Hindawi

Dermatology Research and Practice

Volume 2018, Article ID 1965674, 9 pages
https://doi.org/10.1155/2018/1965674

Review Article
Skin Cancer Knowledge, Attitudes, and Practices among Chinese
Population: A Narrative Review

Philip M. Stephens ,1 Brian Martin,1 Ghazal Ghafari,1

James Luong,1 Vinayak K. Nahar ,2 Linda Pham,1 Jiangxia Luo,3,4
Marcelle Savoy,5 and Manoj Sharma 6
1
DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Harrogate, TN, USA
2
Center for Animal and Human Health in Appalachia, College of Veterinary Medicine, DeBusk College of Osteopathic Medicine,
and School of Mathematics and Sciences, Lincoln Memorial University, Harrogate, TN, USA
3
Department of English, Gannan Medical University, Ganzhou, Jiangxi, China
4
Carter and Moyers School of Education, Lincoln Memorial University, Harrogate, TN, USA
5
Lon and Elizabeth Parr Reed Health Sciences Library, DeBusk College of Osteopathic Medicine, Lincoln Memorial University,
Harrogate, TN, USA
6
Department of Behavioral & Environmental Health, School of Public Health, Jackson State University, Jackson, MS, USA

Correspondence should be addressed to Vinayak K. Nahar; [email protected]

Received 31 January 2018; Accepted 22 April 2018; Published 4 June 2018

Academic Editor: Gavin P. Robertson

Copyright © 2018 Philip M. Stephens et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Skin cancers are becoming a substantial public health problem in China. Fair skin and increased exposure to ultraviolet B (UVB)
rays from the sun are among the most substantial risk factors for skin cancer development, thus making the Chinese people
vulnerable to this group of diseases. The purpose of this article is to present a narrative review of the knowledge, attitudes, and
practices (KAP) related to skin cancers within the Chinese population. A systematic electronic search of MEDLINE (PubMed),
CINAHL, ScienceDirect, and Google Scholar databases yielded nine articles that met the inclusion criteria. The review found
that although sunscreen application was a commonly used method of skin protection among the general Chinese population,
educational interventions enhancing current knowledge and attitudes about the effects of UVB rays on skin from undue sun
exposure were limited in many smaller communities of the country. Hence, there is an essential need to design effective, evidence-
based educational programs promoting sun protection behaviors in both congregated and sparsely populated areas of China.

1. Introduction from 16.0 to 31.8 per 10,000 new cases, contributing to 60% of
newly diagnosed skin cancers [5]. Squamous cell carcinoma
Skin cancers, the most commonly diagnosed of all cancers, (SCC) is the second most diagnosed type of skin cancer
are typically viewed as ailments affecting primarily Caucasian among the Chinese population [5]. Also reflected in the
populations in countries such as Australia, New Zealand, overall number of cutaneous malignancies is the increased
Slovenia, and Norway [1–3]. However, worldwide skin cancer mortality rate from melanoma between 1988 and 2007 in the
rates have increased over the last three decades [4]. Pop- cities of Shanghai and Beijing [6].
ulations which previously had low skin cancer rates may The majority of the Chinese population have fair skin
present the biggest challenge for public health officials due along with increased exposure to ultraviolet B (UVB) rays
to the lack of established preventative measures. The rise in from the sun—creating a heightened risk for the development
the incidence of skin cancer is becoming a significant public of skin cancer diseases [7, 8]. Specifically, BCC is linked
health problem in China. Between the years of 1990 and 1999, with short-term burning incidents or long-term exposure
the rate of basal cell carcinoma (BCC) in the nearly doubled of the head and neck; SCC is often related to extended
2 Dermatology Research and Practice

