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Am J Public Health. 2009 April; 99(4): 734–741.
PMCID: PMC2661486

Acculturation and Sun-Safe Behaviors Among US Latinos: Findings From the 2005 Health Information National Trends Survey

Abstract

Objectives. We examined the relationship between acculturation and sun safety among US Latinos.

Methods. We used linear regression models to analyze data from 496 Latino respondents to the 2005 Health Information National Trends Survey. Using sunscreen, seeking shade, and wearing protective clothing were the primary outcomes and were assessed by frequency scales. Acculturation was assessed with a composite index.

Results. In bivariate models, acculturation was negatively associated with use of shade and protective clothing and positively associated with sunscreen use (all, P < .004). In adjusted models, acculturation was negatively associated with seeking shade and wearing protective clothing across gender and region of residence (all, P < .05).

Conclusions. Our results demonstrated both adverse and beneficial effects of acculturation on Latinos’ risk behaviors relating to skin cancer. Education about sun safety is needed for all Latinos and should be tailored to different levels of acculturation. Initiatives for Latinos who are not yet acculturated could focus on reinforcing existing sun-safe behaviors and presenting new ones, such as use of sunscreen; initiatives for highly acculturated Latinos might require more resources because the objective is behavior modification.

Latinos represent the most rapidly growing segment of the US population and live primarily in areas with high levels of ultraviolet (UV) radiation, such as California and Texas.1 UV radiation exposure, however, might predispose individuals toward melanoma and is clearly implicated in nonmelanoma skin cancer development.24 Although skin pigmentation is protective,5,6 research has linked UV radiation exposure with DNA damage and skin cancer across skin types.5,7,8 The annual age-adjusted melanoma incidence among US Latinos was 3.7 per 100 000 from 1992 to 1996, and from 2001 to 2005 it reached 4.9 per 100 000 (32.4% change).9,10 Melanoma incidence increased 1.8% annually among Latino men in California from 1988 to 2001.11 Latinos experience more advanced tumors with a poorer prognosis than do non-Latino Whites,1113 possibly because they have less awareness about risk factors or symptoms,6,14 are more likely to lack health insurance,15 are not targeted in melanoma-screening efforts,11 and may delay seeking treatment.16,17

Recent research documented that Latinos were at greater risk of sunburn (regarded as a UV radiation overexposure estimate11) than were non-Latino Whites.18 Adult sunburn prevalence (i.e., reporting ≥ 1 sunburn episode during the preceding year) was 35.6% among non-Latino Whites and 45.6% among Latinos. The 2 groups were almost equally likely to report 4 or more sunburn episodes.18 These findings about Latinos might be partially explained by low perceived skin cancer risk that leads to high UV radiation exposure.14,19

Sun safety is important for the primary prevention of skin cancer and can be achieved by preventing UV radiation overexposure through applying sunscreen, avoiding midday sun exposure, and wearing protective clothing.2 The few studies conducted to date on sun-safe behaviors and attitudes among adults in Latin America revealed less perception of suntans as healthful than in the United States20,21 and suggested that sun-safe behaviors were not optimal but might be more prevalent than in the United States.2023 Recent data showed that US Latinos aged 18 to 39 years were about half as likely as non-Latino Whites to report multiple skin cancer risk behaviors.24 However, no racial/ethnic group appeared to meet existing sun safety recommendations.

The growing melanoma incidence among US Latinos could be partially attributable to declines in sun-safe behaviors with increasing acculturation, which has been established as an independent risk factor for several other health practices.2528 Acculturation describes the process of interchange by which immigrants accommodate the language, behaviors, and norms predominant in the host country.29 Among Latinos, greater acculturation has been associated with increased substance use and cancer incidence and deteriorating dietary practices (e.g. decreased fruit and vegetable consumption).3032 Evidence suggests that women experience more unfavorable acculturation effects than do men,25,33,34 because of baseline differences in certain behaviors (e.g., smoking) and gender-based social norms.35,36 Research also indicates that vulnerability to the adverse effects of acculturation decreases with age because distress factors related to mainstream integration might act less powerfully on older adults.28

We investigated the influence of acculturation on Latinos’ sun-safe behaviors, which could affect their skin cancer risk. Because the US cultural norm favors sunscreen use more than the cultural norm among Latinos,22,37 we expected that sunscreen use would increase among Latinos as acculturation increased. Also, because the US cultural norm is more accepting of suntans21 than is the Latin America cultural norm,20 we expected that acculturation would be negatively associated with use of shade or protective clothing. Consistent with the literature,25,38,39 we hypothesized that the observed effects would be stronger among women than men and among younger than older Latinos. We also hypothesized that the observed effects would be more pronounced in areas with higher versus lower UV radiation levels. Finally, drawing on findings among non-Latino Whites,40 we hypothesized that the role of acculturation in sun safety would be greater among those of higher socioeconomic status (SES). We used Bandura's social cognitive theory,41 which has been applied in previous sun safety research4244 and which accommodates the influence of the sociocultural environment on health behaviors.

