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College Students’ Attitudes and Behaviors Related to Sun Safety and Appearance in Relation to Health Information-Seeking Behavior and Social Media Use: Cross-Sectional Study

Background: Skin cancer is the most common type of cancer in the United States. Rates of melanoma, a malignant form of skin cancer, are on the rise and are high among people under 30 years of age. Objective: This study aims to explore factors related to sun protection and tanning behavior and examine the influence of social media use and health information-seeking behaviors (HISB) on sun protection actions among a group of college students. Methods: In this cross-sectional study, students (N=258) at a large public university completed a survey that included questions on sun safety and tanning attitudes and behaviors, as well as HISB. A sun protection behavior score was created on the basis of behaviors related to seeking shade, using sunscreen, tanning booth and bed use, and the number of lifetime blistering sunburns. Multivariate logistic regression analyses were performed to assess associations between high and low sun protection behavior and sun safety and tanning attitudes and HISB. Results: The majority of participants were females (164/258, 63.8%), 31.0% (80/258) were white, and the mean age was 20.3 (SD 4.1) years. Females (odds ratio [OR] 0.42, 95% CI 0.22-0.81) and believers that suntan improves appearance (OR 0.25, 95% CI 0.10-0.66) were less likely to have “high” sun protection behaviors. Conclusions: The cultural belief that having a suntan improves appearance, especially among female college students, results in low sun protection behaviors. Interventions can be developed to improve skin cancer-related HISB among college students with the aim of developing better cognizance of skin cancer and sun protection behaviors.


Introduction
Skin cancer is the most common type of cancer in the United States [1]. Rates of melanoma, a malignant form of skin cancer, have risen over the years [1,2]. The American Cancer Society estimates there will be 99,550 new cases of skin cancer in 2018, excluding basal and squamous types (as there is no requirement to report these to cancer registries), of which, 91,270 (92%) are melanoma [3]. In addition, a recent study suggested that the number of individuals diagnosed with melanoma will nearly double in 2026-2031 [4]. Melanoma is among the most common cancers in people under 30 years of age [4]. Ultraviolet exposure is a well-known risk factor for the development of melanoma [5]. College students tend to have high levels of sun exposure, low levels of concern for sun protection, and a strong desire to suntan [6][7][8][9][10].
Behaviors can be influenced by a number of factors, one of which is social media. The use of digital platforms, particularly social media, is at an all-time high [11]. The emergence of social media has allowed individuals opportunities in networking, navigation, and real-time connection [11,12]. College-aged individuals, who are part of a technologically adapted generation, frequently use social media, with 88% of those aged 18-29 years reporting that they are using social media [13]. College-aged individuals (age: 18-24 years) are markedly more likely to use Twitter, Snapchat, and Instagram, highly popular social media platforms [13]; of individuals in this age bracket, 51% reported that social media would be difficult for them to give up [13]. These young consumers are regularly productive through social media (eg, messaging, searching, sharing, and discussing various topics) [12]. As individuals continue to embrace social media, public health professionals should be aware of the potential health implications in nature of the information and messages that are accessed or shared.
One study specifically examined social media use and indoor tanning behavior and determined that social media is a medium that could increase peer pressure to partake in indoor tanning [14]. College-aged individuals, particularly women, are among individuals that frequently tan [15,16] and use social media [13]. As social media is so widespread, there are potential risks in spreading messages that could endanger health. As active information and image sharing on these platforms may be encouraging indoor tanning [14], a concern should be raised as indoor tanning is a major risk factor for skin cancer [17].
With the use of social media on the rise, there is a heightened sensitivity to self-image and physical appearance among younger age groups [18][19][20]. Many of these individuals associate tanned skin to attractiveness. Recent studies indicated that appearance dissatisfaction and tanning intentions strongly associated with social media use [18,21]. Current literature regarding social media [18,22] is consistent with research on traditional media in that images are often pro-tan and lack focus on skin cancer prevention [23][24][25][26][27].
As social media is reportedly used to promote tanning activity [28], it can also be used to promote health and can be highly effective as a medium for disseminating information in this population and promoting prevention efforts [29,30]. There remains a gap in the literature in terms of health information-seeking behaviors (HISB) of college students when it comes to skin cancer. Therefore, this study aims to explore factors related to sun protection and tanning behavior and examine the influence of health information seeking on sun protection behaviors among a group of college students.

