a similar mean and confidence intervalwhen compared with objective measurement toolsof sunscreen use.16

Data analysisBasic descriptive analyses examined frequencies

for skin type, age, school year, reapplication ofsunscreen, and cloud level and means for age andtemperature for both groups. Player sunscreenapplication was reported as mean days of sunscreenuse per week. The x2 analyses assessed both groupsfor significant differences in skin type, age distribu-tion, school year, and cloud level. Student t testanalyses examined between group differences inmean age, mean temperature, and overall weeklysunscreen use at the end of the intervention. Inaddition, a McNemar test evaluated sunscreen reap-plication differences before and after the interven-tion in each group for both practice and competition.Lastly, a linear regression model adjusted forbaseline differences in initial sunscreen use betweenthe two groups and determined the increased num-ber of days of sunscreen use attributable to theintervention.

RESULTSParticipant characteristics

A total of 83 (39 control, 44 treatment) femaleparticipants completed the study questionnaire.There were no statistical differences between thecontrol and treatment groups in terms of skin type,age, or year in school (Table I).

Weather characteristicsTheweather characteristics recorded for the control

and treatment groups during the study month in-cluded daily mean high temperature and cloud level.There were no significant differences between thetwo groups for either weather parameter (Table II).

Sunscreen useThere was no statistical difference in sunscreen

use preintervention between the control and treat-ment groups. Treatment group participants sig-nificantly increased their sunscreen use, whereascontrol group players decreased sunscreen applica-tion after the intervention (P = .01) (Table III). Afteradjusting for sunscreen use before the study, a linearregression model demonstrated that making

Table I. Comparison of participant characteristics

Characteristics Control N = 39 Treatment N = 44 P value

FST, n (%)I 0 (0) 0 (0)II 6 (15) 4 (9)III 10 (26) 22 (50)IV 17 (44) 10 (23)V 5 (13) 8 (18)VI 1 (3) 0 (0) .09

Age, y, n (%)# 18 9 (23) 13 (30)19 8 (21) 14 (32)20 9 (23) 6 (14)21 10 (25) 10 (22)22 3 (8) 1 (2) .45

Age, y, mean (SD) 19.74 (0.99) 19.34 (1.24) .17Collegiate y, n (%)First 9 (23) 13 (30)Second 8 (21) 13 (30)Third 13 (33) 8 (18)Fourth 7 (18) 8 (18)Fifth 2 (5) 2 (4) .58

No statistical differences between control and treatment groups.

FST, Fitzpatrick skin type.

Table II. Comparison of weather characteristics

Weather characteristic Control Treatment P value

Daily high temperature, 8C,mean (SD)

24.8 (0.86) 24.2 (0.70) .15

Cloud level, n (%)*Sunny 26 (17) 24 (16)Partly cloudy 76 (51) 62 (41)Cloudy 48 (32) 64 (43) .15

*Based on National Weather Service data for home and travel

locations for each day in both study groups.

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sunscreen readily available to athletes in the lockerroom accounted for an increase of 1.13 more daysper week of sunscreen use (P = .008).

There was no significant increase in the reappli-cation of sunscreen during practice for treatment orcontrol groups after the intervention (Table III).Players with ready access to sunscreen during com-petition increased their reapplication thereof by 20%,although this did not reach statistical significance(P = .10) (Table III), whereas control group partic-ipants’ sunscreen reapplication remained virtuallyunchanged (Fig 1).

Survey commentsThe study questionnaire included one free re-

sponse question allowing participants to commenton barriers to sunscreen use. Responses within thecontrol group mirrored those provided to the ques-tionnaire used in the 2005 study of collegiate sun-screen use by Hamant and Adams.13 The majority(85%) of written responses from the control groupcited inaccessibility and inconvenience as the mainbarrier to daily sunscreen application. Responseswithin the treatment group, however, centered uponmisinformation and lack of sun-protection education(60%). Most treatment participants cited their abilityto tan easily and inability to sunburn as reasons toforego sunscreen use. The remainder of the treat-ment participants cited a psychosocial preference fortanned skin (40%).

DISCUSSIONAthletes continue to accrue hours of unprotected

UV radiation exposure during their collegiatecareers. The risk of skin malignancy, however,garners little attention from NCAA athletic programs.Instead, the burden of primary prevention often fallson the athlete. Inaccessibility, inconvenience, andmisinformation provide the largest hurdles blockingthe assimilation of proper sunscreen habits amongathletes.13 This study demonstrates that providingsunscreen and placing it in opportune locations(ie, locker rooms and golf bags) significantly mini-mized one major obstacle between athletes andproper sun protection.

