Consistent with prior research, the results of the current study indicate that many Hispanic adults fail to engage in one or more sun protection behaviors [16, 27]. Participants reported more routinely (i.e., most of the time or always) staying in the shade (53.7%) in comparison with sunscreen use (32.3%) and using sun protective clothing (18.1%). A similar pattern has been observed among non-Hispanic white adults in the United States . More than one third of the participants indicated that they never use sunscreen and 43% reported having one or more sunburns in the past year. Results of the univariable analyses indicated that greater acculturation among U.S. Hispanics is linked with both risky (i.e., not wearing sun protective clothing) and protective sun-related practices (i.e., using sunscreen). While there is some epidemiological research linking such behavioral practices with the risk for melanoma, there is more consistent evidence regarding the role that sunburns play as a risk factor for melanoma . We found that around half of the more acculturated Hispanics reported having a sunburn in the past year, which is considerably higher than the approximately one in three rate among less acculturated individuals. While sunscreen use is commonly endorsed by the public and also depicted in the media [30, 31], other sun protection behaviors such as staying out of the sun and using sun protective clothing may be more effective in reducing sunburns and the risk for melanoma [28, 29, 32]. These non-sunscreen behaviors should be strongly emphasized by healthcare providers and in public health initiatives to prevent skin cancer, particularly when targeting more acculturated, English-speaking Hispanics.
The current study provides novel insight on differences in sun protection and exposure behaviors among Hispanics of varying origin. For example, individuals of Mexican origin reported comparably high rates of using sun protective clothing, yet they were more likely to report having a sunburn than Hispanics with origins from several other regions. Participants from Puerto Rico also reported comparatively high rates of having a sunburn. Future research is needed to explore additional sun exposure factors among Hispanics of varying origins, such as the amount of time spent outside during peak hours for UV exposure, which was not assessed in the 2010 NHIS. The fact that sun protection and exposure behaviors differ among Hispanics of varying origins highlights the importance of designing and implementing culturally relevant, tailored skin cancer prevention interventions for Hispanics that take into account heterogeneity among individuals and across population subgroups.
The associations identified in the univariable analyses between the acculturation factors and the sun protection and exposure behaviors were not all retained in the multivariable analyses. This suggests that acculturation may be linked with these behaviors in part due to associations with other sociodemographic, skin sensitivity, or occupational sun exposure factors. Indeed, a number of these factors were significantly associated with Hispanics’ sun protection and exposure behaviors. Consistent with results in the general U.S. population [33, 34], as well as a prior study among Hispanic adults , Hispanic men reported being less likely to use sunscreen or stay in the shade, but greater use of sun protective clothing than women. However, the sunburn rate did not differ between men and women. Efforts to reduce the sunburn rate among Hispanics may benefit from focusing on different behaviors across gender, such as promoting shade seeking among men and use of protective clothing among women. There were also considerable differences in sun protection and exposure behaviors across age groups. Although individuals aged 65 years and older reported less use of sunscreen than younger adults, they were more likely to seek shade and had a lower sunburn rate. The greater use of sunscreen reported by more educated Hispanics may in part reflect more knowledge about skin cancer prevention [35, 36], although future empirical research is warranted in that regard. Hispanics with the most sun sensitive skin were more likely to engage in sun protection behaviors than other individuals, but still reported a considerably higher rate of having a sunburn. These findings are consistent with results among the general U.S. population  and strongly suggest that individuals with the most sun sensitive skin should be targeted for skin cancer prevention efforts, regardless of their ethnicity. Although Hispanics at high risk for occupational sun exposure were less likely to seek shade, it is encouraging that they reported greater use of sun protective clothing and had a similar sunburn rate to that of individuals at lower risk for occupational sun exposure. Further research is needed to document and promote sun protection behaviors among Hispanics engaged in occupations that place them at increased risk for sun exposure.
There are several limitations to the current research. Acculturation was assessed using two proxy measures. Although this reflects a practical approach that can be utilized in clinical and public health settings, future research should consider more direct measures of acculturative changes (e.g., bidimensional assessment of attitudes, beliefs, and behaviors with regard to U.S. and Hispanic cultures) . The number of study participants of certain Hispanic origins (e.g., Dominican Republic, Cuba) was relatively low, which although consistent with the U.S. Hispanic population, did not allow us to include them in a separate category (Dominican Republic) or produced wider confidence intervals for the respective associations with the sun protection and exposure behaviors (Cuba). The measures of family history of skin cancer and skin sensitivity to the sun were self-reported, which raises the potential of reporting and other biases. The measure of occupational sun exposure was based on the industry of employment. Future research should consider the type of work performed and the extent to which Hispanics engage in sun protection behaviors during occupational sun exposure.