periods of short- and long-term sun exposure [9]. Thus, skin

cancer rate reduction warrants use of sun protective strategies Citations identified
to lower UV absorption. Examples of modifiable behaviors n = 88
include using sunscreen, limiting direct sun exposure, and
wearing protective clothing. Therefore, addressing attitudes −26
and perceptions related to skin cancer within the Chinese
population can lead to the initiation and continuation of sun Screened on
protective behaviors. titles/abstracts
Local governments in China distribute treatment expen- n = 62
ditures but typically fail to provide money for preven-
−48
tative medicine [10]. Since 2004, the central government
has worked to increase cancer prevention funding [10].
As China’s rapidly aging population continues to strain its Full text read
healthcare system financially, preventative measures are of n = 14
utmost importance due to their cost-saving benefits. The
importance of these actions extends beyond the elderly of −6
China’s population.
A study conducted on staff and volunteers from seven
different Olympic event locations in Beijing found that 79.3% Studies included in
review
were aware of the association between UV exposure and n=8
skin cancers. Nevertheless, only 49.3% of participants wore
protective clothing, 45.3% used sunglasses, and 58.8% applied Reference list
scanned
sunscreen [11]. In another study, sunscreen usage rates were as n=1
low as 23.1% among college-age Chinese residents [12]. These
Final studies
findings suggest that more intervention regarding sun safety included in review
should be provided to young Chinese adults. Education is n=9
especially important due to a significant risk of SCC from
early age exposure in males and lifetime sun exposure in Figure 1: Chart of literature review.
females [9].
This article presents a narrative review on the knowledge,
attitudes, and practices (KAP) related to skin cancers within knowledge, attitudes, beliefs, and behaviors in China were
the Chinese population. Based on this framework, recom- included. Exclusion criteria for the articles included the
mendations of preventative public health strategies to engage following: (1) irrelevant topics to review article aim, (2)
the population have been made. articles that focused on treatment of skin cancers instead of
preventative practices, and (3) comparable studies conducted
2. Methods on similar groups not indigenous to China. The literature
search was conducted by four independent reviewers. Any
In the initial search, a systematic, computer-based liter- disagreement regarding inclusion criteria was resolved via
ature search was conducted using MEDLINE (PubMed), discussion until consensus was reached.
Cumulative Index to Nursing and Allied Health Literature
(CINAHL), and ScienceDirect. The search was performed in 3. Results
these electronic databases using combinations of the follow-
ing terms: “China”, “Chinese”, “skin cancer”, “melanoma”, Electronic searches identified a total of 88 citations. After
“sun protection”, “sun behaviors”, “knowledge”, “attitudes”, removing duplicates (𝑛 = 26), the remaining 62 articles were
“beliefs”, “perceptions”, “sunscreen”, “prevention”, “prac- screened based on titles and abstracts. After screening, the
tices”, and “behaviors”. Results of the initial literature search remaining 14 articles were read in their entirety to determine
conducted in August 2017 included reviews of abstracts and inclusion criteria eligibility. In summary, a total of nine
titles with exclusion of off-topic articles. articles met the eligibility criteria and were included in the
Analyses of further studies updated in October 2017 review (Figure 1).
were performed by reviewing reference lists of the articles Table 1 provides details of the literature review pertaining
of interest, along with searches in Google Scholar. The to skin cancer knowledge, attitudes, and practices among
search was not limited by date of publication or language. the Chinese population. The first column displays the senior
Both English and Chinese language studies that contained author of each corresponding article, as well as the date and
digital and searchable English abstracts and keywords were location of the study. Column two includes the methodolo-
included. gies used for data collection and sample size (𝑛) for each
To the best of the reviewers’ knowledge, all manuscripts study, along with the gender and age of the participants.
published in peer-reviewed journals in the selected databases Extracted data regarding knowledge, attitudes, and beliefs of
were considered for inclusion in this review. Research stud- the participants are located within the third column. Only
ies that measured skin cancer or sun protection related preintervention data were extracted and included in the
 Table 1: Summary of included studies.
Data collection method,
First author, date, and
sample size (𝑛), gender, and Knowledge, attitudes, and beliefs Skin cancer prevention practice
location
age
Questionnaire, 𝑛 = 720 49.3% knew that sunscreen could protect people from both UVA and UVB
(patients and hospital staff) radiation Sunscreen application
Dermatology Research and Practice