METHODS

We analyzed cross-sectional data from the 2005 Health Information National Trends Survey (HINTS). Data were gathered between February and August 2005 via geographic stratification and list-assisted random-digit dialing from a probability-based sample of the US civilian, noninstitutionalized population. One adult (aged ≥ 18 years) was selected at random within each household and was given the option of responding in English or Spanish. Among the 5586 individuals who completed the full interview, 496 answered affirmatively to the question, “Are you Hispanic or Latino?” and thus were eligible for our study. Details on the survey's concept, testing, and implementation have been published elsewhere.45,46 The questionnaire is available at http://hints.cancer.gov/instrument.jsp.

Measures

Sun safety.

We assessed sun safety through 5 primary prevention behaviors, each with a 5-point frequency scale (1 = always, 5 = never). Respondents were told that the questions pertained to sun-protection practices and were asked how often they used sunscreen; wore hats that shaded the face, neck, and ears; wore long-sleeved shirts and long pants; and sought shade when outside for 1 hour or more on a warm, sunny day. These items are comparable to the standardized set of survey measures of sun-protection habits and are considered applicable across different populations.47 Each item was reverse coded so that a higher score reflected a greater endorsement of the behavior. Preliminary psychometric evidence did not converge toward clustering of these behaviors, because each pairwise correlation was low (all, r < 0.37), the Cronbach internal reliability score was low (α < 0.44), and the items did not form a single sun safety factor in exploratory factor analyses. Each item was therefore treated as a separate outcome variable, consistent with our hypotheses.

Acculturation.

Five items were available for the assessment of the primary predictor. Three items applied to all respondents: nativity (US or foreign born), interview language (English or Spanish), and a 6-level item for perceived comfort with the English language (1 = completely comfortable, 6 = do not speak English). Two continuous measures applied only to foreign-born respondents: age at arrival to the United States (calculated by subtracting the year of birth from the year of arrival) and duration of US residence (calculated by subtracting the year of arrival from the year of data collection, 2005). As in previous acculturation research,48 each item was standardized (mean = 0; SD = 1) and the Cronbach reliability score was calculated (α = 0.75). The acculturation index was obtained by computing the mean of all items that loaded on a single factor in exploratory factor analyses.

Moderators and covariates.

Moderators included gender, age, SES (i.e., education level measured on a continuous scale), and census region of residence. We divided regions into areas with high (South, West) and low (Midwest, Northeast) UV radiation, relying on the methods of Saraiya et al.49 and evidence that latitude and mean annual UV radiation index were strongly correlated.9 Nonetheless, these categories represented a crude proxy for UV radiation exposure. Covariates included recoded dichotomous measures of marital status (married or living with partner versus other), employment (employed or self-employed versus other), availability of health care coverage (yes or no), cancer history (yes or no), and a scale for current health status (1 = excellent, 5 = poor). All “refused” and “don't know/other” responses were coded as missing.

Statistical Analyses

We started with descriptive univariate and bivariate analyses, including a stratified 2 × 2 χ2 test to assess the distinctiveness of the sun-safe behaviors. Because each sun-safe behavior was a 5-level dependent variable and because of the fairly large sample size (which arguably justified the use of parametric tests despite some nonnormality of the underlying distributions), we performed multiple linear regression analyses. In the adjusted models, we included only variables with statistical significance in the preliminary analyses to minimize type 1 errors (which become more likely as the number of tests increases) and to investigate only targeted hypotheses.50

The differential effect of acculturation on sun safety attributable to gender, age, SES, and region was assessed with tests for interaction. Because our primary interest was in establishing associations and not in making predictions or obtaining population estimates, we considered the magnitude and significance of the regression slopes (i.e., the unstandardized parameter estimates), without including sampling weights (especially because only a small subset of the 2005 HINTS data was used). The level of significance for all tests was set at α = .05. All statistical procedures were performed with SAS version 9.1 (SAS Institute Inc, Cary, NC).

