Sun Protective Behavior among Filipino Medical Interns in a Tertiary Hospital

using Readiness to Alter Sun-Protective Behaviour Questionnaire (RASP-B), a

Pilot Study
Camelia Faye R. Tuazon, MD, Benedicto Carpio, MD, Eileen Regalado-Morales, MD, Armelia Torres, MD
Ospital ng Maynila Medical Center, Department of Dermatology, Quirino Ave., Manila, Philippines

Background
The incidence of UV associated skin disease specifically skin aging and skin cancer
have increased in years not just among Caucasians but also in Asians. Numerous
campaigns have been started to promote sun protection, however, long-term changes in
behavior and compliance with sun protection measure were not satisfactorily achieved.
The aim of this study is to know the current sun protective behavior of medical interns
using Readiness to Alter Sun Protective Behavior (RASP-B) and to change their
behaviors based from their assigned stage of change according to transtheoretical
model behavior of change. Methods: A sample of 122 medical interns from a tertiary
hospital, were recruited and completed the RASP-B questionnaire (12-item
questionnaire about their attitudes toward sun protection). Results: Responses
obtained from the 12 RASP-B items were converted into stage scores. Highest
percentage was on the precontemplation stage followed by action and contemplation
stage respectively. Participants in the action stage reported higher levels of sun-
protective behavior in comparison with precontemplation and contemplation stages.
Conclusion: The RASP-B can be self-administered and can be used to determine the
behavior of an individual towards sun protection. This tool can be utilized in health care
settings to promote education.

Introduction

According to WHO, the incidence of both non-melanoma and melanoma skin cancers
has been increasing over the past decades. Currently, between 2 and 3 million non-
melanoma skin cancers and 132,000 melanoma skin cancers occur globally each year.
In the Philippines, annual mortality rate per 100,000 were affected by malignant skin
melanoma since 1990, an average of 4.2% a year. Both men and women were affected
at age 80 and up. In 2013, the peak mortality rate for women was higher than that of
men which was 5.6 per 100,000 men.
As ozone levels are depleted, the atmosphere loses more of its protective filter function
and more solar UV radiation reaches the Earth’s surface. The global incidence of
melanoma continues to increase, however, the main factors that predispose to the
development of melanoma seem to be connected with exposure to the sun and a
history of sunburn.
Photoaging and skin cancer can be reduced by avoiding sunburns and intermittent high-
intensity sun exposure. Engaging in sun protective behaviors when outside can
minimize UV radiation. Epidemiological studies suggested that sunlight exposure is
associated with higher rates of all major types of skin cancer. According to Borschmann
et.al, five percent of natural sunlight is composed of ultraviolet radiation (UVR) and this
UVR can cause harmful damage to the skin. UVB, which is a section of UVR, causes
biological damage causes 80% of harmful effects associated with sun exposure. UVA
radiation contributes to the remaining 20%, which causes wrinkles and
hyperpigmentation.
World Health Organization recommends several sun-protective behaviors which
includes regularly applying sunscreen when outdoors. However, despite promotion
campaigns and education to the public, still the increasing data of photoaging,
melanoma and non-melanoma skin cancer still continue to rise.
Behavioural link between sun exposure and skin cancer can provide a good avenue for
decreasing the incidence of harmful effects of sun exposure. By knowing the current
stage of change, attitude of an individual can be modified to accept the readiness to
change their sun exposure behaviors.
Young people, especially those in the medical field, will be helpful in influencing
individuals to use sun protection.

The transtheoretical model of behavior change

The transtheoretical model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, &
Norcross, 1992) is an integrative, biopsychosocial model to conceptualize the process
of intentional behavior change. This model seeks to include and integrate key
constructs from other theories into a comprehensive theory of change that can be
applied to a variety of behaviors, population, and settings- hence, the name of
Transtheoretical.
This model posits that health behavior change involves progress through three stages
of change: precontemplation, contemplation and action. Basic research has generated a
rule of thumb for at-risk populations: 40% in precontemplation, 40% in contemplation,
and 20% in action. Applied research has demonstrated dramatic improvements in
recruitment, retention and progress using stage-matched interventions and proactive
recruitment procedures.
Precontemplation is the stage in which people are not intending to take action in the
foreseeable future, usually measured as the next 6 months. People may be in this stage
because they are uninformed or underinformed about the consequences of their
behavior. They are often characterized in other theories as resistant or unmotivated
clients for health promotion programs.
Contemplation is the stage in which people are intending to change in the next 6
months. They are more aware of the pros of changing but are also acutely aware of the
cons. This is often characterized as behavioral procrastination. Patients in this stage are
not ready for traditional action-oriented programs.
Action is the stage in which people have made specific overt modification in their life
styles within the past 6 months. Since action is observable, behavior change often has
been equated with action. People must attain a criterion that professionals agree is
sufficient to reduce risks for disease.
One of the advantages of the TTM is that it addresses the transitional nature of change
and it does not assume any pre-existing level of willingness to change.

Sun- protective behavior and the TTM

Despite the benefits associated with engaging in sun-protective behavior, there is

currently no questionnaire in the literature that accurately assesses how willing
individuals are to change their current levels of sun-protective behavior.
Accurately assessing an individual’s current stage of change in relation to sun-
protective behavior could potentially serve three primary functions: Firstly, it may help
increase level of sun protective behavior. Secondly, it may help to decrease the
individual’s level of deliberate sun exposure. Finally, it may contribute to more efficient
and effective use of time allocated to health promotion interventions in primary health
care settings.