Cheng, 2008, and

424 females, mean age = 37 Groups within the populations of males, middle-aged, elderly, Use sunscreen very often: 40%
Beijing [21]
years (SD = 27.5), age range low-education, and people with skin phototype I and II had Reapply sunscreen in burning sun: 43.3%
= 14–72 years misunderstandings of sunscreen’s recognition and application
Fluorescent agent detection according to skin site
Dermatologists:
Hairline of forehead = 51.3%, forehead = 92.3%, temples = 74.4%, cheek =
100%, nose = 92.3%, perioral = 82.1% (male = 61% female = 100% 𝑝 < 0.01),
ears, neck, hands, and wrists: 0%
Photosensitive patients:
Hairline of forehead = 36.6%, forehead = 100%, temples = 41.5% (male =
28% female = 57% 𝑝 < 0.05), cheek = 100%, nose = 75.6%, perioral =
Direct observation, 𝑛 = 39
73.2%, ears = 2.4%, Sunscreen cream application
(dermatologists, 28
neck = 0%, hand and wrists = 4.9% Dermatologists:
attending, 11 residents), 21
Density of fluorescent agent (mg/cm2 ) 28.2% put cream on the tip of finger
females, mean age = 35.3
Dermatologists: 71.8% put cream in the palm of the hand and rubbed
Yang, 2009, and years, age range = 27–48
Hairline of forehead: male = 0.5 (SD = 0.31), female = 0.5 (SD = 0.38), the hands together before applying to target skin sites
Nanjing [15] years
forehead: male = 1.0 (SD = 0.38), female = 1.5 (SD = 0.02), temples: male = Photosensitive patients:
𝑛 = 41 (photosensitive
0.5 (SD = 0.41), females = 1.0 (SD = 0.29), cheek: male = 1.0 (SD = 0.29), 17.1% put cream on the tip of finger
patients), 23 females, mean
female = 1.0 (SD = 0.25), nose: male = 0.5 (SD = 0.35), female = 1.0 (SD = 82.9% put cream in the palm of the hand and rubbed
age = 49 years, age range =
0.21), perioral: male = 0.5 (SD = 0.32), female = 1.0 (SD = 0.17), ears: 0% the hands together before applying to target skin sites
19–72
Neck/V area of the chest = 0%, Hand and wrist: 0%
Photosensitive patients:
Hairline of forehead: male = 0.5 (SD = 0.47), female = 0.5 (SD = 0.44),
forehead: male = 1.0 (SD = 0.33), female = 1.5 (SD = 0.36), temples: male =
0.5 (SD = 0.27), female = 0.2 (SD = 0.31), cheek: male = 1.0 (SD = 0.28),
female = 1.0 (SD = 0.23), nose: male = 0.5 (SD = 0.26), female = 0.5 (SD =
0.35), perioral: male = 0.5 (SD = 0.36) female = 0.5 (SD = 0.25), ears: 0%
Neck/V area of the neck: 0%, Hand and wrist: male = 0.1, female = 0
3
 4