RESULTS

The mean age in the sample was 41.3 years (SD = 15.5; range = 18–95 years), and there were more women (61.5%) than men (Table 1). Approximately one third (35.7%) of the participants were US born and slightly more than half (54.6%) were interviewed in Spanish. Exploratory factor analyses showed that the acculturation items clustered into 1 factor (eigenvalue = 2.31). Factor loadings for all items except nativity ranged between 0.72 and 0.80. The nativity item did not load onto the factor and was dropped from further modeling. The exploratory factor analyses supported the inclusion of level of comfort with English, interview language, age at arrival to the United States, and duration of US residence in the acculturation index, which had a mean of 0.15 (SD = 0.83; range = −1.82 to 2.29). The index had relatively high reliability (Cronbach α = 0.75).

TABLE 1
Demographic and Acculturation Characteristics of Latino Respondents (N = 496): Health Information National Trends Survey, 2005

Sun Safety Prevalence and Associations With Demographic Variables

Wearing long pants and seeking shade had the highest “always” endorsement (approximately 43% and 26%, respectively; Table 2). Using sunscreen and hats had the highest “never” response rate (approximately 39% and 33%, respectively). Data from the full 2005 HINTS sample showed that among racial/ethnic groups, Latinos reported wearing long-sleeved shirts and long pants most frequently.51

TABLE 2
Prevalence of Sun-Safe Behaviors Among Latino Respondents (N = 496): Health Information National Trends Survey, 2005

Bivariate regression analyses revealed significant differences by gender: women were more likely to report using sunscreen and shade (for both reports, P < .001), and men were more likely to report wearing the various types of protective clothing (all, P < .02). We also observed a significant positive association between age and wearing protective clothing (P < .05). Respondents from the South and West regions were more likely than were those from other regions to report using sunscreen and protective clothing (P < .05). Perceived health status was negatively associated with sunscreen use and positively associated with wearing long pants (both, P < .05).

Education level was positively associated with sunscreen use (P < .001) but negatively associated with seeking shade or with wearing protective shirts or pants (all, P < .03). Participants with health care coverage were less likely to report wearing long-sleeved shirts (P = .05) or long pants (P < .001) but were more likely to report using sunscreen (P < .02). We found no statistically significant differences in sun safety by marital status, employment status, or personal cancer history. Finally, participants who were more acculturated were more likely to be older, to have more formal education, and to have health care coverage than were their less acculturated counterparts (all, P < .02). Because of the statistically significant correlation between education and availability of health care coverage and for reasons of parsimony, only education was retained as an SES indicator for further modeling.

Associations Between Acculturation and Sun-Safe Behaviors

We performed several stratified 2 × 2 χ2 tests to assess whether sun safety varied by acculturation when holding 1 of the sun-safe behaviors constant. For these supplementary analyses only, we dichotomized acculturation into high or low (split by the mean) and each sun-safe behavior into always or other. For example, we tested whether sun safety varied by acculturation among all participants who reported always seeking shade (n = 128) and did not find any statistically significant associations (all, P > .06). Among participants who reported always wearing long pants when outdoors in the sun (n = 213), the other sun-safe behaviors did not vary by acculturation (all, P > .08). Thus, we confirmed the distinctiveness of the sun-safe behaviors explored in the study.

As shown in Table 3, each bivariate relationship was in the hypothesized direction. Participants with greater acculturation were more likely to report using sunscreen (P < .01) but less likely to report seeking shade (P < .002) or wearing long-sleeved shirts (P < .001) or long pants (P < .001) when in the sun than were less acculturated participants. The association between acculturation and wearing hats was not statistically significant (P > .9) and was not explored further. Following these analyses, we tested multiple linear regression models; the results are summarized in Table 4. All models were adjusted for gender, age, SES, health status, and region. We found no statistically significant interaction between acculturation and either gender or region regarding sun safety (results not shown). However, among individuals with higher SES only, greater acculturation was associated with less use of long pants when outdoors in the sun (P < .001). Among younger participants only, more acculturation was associated with more sunscreen use (P < .001) and less use of long-sleeved shirts (P < .001; results not shown).

TABLE 3
Bivariate Linear Regression Models of Acculturation and Sun-Safe Behaviors Among US Latinos (N = 496): Health Information National Trends Survey, 2005
TABLE 4
Multivariable Linear Regression Models of Sun-Safe Behaviors Among US Latinos (N = 496): Health Information National Trends Survey, 2005

As we hypothesized, acculturation was strongly and negatively associated with wearing long pants when outside on sunny days (F = 12.53; P < .001). Significant associations were also found for seeking shade and wearing long-sleeved shirts (F = 5.58 and F = 7.31, respectively; both P < .001), with greater acculturation associated with lower prevalence of these behaviors. The positive association between acculturation and sunscreen use was attenuated after we included covariates (P > .48). In the results for our final, fully adjusted models, we noted that acculturation accounted for sun safety variance above and beyond the demographic variables.