The increase of just over 1 day of sunscreen useper week may appear small. This increase, however,signifies an average improvement of up to 100sunscreen applications per athlete each athleticseason. In addition, the reapplication of sunscreenincreased nearly 20% among the treatment teamsduring competition. Although not statistically signif-icant, the degree of increase in sunscreen reapplica-tion among treatment participants warrants attentionwhen compared with the decrease (3%) in sunscreenreapplication among control group members. Thisincrease could reach statistical significance whenlarger collegiate populations are studied.

The cost of providing sunscreen to all outdoorathletes may, however, create a financial burden formany NCAA programs. Sunscreen companies canassist in this effort by sponsoring collegiate athleticteams and programs. Sponsorshipsmay also increasepublic interest in skin cancer prevention, as athletesact as rolemodels formany children and adolescents.Media coverage and advertisementswill provide newavenues to teach this vulnerable population and theirfans about the dangers of sun exposure.

Along with sunscreen, athletes need continuededucation concerning proper sun safety. Athleteswithin both study groups mentioned multiple ill-informed excuses trying to explain their lack of dailysunscreen use. Many athletes (40% of treatmentparticipants) cited a psychosocial desire to be tan as

Fig 1. Effect of intervention (sunscreen provision) onathletes’ reapplication during competition.

Table

III.Effect

ofsunscreenavailability

onathlete

sunscreenuse

andreap

plication

Sunscre

enuse

Control(n

=39)

P(w

ithin

gro

upanalyses

betw

een

preinterv

ention

andpostintervention)

Treatm

ent(n

=44)

P(w

ithin

gro

upanalyses

betw

een

preinterv

ention

andpostintervention)

P(betw

een

gro

upanalysis

postintervention)

Preintervention

Postintervention

Preintervention

Postintervention

Initialap

plication*

Mean

,d/w

k(SD)

3.10(2.04)

2.69(1.69)

3.05(2.00)

3.80(2.26)

.01

Practice

reap

plication,y

n(%

)Yes

12(31)

11(28)

.76

12(27)

9(20)

.37

No

27(69)

28(72)

32(73)

35(80)

Competition

reap

plication,z

n(%

)Yes

21(54)

20(51)

.78

20(45)

28(64)

.10

No

18(46)

19(49)

24(55)

16(36)

*Applicationofsunscreenat

beginningofpracticeorcompetition.

y Repeat

applicationofsunscreenduringpractice.

z Repeat

applicationofsunscreenduringcompetition.

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NOVEMBER 2012876.e5 Dubas and Adams

their reason to eschew sunscreen use. Others alludedto a perceived SPF secondary to skin color (60% oftreatment participants). Even though availability ofsunscreen increased sunscreen application, playersneed to be educated on how to use the providedproduct. Coaches can use their influence as a meansto educate athletes about proper sun protection andprovide daily sunscreen reminders.17 In addition, theteams’ physicians, nurses, residents, or even medicalstudents may provide teaching on proper sun safetybefore each season. Presentations on applicationmethods, reapplication principles, and clothingchoices may further decrease an athlete’s UV expo-sure risk.

There are several limitations to this study. Thequestionnaire used in the 2005 examination ofHamant and Adams13 of collegiate sunscreen usestood as the template for the study. This specificsurvey did not undergo validity testing; however,previous work supports the use of these questions.13

In addition, the recruitment of only female golfteams limits generalizability for male athletes andother collegiate sports. Future investigations shouldexamine sunscreen use within a larger populationincluding multiple outdoor collegiate sports andboth genders. The treatment group received onlyone formof sunscreen vehicle, which limited players’options. As sunscreen preference differs amongsports and between genders,18 future studies shouldinvestigate the use of various sunscreen vehicles.

CONCLUSIONThis study illustrates the need for increased sun-

screen accessibility among NCAA collegiate athletes.The application of sunscreen increased significantlywhen athletes had easy access to sunscreen during

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practice and while traveling. Along with sunscreenavailability, education, UV-protective clothing, andschedule adaptation highlight other avenues avail-able for study. The importance of these investiga-tions should not be minimized, as more than aquarter million NCAA athletes stand to benefit.

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