Table 1: Continued.
Data collection method,
First author, date, and
sample size (𝑛), gender, and Knowledge, attitudes, and beliefs Skin cancer prevention practice
location
age
Total knowledge score of types of UV that can damage the skin = 29.7%,
Sunscreen = 58.8%, men = 28.2%, women = 77.7%
men = 12.6%, women = 40.3%
Protective clothing = 49.3%, men = 59.7%, women =
Total knowledge score that people should take precautions from the sun in
42.9%
the morning or at nightfall = 73.0%, men = 58.4%, women = 82.1%
Hat = 42.2%, men = 39.5%, women = 43.9%
Total knowledge score that people should take precautions from the sun on
Parasol (sun umbrella) = 45.4%, men = 14.3%,
a cloudy day = 58.8%, men = 44.5%, women = 67.5%
women = 64.7%
Total knowledge score that UV-induced skin damage is accumulative =
Sunglasses = 45.3%, men = 42.9%, women = 46.8%
80.3%, men = 71.4%, women = 85.7%
Questionnaire, 𝑛 = 623 No protection = 9.0%, men = 16.4%, women = 4.4%
Meaning of SPF total knowledge score = 61.2%, men = 51.3%, women =
Cheng, 2010, and (volunteers), 61.8% female, Have ever used sunscreen before = 80.3%, men =
67.3%
Beijing [11] mean age = 24.6 (SD = 6.7), 59.2%, women = 93.2%
Meaning of PA total knowledge score = 34.4%, men = 31.5%, women =
age range = 18–60 years Correct sunscreen use among those who have ever
36.1%
used sunscreen before = 45.0%, men = 14.9%,
Know how to use sunscreen correctly 74.2%, men = 58.8%, women = 83.6%
women = 56.8%
Awareness score of what types of skin damage the sun causes: burn (total =
Mean SPF value of sunscreen used = 27.7 (SD = 9.2),
81.2%, men = 70.2%, women = 88.1%), skin cancer (total = 79.3%, men =
men = 30.7 (SD = 11.2), women = 26.7 (SD = 8.2)
73.1%, women = 83.1%), tan (total = 52.0%, men = 40.8%, women = 59.0%),
Mean Protection Grade (PA) value of sunscreen used
skin aging (total = 65.8%, men = 53.8%, women = 73.3%), blemishes (total
= 2.3 (SD = 0.6), men = 2.6 (SD = 0.7), women = 2.3
= 73.4%, men = 60.9%, women = 81.0%), do not know (total = 2.4%, men =
(SD = 0.6)
5.0%, women = 0.8%)
Sunscreen: 61.6%
Questionnaire, 𝑛 = 1501
Long-sleeved clothing and pants: 48%
(freshmen military cadets),
Fan, 2012, and Hefei 78.8% and 81.7% of the subjects did not know that the UV consists of three Umbrella and hat: 61.8%
1488 males, mean age =
[22] parts and the meaning of the PA and SPF, respectively. Sunglasses: 63.8%
20.35 (SD = 2.13), age range
32.7% had been taken protective measures, and only
= 15–29
50 cases did a professional skin examination.
Despite the difference in cognition degrees between the two groups, both
groups have high degrees of cognition on the damage of UV to skin
Walking in shadows: 63.6%
Questionnaire, 𝑛 = 217 (all Both groups have low basic UV knowledge
Avoiding going out at noon: 60.8%
females) 66.4% females 24.9% of the two groups have correct knowledge about types of UV
Sunscreen: 62.2%
He, 2012, and Beijing from Beijing and 33.6% 22.6% of the participants were aware that sun protection should be started
Wearing long-sleeved t-shirts: 18.4%
and Ningxia [23] from Ningxia, mean age = as early as in one’s infancy
Hats: 26.7%
32 years (SD = 9.7), age People get access to knowledge of sunburn and sun protection from the
Umbrellas: 53%
range = 17–59 years same sources: television 40.2%, magazines 27.6%
Sunglasses: 30.9%
27.6% knew the meaning of SPF
6.3% knew the mean of PA
Dermatology Research and Practice
 Table 1: Continued.
Data collection method,
First author, date, and
sample size (𝑛), gender, and Knowledge, attitudes, and beliefs Skin cancer prevention practice
location
age
Sun exposure behavior by gender
Knowledge about UV-induced risk by gender
Avoid outdoor actives in strong sunlight: male =
Premature aging: male = 59.7%, female = 73.3%
71.2%, female = 82%
Immune suppression: male = 47.8%, female = 58.5%
Avoid extensive exposure in sunny midday:
Skin cancer: male = 50.3%, female = 59.5%
Questionnaires, 𝑛 = 5964 male = 72.2%, female = 84.2%
Sun protection attitudes by gender
Yan, 2015, and (residents), 53.2% females, Average daily sun exposure time (min) by gender
Need sun protection in winter: male = 27.8%, female = 43.1%
Shanghai [12] mean age = 43.2 years and 7AM–5PM: male = 111.8 (SD = 105.7), female = 82.2
Need sun protection indoors or in the vehicle: male = 21.9%, female = 32.6%
age range = 20–60 years (SD = 64.7)
Tanning attitudes by gender
Dermatology Research and Practice