Because of the lack of consensus about the assessment of acculturation32,52 and to increase our confidence in the findings, we reestimated the adjusted models with the English-comfort variable used as a proxy for acculturation. The results regarding use of sunscreen, long-sleeved shirts, and long pants were almost identical across the 2 acculturation measures. The findings regarding seeking shade were similar, although the statistical significance of the link between level of comfort with English and seeking shade was attenuated (results not shown).

DISCUSSION

In our sample, 15% of the participants reported always using sunscreen, in contrast to Latino postal workers (23%)22 and Latino farmworkers (1.5%).53 The postal workers study, however, assessed sun safety during the previous 5 workdays; in the farmworkers study, sun safety was assessed when participants were in the sun for more than 15 minutes. Thus, variability in findings about sunscreen use might be attributable to differences in measures and to the demographic characteristics of the samples, especially occupation. Among the farmworkers, for example, 83% reported always or often wearing long-sleeved shirts,53 but only 24% of our respondents reported this sun-safe behavior. Approximately one third of all US adults reported using sunscreen, shade, or protective clothing when outdoors in the sun.54

Although most of our findings tend to confirm the adverse effect of acculturation on health practices3032 and are consistent with the Hispanic paradox,55 a beneficial effect of acculturation on Latinos’ sun safety was also observed in some of our unadjusted models. In particular, we noted that Latinos who were more acculturated reported increased sunscreen use than did their less acculturated counterparts. To our knowledge, our study was the first to document that acculturation influences Latinos’ skin cancer risk–related behaviors. As hypothesized, in adjusted models, acculturation was negatively associated with seeking shade or wearing protective clothing when outdoors on sunny days. Because dress customs are generally incorporated faster with increasing acculturation than are less tangible qualities such as values and norms,56 acculturation might increase acceptance of US clothing and sun-exposure practices while exerting a weaker effect on sunscreen use. We found that less acculturated Latinos were more likely to behave in ways that were believed to reduce the risk of skin cancer than were their more acculturated counterparts, who were more similar to non-Latino Whites.

We found no evidence of gender-specific acculturation effects in sun safety, possibly because these behaviors are not shaped by strong social norms. However, the statistically significant effects of age and SES as moderators are consistent with existing knowledge. Education level has been shown to affect sun-safe behaviors among non-Latino Whites, possibly because of increased awareness about skin cancer risk factors and symptoms40,57 and changes in leisure-time behavior patterns.58,59 Research with diverse populations has revealed that sun safety is positively associated with age,39 conceivably because of decreased importance of sensual and sociocultural factors.60,61 Finally, because we wanted to investigate only targeted hypotheses, we did not test wearing hats as an outcome variable in the final models after preliminary analyses showed no significant association between acculturation and this behavior.

Our acculturation index included items that are considered proxies of acculturation and are often employed in acculturation research.26,6264 Use of an index instead of a dichotomous measure is consistent with modern concepts of acculturation as a process and not a dichotomy.

Limitations

We used data from roughly 9% of the 2005 HINTS sample, which was composed predominantly (> 73%) of non-Latino Whites. To improve the representativeness of Latinos according to national estimates,1 the 2007 HINTS (data collected in 2008) will oversample Latinos. For our study, representativeness concerns were somewhat mitigated because many of the demographic characteristics of our sample paralleled those in nationally representative health behavior research. For example, weighted prevalence estimates from the 2000 National Health Interview Survey (n = 4558 Latino adults) showed that 45% of the participants had less than a high school education (versus 42% in our study) and 38% were US born (versus 36% in our study).64 In addition, current census information reveals that 33% of Latinos do not have health insurance,15 which corresponds to our prevalence estimate.

Some selection bias related to sampling Latinos by landline telephones, social desirability effects, and nonresponse might have occurred. As in other telephone surveys, the HINTS response rate was low.45,65 Estimates suggest that in January 2004 to June 2005, 7.2% of Latino households had only wireless telephones and 3.2% had no telephone service.66 Research indicates that individuals without landline telephones may be more likely to be uninsured and that substitution of wireless telephones for landlines is more prevalent among persons younger than 24 years and those living in poverty.66 Thus, our findings might be more generalizable to Latinos who are relatively more acculturated, have been in the country longer, and have greater resources. A selection bias in the direction of noncoverage of the least acculturated Latinos might have occurred, and the results might underestimate true effects. Finally, psychometric and nonresponse analyses for HINTS are not currently available.65

Several limitations pertain specifically to our acculturation measure. First, acculturation implies a linear time sequence despite the use of cross-sectional data, which also prevented the establishment of causality. Second, HINTS data allowed for the assessment of acculturation on a unidirectional scale, but a bidirectional measure—with Latino and US orientations as separate scores—would have been the measure of choice. Third, in computing the acculturation index, we used the mean of all available variables for all available participants. In exploratory factor analyses, dichotomous variables do not perform as well as did multiple-category or continuous variables, and this might explain why nativity did not load onto the acculturation factor.