Methods
This cross-sectional study, conducted in March-May of 2018, was ancillary to a larger study that focused on HISB of college students in general [31]. Instructors of 9 sections of a personal health course at a large public university in New Jersey distributed surveys to all students who were present (n=329) in class and voluntarily participated (n=258). The response rate was 78.4%. Of note, the course is part of the University Core Curriculum in which all students must take a personal health course, and this course is one of the offerings. Survey questions were adapted from the Health Information National Trends Survey questionnaire, and from our prior study on sun safety [6]. The survey questions pertinent to this study are described below.
Sun safety and tanning behaviors were captured in 5 questions. Sun safety behaviors were measured in 2 questions aimed at the likelihood that respondents would (1) seek shade; and (2) use sunblock on a sunny day. In addition, tanning behaviors were captured in 2 questions that encompassed the likelihood that respondents would go indoor tanning and specifically how many times they have used a tanning booth and bed in the past 12 months. The overall exposure was measured by asking how many blistering sunburns respondents experienced in their lives.
When looking at reasons for tanning and sun protection, we queried students regarding their perceived satisfaction in appearance and whether they believed that having a tan improves appearance. Moreover, we included questions concerning self-esteem and stress to further investigate the influence of social factors and individual thoughts and beliefs about the tanned skin. Appearance-based questions included the following: Have you ever been dissatisfied with your appearance? Are you currently satisfied with your physical appearance?Do you think having a suntan improves your appearance?Do you think having a suntan improves your self-esteem?Do you think sun-tanning or sunbathing is a way to relieve stress?
Respondents were asked questions related to HISB, specifically how many hours per day they were engaged on social media. Furthermore, questions were posed to assess respondents' attitudes toward the accuracy of information on social media, in general, and beliefs related to the helpfulness of social media as resources for health issues.
Descriptive analyses included frequency distributions, mean, median, and range. To construct the outcome variable, "sun protection behaviors," the following variables were recoded and summed: seek shade on sunny days ("likely" or "very likely"), use sunscreen on sunny days ("likely" or "very likely"), use a tanning booth and bed ("very unlikely" or "unlikely"), zero times using a tanning booth and bed in the past 12 months, and zero blistering sunburns in one's lifetime. The potential range of the 5 variables was 0-5; mean and median scores were 3.1 (SD 1.0) and 3.0, respectively. The sun protection behavior score was dichotomized with values of 0-3 coded as "low" sun protection behaviors and values of 4-5 as "high" sun protection behaviors. The race was recoded as black or African American individuals versus all other races and college year as "freshmen" versus "upper classmen." Variables coded on a 5-point Likert scale "very inaccurate" through "very accurate" were collapsed and recorded as "inaccurate" versus "accurate" and "strongly disagree" through "strongly agree" as "disagree" versus "agree." Univariate analyses were performed to test the association between sun protection behaviors (low vs high) using the chi-square test for categorical variables and the analysis of variance for continuous variables.
The unadjusted logistic regression was conducted for all variables with P<.05 in the univariate analysis followed by the backward, stepwise multivariable regression. Because the number of variables in each family examined (eg, demographics, attitudes toward tanning and sun protection, use of internet, social media, and attitudes toward internet, social media) were relatively few and a single comparison (low vs high sun protection behaviors) was conducted, Bonferroni correction for multiple analyses was not judged to be necessary. All analyses were conducted using IBM SPSS version 25. In addition, P<.05 was considered statistically significant. This study was approved by the Institutional Review Board at William Paterson University. Table 1 outlines the demographic characteristics, sun protection attitudes and behaviors, and health information-seeking beliefs and attitudes. Of 258 respondents, 63.8% (164/258) were females. The race was fairly equally distributed with 25.2% (65/258) black or African American, 28.3% (73/258) Hispanic, and 31.0% (80/258) white individuals. The mean age of a respondent was 20.3 (SD 4.1) years, and most were freshmen (156/258, 60.5%). Slightly more than half of the respondents declared a health-related major (135/258, 52.3%). No respondents reporting personally having had skin cancer, and few had a friend or family member with skin cancer (36/258, 14.0%). Approximately one-third of respondents reported they were "likely" to seek shade (93/258, 36.1%) and use sunscreen on a sunny day (71/258, 27.5%). The majority (225/258, 87.2%) were "very unlikely" or "unlikely" to use a tanning booth and bed, with 92.2% (238/258) stating they have not used a tanning booth and bed in the past 12 months. Nearly two-thirds were dissatisfied with their appearance at some time in the past, but 57.4% (148/258) were currently satisfied with their appearance. One-third believed that tanning improved their appearance (87/258, 33.7%), whereas roughly one-quarter believed it improved their self-esteem (66/258, 25.6%) or felt that sun tanning was a way to relieve stress (60/258, 23.3%). The use of social media was limited to about 4.5 hours per day with many (125/258, 48.4%) believing that social media is accurate to some degree and a helpful resource for health information (108/258, 41.9%). Table 1. Demographic characteristics, sun protection attitudes and behaviors, and health information-seeking beliefs and attitudes among college students.  