10AM–2PM: male = 31.1 (SD = 45.1), female = 20.1

Appears healthy: male = 11%, female = 10.2%
(SD = 28.9)
Looks attractive: male = 5.7%, female = 4.3%
21.3% of the participants have applied sunscreen with
Not favorable: male = 13.7%, female = 38.1%
93.3% of respondents female
Intention to use sunscreen mean score
Questionnaire, 𝑛 = 253 Standard care group: 2.64 (SD = 1.41)
(college students) standard Self-regulation group: 2.71 (SD = 1.09)
care group = 126, Sunscreen action planning mean score Mean sunscreen use:
Zhou, 2015, and
self-regulation group = 127, Standard care group: 1.79 (SD = 0.89) Standard care group: 1.77 (SD = 1.15)
Nanjing [13]
97.6% females, mean age = Self-regulation group: 1.87 (SD = 0.86) Self-regulation group: 1.95 (SD = 1.21)
21.26 years (SD = 1.34), and Sunscreen coping planning mean score
age range = 18–24 years Standard care group: 1.83 (SD = 0.90)
Self-regulation group: 1.74 (SD = 0.81)
Mean knowledge score of men = 2.41 (SD = 1.51) and women = 2.56 (SD =
1.38) out of maximum total score of 6, no gender difference among scores
𝑝 = 0.31 Most students lacked sun exposure because they did
Highest rate of correct responses 68.0%, lowest rate 9.6% not want to get tan
Students that thought sun exposure was enough = 67.5% Length of sun exposure:
Students with negative sun exposure response = 32.5% <15 mins/d = 6.8%
Most common reasons among 44 male students for inadequate sun 15–30 mins/d = 31.8%
exposure: 43.2% avoiding dark skin, 18.2% no desire to go out, 13.6% skin 30–45 min/d = 27.4%
cancer Not in sun for >45 min/day = 34.0%
Most common reasons among 124 female students for inadequate sun 82.7% of students used some sun protections
Questionnaire, 𝑛 = 515
Zhou, 2016, and exposure: 75.0% avoiding dark skin, 16.1% skin cancer, 12.1% accelerated Frequency of sun protection use
(medical students), 73.2%
Nanjing [24] aging Never: male = 49.3%, female = 5.6%
females
Student knowledge of Vitamin D obtained from: Rarely: male = 29.4%, female = 23.0%
media = 59.9%, health professionals = 43.3%, classmates and friends = 25%, Sometimes: male = 13.2%, female = 36.1%
parents = 8.8% Often: male = 8.1%, female = 30.2%
68% of students correctly knew that the human body can get vitamin D Always: male = 0%, female = 5.1%
through sun exposure Types of sun protection
3.0% of students had no desire to learn about vitamin D Sunscreen: male = 33%, female = 75%
Female students had greater desire to learn compared to male students Hats; male = >50%, female = 42%
(88.3% versus 78.5%) Umbrellas: male = 20%, female = 72%
Male students had greater indifferent attitude than female students (18.5%
5

versus 8.7%)
 6

Table 1: Continued.
Data collection method,
First author, date, and
sample size (𝑛), gender, and Knowledge, attitudes, and beliefs Skin cancer prevention practice
location
age
Mean time spent in the sunshine per day:
<2 h: 49.8%, male = 47.7%, female = 52.1%
Reasons why parents supported their children in preventing sun exposure: 2–4 h: 43.9%, male = 44.6%, female =
50.9% protecting from suntan, 75.6% protecting from sunburn, 15.3% 43.1%
preventing skin photoaging, 4.9% unclear, 3.1% other >4 h: 6.3%, male = 7.7%, female = 4.8%
Reasons why parents did not support their children in preventing sun Weather in which protective measures were taken:
exposure: 23.2% UV is beneficial to the child’s skin, 11.7% UV is no harm to Sunny day: 93.6%
the child’s skin, 30.7% benefits of UV to the child’s skin are greater than its Cloudy day: 8.3%
Questionnaire, 𝑛 = 3083 harm, 52.5% the child’s skin does not need sun protection Rainy day: 8.4%
(parents/guardians and Parent’s opinions on using a different sunscreen for children than for Cloudy to sunny day: 17.5%
their children), 51.6% male parents: Occasions for sun protection:
children, children mean age 69.7% the child’s skin is different from the parent’s skin, 27.7% the child’s Travel: 57.8%
Wan, 2016, and
= 7.70 years (SD = 2.78), skin is easily allergic, 2.6% other Outdoor leisure activities: 56.4%
Guangzhou City [14]
children age range = 3–13 Parent’s opinions on the nonuse sunscreen for children: Swimming: 36.5%
years, mean rent/guardian 44.4% sunscreen is not suitable for children, 27.9% do not know how to Playing ball: 16.1%
age = 36.72 years (SD = choose the sunscreen for children, 28.2% use alternative sun protection Physical education: 9.8%
5.95), 70.5% female methods, 44.3% worried that the child’s skin is allergic to sunscreen, 9.2% Others: 3.2%
other Stayed under shade: 12.8%, male = 12.3%, female =
Sources of sun protection information for increasing parents/guardians 13.4%
knowledge: 52% television advertisements 37.6% newspapers, 37% Sunscreen: 38.2%, male = 30.2%, female = 46.6%
magazines, 31.1% friends, 28.2% books, 17.5% beauty parlors, 16.2% family Long-sleeved shirt: 27.6%, male = 23.8%, female =
members, 12.4% radio advertisements, 10.3% relatives, 10% dermatologist, 31.7%
12.5% others Hat: 61.9%, male = 60.7%, female = 63.2%
Umbrella: 53.2%, male = 40.8%, female = 66.4%
Sunglasses: 26.8%, male = 25%, female = 28.7%
Dermatology Research and Practice
Dermatology Research and Practice 7