For foreign-born participants, the mean acculturation score included interview language, level of comfort with English, duration of US residence, and age at arrival to the United States; for their US-born counterparts, the corresponding score included language of interview and level of comfort with English. Language items, however, generally explain most of the variance in acculturation scales.67,68 Nonetheless, caution should be used when interpreting the acculturation measure, which differed slightly between immigrant and US-born respondents. Our study could serve as a starting point for research into acculturation and sun safety, and future studies should replicate our models with other acculturation measures.

Another data limitation was an inability to distinguish among Latino subgroups. Yet, out of various risk factors explored among Latinos (e.g., risky sun exposure, smoking, drinking, poor diet, insufficient exercise), sun safety has shown the least variation across countries of origin.69 This might be attributable to Latinos having less awareness of sun safety than of other health practices. Further, research has suggested that skin color may be a confounding factor (which could not be assessed with HINTS data) in acculturation, such that it might affect an individual's motivation or ability to acculturate because of perceived socioeconomic discrimination against dark-skinned people.70,71 However, this does not indicate that acculturation causes people to discontinue engaging in sun safety.

Finally, research has documented a negative association between acculturation and occupational physical activity: access to nonmanual labor opportunities improves with acculturation.72 Because HINTS did not include occupation data, we considered modeling income, but the continuous measure of combined household annual income had 185 (37%) missing responses. Evidence from the National Health Interview Survey 2000 that income and education were strongly associated among Latinos64 reassured us that our findings were not seriously compromised by the exclusion of income. Nonetheless, we acknowledge this as a limitation and suggest it for future research.

Future Directions

Sun safety education initiatives often produce only modest behavioral effects among non-Latino Whites,60,73,74 and it might be even harder to reach Latinos because of their lower levels of awareness about risk factors or symptoms. Our findings suggest that such efforts should target acculturation, age, and SES factors. Factors associated with low levels of acculturation (e.g., being monolingual, lack of health care coverage, familism, manual occupations) should be taken into consideration.72,7577 Sun safety messages for less acculturated Latinos could use informal, Spanish-language strategies, such as posting leaflets in bus stations, churches, and community centers advocating the use of shading structures and sunscreen. Such messages could also emphasize the importance of having a healthy family and could be incorporated in interactive activities at Latino cultural events. Our findings also echo recommendations for protection for outdoor workers (e.g., sun safety posters, supervisor training),78 because many Latinos who work outdoors are less acculturated.53

Education efforts with less acculturated Latinos could be resource efficient because the aim would be to reinforce existing sun-safe behaviors. By contrast, education efforts with highly acculturated Latinos might require more resources because of the need for behavior modification. Messages emphasizing modification of individual risk behavior could be in English and could be delivered in health clinics and through the media, similarly to initiatives targeted at the general US population.

Our results reinforce the importance of existing services and policy recommendations (e.g., authorizing periodic health surveillance for early identification of skin cancer and providing shading structures and sunscreen dispensers at outdoor worksites).78 Future research could augment our findings by analyzing longitudinal data sets. Despite data limitations, however, we demonstrated that acculturation has a largely adverse effect on Latinos’ skin cancer risk–related behaviors. Appropriate interventions with this population could improve engagement in sun safety as well as knowledge about skin cancer signs and symptoms and could result in decreased rates of advanced melanoma.

Acknowledgments

M. G. Cockburn was supported in part by the Centers for Disease Control and Prevention (grant U55/CCU921930-02), the National Institute of Environmental Health Sciences (grant 5P30 ES07048), and the National Cancer Institute (grant R01CA121052). L. Baezconde-Garbanati was supported by the Southern California Cancer Information Services Partnership Program of the National Cancer Institute (grant 2P30 CA014089) and the National Institute of Environmental Health Services (grant ES07048), Patient Education and Community Outreach Center, Norris Comprehensive Cancer Center, Department of Preventive Medicine, University of Southern California, Los Angeles. K. D. Reynolds was supported by the National Cancer Institute (grant CA100285).

The authors are grateful to the reviewers of the article for their insightful comments and suggestions. They also acknowledge the assistance of Richard P. Moser and Lila J. Finney Rutten of the National Cancer Institute.

Human Participant Protection

Institutional review board approval was not required for this study.

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