Table 2 presents a comparison of demographic characteristics, sun protection attitudes, and health information-seeking attitudes and behaviors by the level of sun protection behavior. Those who reported "low" sun protection behaviors (153/241, 63%) more often stated that tanning improves one's appearance (43.1% vs 17.8%, P<.001), that tanning improves their self-esteem (31.4% vs 15.7%, P=.01), and that sun tanning relieves stress (29.1% vs 12.6%, P=.004) compared with those with "high" sun protection behaviors. In addition, individuals with "low" sun protection behaviors more often believed that social media was an accurate source of health information (10.5% vs 3.3%, P=.046) and a helpful resource for health information (62.5% vs 46.7%, P=.02) compared with those with a "high" sun protection behavior score. More often females (76.7% vs 57.2%, P=.01) and those who were in a health-related major (60.7% vs 47.7%, P=.05) had a "high" sun protection behavior score. .05 Health-related major concern, n (%)  In the unadjusted logistic regression (Table 3), females (odds ratio, OR, 0.41, 95% CI 0.23-0.74) and individuals who believed a suntan improves appearance (OR 0.28, 95% CI 0.015-0.53), suntan improves self-esteem (OR 0.41, 95% CI 0.21-0.79), sun tanning relieves stress (OR 0.35, 95% CI 0.17-0.73), and that social media is a helpful resource for health information were all less likely to have "high" sun protection behaviors. After including all variables in the multivariate model, females (OR 0.42, 95% CI 0.22-0.81) and believers that suntan improves appearance (OR 0.25, 95% CI 0.10-0.66) remained less likely to have "high" sun protection behaviors.

Discussion
This study revealed that white female respondents were less likely to have a high sun protection behavior; this is consistent with the literature [16] and remains troubling, as this is a high-risk group for the development of melanoma [3]. In addition, this study corroborates previous research reporting that college students tan for psychosocial reasons, namely appearance [9,32]. In addition, this study revealed that those who were dissatisfied with their appearance were markedly more likely to believe that suntan improves self-esteem. Interestingly, those who spent more time on the internet were more likely to be dissatisfied with their appearance.
Research indicates that knowledge does not necessarily result in the adoption of healthy behaviors [9]. Reportedly, college students who understand the dangers of tanning and sun exposure, but also feel having a tan is important, often still desire to tan and forego means of sun protection [9,32]. Students in this study reported that they, by and large, felt that information related to health on the internet was accurate. Our ancillary study on HISB delves deeper into how these respondents use the internet to seek health information [31]. A tenet of HISB is that as an individual utilizes technology and understands more about how to use it, the person is more likely to use that specific technology as a source to search and gather health-related information [33,34]. Future studies can focus on interventions to ascertain the rate at which college students follow best practices in skin cancer-related HISBs.
Although social media is linked to risky behaviors, this source can incite opportunities for interventions promoting behavioral changes. Key issues can be communicated through popular social media platforms, such as Instagram, Twitter, and Facebook. To effectively address issues related to using Web-based methods, the target population must also understand the purpose of interventions. On the topic of skin cancer, interventions should inform college students regarding the influence of social media on knowledge and attitudes, and how this may lead to the adoption of risky health behaviors. Much like electronic health literacy, media literacy should be carefully utilized to increase the understanding of skin cancer; however, it must be strategic, as audience members may respond differently to an array of communication platforms. For instance, research confirms that young women, in particular, are visually oriented social media users, thus using images with prevention messages may be more effective [18,30]. By improving the methods of Web-based skin cancer prevention, college students may be motivated to appropriately and efficiently engage in HISB and, in turn, adopt healthier behaviors in the long term.
This study has several limitations that warrant mention. First, the cross-sectional design creates the inability to generalize these results. Second, the data were based on self-report and, thus, subject to recall bias. Third, the timing of the survey could influence thoughts and ideas related to sun safety. Despite these limitations, this study contributes to the literature on an important topic.
In sum, sharing content on social media is common. Personal stories of this nature can spark public engagement and result in Web-based search related to skin cancer and prevention [29]. By incorporating personal stories and graphic images with skin cancer prevention messages, this may improve message recall. The degree to which this incites a behavioral change warrants further study. Given that knowledge alone may not necessarily influence behaviors, effective interventions focused on skin cancer prevention and sun protection behaviors must be multifaceted. Furthermore, future research may be able to present critical data on seeking information about health topics (skin cancer, particularly) in social media, an underrecognized area of study.