table for studies utilizing experimental design. Prevention population’s perspective, particularly men, on skin cancer
practices of participants in each study are described in the prevention and to increase their involvement.
last column. Sun exposure during childhood has been correlated with
skin cancer development later in life [14]. The percentage of
4. Discussion children with a history of experiencing a sunburn increases
as age increases. Therefore, it is imperative for educational
The purpose of this article was to conduct a narrative review programs to be introduced at an early age before multi-
to summarize the knowledge, attitudes, and practices (KAP) ple sunburns have been manifested. Interestingly, a large
related to skin cancers within the Chinese population. The percentage (93.6%) of parents reported utilizing sunscreen
Chinese are generally fair-skinned thus making them vul- for skin protection on their children (including 38.2% who
nerable to cutaneous cancers. The other primary modifiable are less likely to utilize the same methods for themselves),
preventative risk factor for skin cancers is exposure to UVB citing sunburn prevention as the main reason [14]. Involving
radiation, especially from the sun. The best protective mea- parents in their children’s educational program presents a
sure, therefore, is limiting exposure to sunlight, particularly possible avenue for improving adult attitudes as well.
during the peak hours between 10 am and 2 pm. Other The appropriate application of sunscreens is another area
methods suggested to reduce skin cancer incidence include of concern. Frequently, inadequate amounts of sunscreens
covering the skin with protective clothing—sunglasses, long were found to be used in addition to inconsistent methods
sleeves, and hats—and the regular application of sunscreens of application, i.e., some areas of the body received more
with a sufficiently high sun protection factor (SPF) [8]. sunscreen, leaving other areas at risk. An application density
Sunscreen use was found to be a popular method of skin of 2 mg/cm2 has been found to be most appropriate to receive
protection due to its enhanced affordability in an improving the full SPF of the sunscreen [15]. Parents who did not use
Chinese economy [11]. However, these findings were not in sunscreens on their children were fearful either that the
agreement with the results from a survey conducted among products were unhealthy or that they would cause an allergic
11 communities in Shanghai, where only 21.3% utilized sun- reaction, but among those who did use this preventative
screen, while the majority of the other participants preferred measure, nearly half did not follow the recommended reap-
shade or hats as their primary means of skin protection [12]. plication rate of every 2-3 hours or used a product strength
While the prevalence of skin cancer is lower in China that was often less than 30 SPF [14].
relative to some of the Western countries [11], BCC and SCC Before introducing UVB awareness and skin protection
remain common cancers; therefore, skin protection remains programs to the Chinese population, modifications should
important for public health [12]. One possible explanation be made to assure cultural and ethical appropriateness. One
for the reduced incidence of skin cancer may be that the such concern is the risk of vitamin D deficiency, which
average complexion among the Chinese populace is not as Asian adults face due to their complexion [16]. In terms
fair as that found in Western countries. One study found that of disseminating knowledge and awareness to the public at
the majority of the Chinese population is skin type IV on large, television advertisements were selected by parents as
the Fitzpatrick scale, making them amenable to easy tanning an important medium for sun protection information (52%
and rare burning [12]. Darker-skinned populations have a agreement) [14]. This finding suggests that the Chinese pop-
lower incidence of skin cancer in general but are likely to ulation is receiving a substantial portion of its medical infor-
be diagnosed with more advanced stages of the disease, if it mation from nonmedical sources. Mass media campaigns,
does develop [12]. Another possible explanation may be that, therefore, should attempt to involve medical professionals in
in contrast to Western populations, many Chinese citizens their creation to improve the broad dissemination of effective
find paler complexions more desirable and are therefore more skin protective strategies.
likely to avoid unnecessary sunlight exposure and tanning Knowledge alone has not been found to be a strong
[13]. predictor of behavioral change [13]. The level of health
Studies have found educational programs to reduce rates literacy was a significant factor in the relationship between
of sunburn and skin aging in the general population [11]. knowledge and behavior. For example, in the context of
However, based on this review we found that such initiatives vitamin D absorption and sun exposure, individuals with
are rather few in China, with the effects of UVB being high health literacy were more likely to discern appropriate
largely ignored [12]. Furthermore, knowledge and attitudes amounts of sun exposure to maximize the amount of vitamin
pertaining to UVB radiation have been found to be somewhat D absorption; unfortunately, poor attitudes counteracted
deficient among many Chinese communities. Among men the benefits of health literacy [17]. This suggests that any
and women, one study found that only 55.2% knew that educational initiative should not only focus on increasing
UV radiation causes skin cancer [12]. Similar to Western knowledge and health literacy, but also on improving societal
populations, women scored higher on skin protective knowl- attitudes, which insure the initiation and continuation of
edge tests than men [11, 12]. Men were found to be less healthy behavioral changes related to skin protection and
likely to care for their skin regularly compared to women, sun exposure. Thus, evidence-based theoretical approaches
with many men expressing that sunscreen and umbrella need to be instituted to foster effectual behavior change [18].
usage are women’s activities. Men were also less willing to In present day context, fourth generation behavior changes
participate in educational programs about skin protection that utilize multiple theories are in vogue [19]. One such
[11]. Additional efforts should be made to improve the utilization is through the multi-theory model (MTM) of
8 Dermatology Research and Practice