2. Materials and methods

2.1 Study design

Study design is a descriptive study using RASP-B, a 12 item questionnaire originally

developed by Borschmann et. al. An email was sent to the author to ask permission if
we can use the developed questionnaire survey here in the Philippines for pilot study.
Permission was given.
Informed consent will be given prior to administration of the questionnaire. RASP-B can
be self-administered in approximately 5 minutes. (see Appendix 2)
2.2 Sample Population
The sample size was based from the original paper of Borschman et. al (see appendix
1). Participants will be recruited from medical professionals specifically junior and senior
interns of a tertiary hospital in Manila. The sample consisted of 122 medical interns,
ranging in age from 21-30 years old.

2.3 Questionnaire
RASP-B contains 12 items and is designed to assess which stage of change
respondents are with regard to sun protective behavior. Four items refer to each of the
precontemplation, contemplation and active stages of the transtheoretical model of
behavior. Respondents will be asked to endorse one of 5 options ranging from “strongly
agree” to “strongly disagree” (see appendix 1).

Table 1
RASP-B Items
1 I do not think I spend too (P)
much time exposed to
the sun.
2 I am trying to spend less (A)
time in the sun that I
used to.
3 I enjoy spending time in (C)
the sun, but sometimes I
spend too much time in
the sun
4 Sometimes I think I (C)
should spend less time
in the sun.
5 It’s a waste of time (P)
thinking about how
much time I spend in the
sun.
6 I have just recently (A)
changed my sun
exposure habits.
7 Anyone can talk about (A)
wanting to do something
about reducing their sun
exposure, but I am
actually doing something
about it.
8 I am at the stage where I (C)
should think about
spending less time in the
sun.
9 The amount of time I (C)
spend in the sun is a
problem sometimes.
10 There is no need for me (P)
to think about changing
my sun exposure habits.
11 I am actually changing (A)
my sun exposure habits
right now.
12 Spending less time in the (P)
 sun would be pointless
for me.
P, precontemplation; C, contemplation; A, action.

3. Results
Calculation of Scale Score
In order to calculate, response obtained from the questionnaire will be converted into
stage scores. Responses of each stage of change item will be scored as follows: -2
strongly disagree, -1 disagree, 0 neither agree/disagree, +1 agree, +2 strongly agree.

3.1 Allocation of stage of change

Each participant was assigned to a stage of change. A total score for each stages was
calculated from their responses to the 12 RASP-B items. Using this method, 50
(40.98%) participants were allocated to the precontemplation stage, 34(27.86%) to the
contemplation stage and 38 (31.14%) to the action stage. This is consistent with the
original study done by Borschmann et.al that approximately 40% of people will fall into
each of the precontemplation and contemplation stages.

3.2 Stage of change and gender

Table 2
Observed (and expected) frequencies for stages of change by gender

Observed frequencies for stages of change by

gender
     Total

Precontemplation Contemplation Action

29 20 14
Male 25.82 17.56 19.62 63
( 0.39) ( 0.34) ( 1.61)

21 14 24
Female 24.18 16.44 18.38 59
( 0.42) ( 0.36) ( 1.72)

  50 34 38 122
χ2  =  4.844,     df  =  2,     χ2/df  =  2.42 ,         P(χ2 > 4.844)  =  0.0887
expected values are displayed in italics, individual χ2values are displayed in (parentheses)

A Chi-square analysis was performed on the demographic data to determine whether

significant differences existed between male and female participants in relation to their
distribution across the stages of change for sun protective behavior. Significant
differences were observed in the distribution of male and female participants across the
stages of change: χ2 =  4.844, p <.10. Specifically, a higher proportion of male
participants were found to be in the precontemplation stage than females, and a
higher proportion of female participants were found to be in the action stage than
males.

4. Discussion

The aim of this study is to know the current sun protective behavior of medical interns
using Readiness to Alter Sun Protective Behavior (RASP-B) and to change their
behaviors based from their assigned stage of change according to transtheoretical
model behavior of change. Majority of the participants fell in the precontemplation stage.
A Chi-square analysis was done to observe frequencies for stages of change by
gender. Result revealed that male participants were found to be significantly higher in
the precontemplation stage and higher proportion of females were seen in the action
stage.
The RASP-B requires approximately 5 minutes to complete, can be self-administered
and has satisfactory psychometric properties; thus this questionnaire can be used in
primary health care settings. The shortness of RASP-B facilitates completion with
minimal distraction.

4.1 Recommendations
Limitation of the present study was that it only utilized medical interns as the sample
population. It is advisable to have another group of population based from educational
attainment. Age is not an issue, because items in RASP-B do not contain any obvious
age bias. In addition to this, a Filipino version of the RASP-B questionnaire can be done
to have a better assessment of the sun protective behavior among Filipinos where
language can be a barrier. A validity of translation is highly encouraged. Lastly,
assessment of current levels of sun protective behavior in comparison to the current
stage of change must be done.

4.2 Conclusions
RASP-B was originally developed by Borschmann et.al with the aim of improving health
education regarding sun protective behavior. It was administered in a tertiary hospital
among medical interns with the permission from the original authors prior to the study.
It was self-administered in approximately 5 minutes.
This study showed the current stage of change of respective participants in relation to
sun protective behaviors using transtheoretical model of change. We conclude that as
dermatologists, it is part of our goal to promote health campaigns regarding sun
protective measures to the public as part of skin health. It can be greatly accomplished
if it will be individualized based from the readiness to change. The RASP-B as
described in this study can help achieve the expected intervention based from their
current state of stage of change.

Conflict of interest

No conflict of interest

Sources of support

Nil.