health behavior change that breaks down behavior change British Journal of Dermatology, vol. 166, no. 5, pp. 1069–1080,
into initiation and sustenance [20]. For initiation of sun 2012.
protection behaviors attitudes that underscore advantages [4] J. Yu, X. Luo, H. Huang, Z. Zhai, Z. Shen, and H. Lin, “Clinical
over disadvantages of such behavior change and behavioral characteristics of malignant melanoma in southwest China:
confidence to use sun protection behaviors along with the A Single-Center Series of 82 consecutive cases and a meta-
changes in physical environment that support sun protection Analysis of 958 reported cases,” PLoS ONE, vol. 11, no. 11, Article
are important. In order to sustain sun protective behaviors, ID e0165591, 2016.
one needs to promote conversion of emotions toward goals [5] S. Y. Cheng, N. M. Luk, and L. Y. Chong, “Special features of
for adhering to and continually practicing these behaviors, as non-melanoma skin cancer in Hong Kong Chinese patients: 10-
well as mobilizing changes in social environment. year retrospective study,” Hong Kong medical journal, vol. 7, no.
1, pp. 22–28, 2001.
5. Limitations [6] H. M. Zeng, S. W. Zhang, R. S. Zheng et al., “Analysis of
incidence and mortality of cutaneous melanoma from 2003 to
There are limitations in the construct and the included studies 2007 in China,” China Cancer, vol. 3, pp. 183–189, 2012.
of this narrative review. Some of the studies are susceptible [7] M. A. Linares, A. Zakaria, and P. Nizran, “Skin Cancer,” Primary
to measurement biases due to self-reported data collection Care—Clinics in Office Practice, vol. 42, no. 4, pp. 645–659, 2015.
methods. Additionally, the data collected via questionnaires [8] Skin Cancer Facts & Statistics, “Skin Cancer Foundation
are subject to the recall bias. Although some of the studies website,” http://www.skincancer.org/skin-cancer-information/
were in Chinese with abstracts in English, the search was skin-cancer-facts#general.
conducted solely using English language accessible electronic [9] C. Pelucchi, A. Di Landro, L. Naldi, and C. La Vecchia, “Risk
databases; therefore it is possible that some relevant articles factors for histological types and anatomic sites of cutaneous
were missed. Furthermore, we omitted searches within the basal-cell carcinoma: An Italian case-control study,” Journal of
grey literature. Finally, caution should be exercised when Investigative Dermatology, vol. 127, no. 4, pp. 935–944, 2007.
making generalizations of findings to the Chinese population [10] X. Ma, C. Lin, and W. Zhen, “Cancer care in China: A general
since this review included only nine studies from six loca- review,” Biomedical Imaging and Intervention Journal, vol. 4, no.
tions. 3, 2008.
[11] S. Cheng, S. Lian, Y. Hao et al., “Sun-exposure knowledge
6. Conclusions and protection behavior in a North Chinese population: a
questionnaire-based study,” Photodermatology, Photoimmunol-
The findings of this study indicate a need for increasing ogy & Photomedicine, vol. 26, pp. 177–181, 2010.
awareness and knowledge among the Chinese population [12] S. Yan, F. Xu, C. Yang et al., “Demographic Differences in Sun
about skin cancer risk factors and institute effectual changes Protection Beliefs and Behavior: A Community-Based Study
and interventions that promote sun protection behaviors. in Shanghai, China,” International Journal of Environmental
More research is needed with this population to gain a Research and Public Health, vol. 12, no. 3, pp. 3232–3245, 2015.
better understanding of attitudes and beliefs and how they [13] G. Zhou, L. Zhang, N. Knoll, and R. Schwarzer, “Facilitating
could be adjusted into meaningful skin cancer prevention Sunscreen Use Among Chinese Young Adults: Less-Motivated
practices. Future studies must attempt to develop evidence- Persons Benefit from a Planning Intervention,” International
based theoretical interventions to help individuals to initiate Journal of Behavioral Medicine, vol. 22, no. 4, pp. 443–451, 2015.
and sustain sun protection behaviors in order to decrease [14] M. Wan, R. Hu, Y. Li et al., “Attitudes, Beliefs, and Measures
their future skin cancer risk. Finally, research should take into Taken by Parents to Protect Their Children from the Sun in
consideration behavior change differences between gender, Guangzhou City, China,” Photochemistry and Photobiology, pp.
753–759, 2016.
age, and socioeconomic status with regard to sun protection
behaviors. [15] H. P. Yang, K. Chen, M. Ju, B. Z. Chang, L. Y. Wang, and H. Gu,
“A study of the way in which dermatologists and photosensitive
patients apply sunscreen in China,” Photodermatology, Photoim-
Conflicts of Interest munology & Photomedicine, vol. 25, no. 5, pp. 245–249, 2009.
The authors declare that they have no conflicts of interest. [16] Q. Gao, G. Liu, and Y. Liu, “Knowledge, attitude and practice
regarding solar ultraviolet exposure among medical university
students in Northeast China,” Journal of Photochemistry and
References Photobiology B: Biology, vol. 140, pp. 14–19, 2014.
[1] F. Xiang, R. Lucas, S. Hales, and R. Neale, “Incidence of non- [17] A. Y. M. Leung, M. K. T. Cheung, and I. Chi, “Supplementing
melanoma skin cancer in relation to ambient UV radiation in vitamin D through sunlight: Associating health literacy with
white populations, 1978–2012: empirical relationships,” JAMA sunlight exposure behavior,” Archives of Gerontology and Geri-
Dermatology, vol. 150, no. 10, pp. 1063–1071, 2014. atrics, vol. 60, no. 1, pp. 134–141, 2015.
[2] J. Ferlay, E. Steliarova-Foucher, J. Lortet-Tieulent et al., “Cancer [18] M. Sharma, Theoretical Foundations of Health Education and
incidence and mortality patterns in Europe: estimates for 40 Health Promotion, Jones and Bartlett Learning, Burlington, MA,
countries in 2012,” European Journal of Cancer, vol. 49, no. 6, USA, 2017.
pp. 1374–1403, 2013. [19] M. Sharma, “Trends and prospects in public health education:
[3] A. Lomas, J. Leonardi-Bee, and F. Bath-Hextall, “A systematic A commentary,” [Editorial]. Social Behavior Research & Health,
review of worldwide incidence of nonmelanoma skin cancer,” vol. 1, no. 2, pp. 67–72, 2017.
Dermatology Research and Practice 9

[20] M. Sharma, “Multi-theory model (MTM) for health behavior

change,” WebmedCentral Behaviour, vol. 6, no. 9, Article ID
WMC004982, 2015.
[21] S. W. Cheng, F. Liu, M. Cao et al., “Knowledge and the Use of
about Sunscreen Among Chinese Population in Beijing,” The
Chinese Journal of Dermatovenereology, vol. 22, no. 9, pp. 566–
569, 2008.
[22] D. Z. Fan, S. Liu, T. Yang, J. L. Wand, K. Ye, and F. M. Pan, “The
Investigation and Analysis on the Awareness of Sun Protection
Knowledge and the Use of Sunscreen Among Cadets in Hefe,”
China Medical Abstract of Dermatology, pp. 6–9, 2012.
[23] R. He, “A questionnaire-based study on sun-exposure knowl-
edge and protection behavior in women from North China,”
Ningxia Medical Journal, pp. 12–031, 2012.
[24] M. Zhou, W. Zhuang, Y. Yuan, Z. Li, and Y. Cai, “Investigation
on Vitamin D knowledge, attitude and practice of university
students in Nanjing, China,” Public Health Nutrition, vol. 19, no.
1, pp. 78–82, 2016.
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