| |

Received: 23 April 2019    Revised: 24 July 2019    Accepted: 1 August 2019

DOI: 10.1111/jocd.13120

ORIGINAL CONTRIBUTION

Awareness about proper use of sunscreen in people of color: A

Jordanian‐based survey

Firas Al‐Qarqaz MD1  | Maha Marji MD1 | Khaldon Bodoor PhD2 |

Diala Al ALshiyab MD1 | Jihan Muhaidat MD1 | Saleh Al Ghamdi MD1

1
Department of Dermatology, Faculty of
Medicine, Jordan University of Science and
Technology, Irbid, Jordan
2
Department of Biotechnology and Genetic
Engineering, Faculty of Science, Jordan
University of Science and Technology, Irbid,
Jordan
Correspondence
Firas Al‐Qarqaz, Department of
Dermatology, Faculty of Medicine, Jordan
University of Science and Technology, Irbid,
Jordan.
Email: fqarqaz@just.edu.jo
Funding information
Jordan University of Science and Technology
Abstract
Introduction: The use of sunscreen is an important preventive measure against skin
cancer and treatment for other skin conditions. There is evidence pointing to lack
awareness and misconceptions regarding use of Sunscreen. This is especially evident
in populations with skin of color (POC).
Methods: This is a cross‐sectional study of 2000 individuals. A structured question‐
naire was designed to collect data on general knowledge and use of sunscreen as well
as reasons for stopping use of sunscreen.
Results: The results of this study indicate a clear deficiency in the use and knowledge
about sunscreen among Jordanians. Females are using sunscreen more than males.
However, the use of sunscreen is inadequate in many aspects including timing of ap‐
plication, frequency of use, and amount used among other things. There is an obvious
lack of knowledge about sunscreen as shown by lack of awareness about benefits
of use in various times of the year, use in children, use for all skin types, and several
misconceptions among other knowledge gaps. Main reasons for stopping sunscreen
include side effects, cost, and being not suitable for skin. Awareness about sunscreen
can be improved by proper counseling by healthcare professionals and utilization of
various media platforms.
Conclusions: The use of sunscreen is inadequate in this population of color (POC).
Lack of proper counseling, failure to read use instructions can contibute to inade‐
quate use of sunscreen. Risks and benefits of sunscreen should be explained by medi‐
cal professionals. The media should be more utilized to disseminate such knowledge.

KEYWORDS
awareness, people of color, sunscreen

1 |  I NTRO D U C TI O N
Dermatologists are well aware of the short‐ and long‐term benefits
of the protective effects of sunscreens, yet it seems that the public
is still not well aware of such benefits. Furthermore, the actual use
of sunscreens is far away from meeting required standards of appro‐
priate use in various aspects.
Sun light exposure has several physiological functions1-6; how‐
ever, excessive sun light exposure plays an important role in the de‐
velopment of most skin cancers.7 For the past several decades, the
incidence of all skin cancers is rising and this is largely attributed to
excessive sun light exposure.8,9 Several countries have initiated cam‐
paigns emphasizing sun protection to the public in the hope of re‐
ducing the overwhelming burden of skin cancer on health sector.10,11

J Cosmet Dermatol. 2020;19:1131–1136. © 2019 Wiley Periodicals, Inc. |  1131

wileyonlinelibrary.com/journal/jocd  
 |
1132       AL‐QARQAZ et al.
However, it seems that the public especially younger people are still
not well‐informed about sun protection and the practice of sun block
use is still far from being anywhere near acceptable standard.12-14
In people with skin of color (POC), the literature is generally lack‐
ing about skin cancer risk, prevalence, and also very lacking in regard
to behavior of sun protection and use of sunscreen. The main objec‐
tives of this study are to examine the knowledge, proper use, and
reasons for stopping use of sunscreen in Jordanians, a population
with predominantly skin of color.
2 |  M E TH O DS
This is a cross‐sectional study carried out at King Abdullah University
Hospital, Irbid, Jordan. A total of 2000 participants were recruited
to this study. A consent form was obtained from each participants
after explaining the purpose of the study. A structured question‐
naire was prepared with a set of questions in relation to sunscreen
use. The questionnaire was divided into three main parts. The first
part was filled by those using sunscreen and contained questions in
relation to correct and adequate use of sun blocks. The second part
had questions assessing the general knowledge about sun blocks
and was filled by all participants. Third part was designed to inquire
about possible reasons that made participants stop using sunscreen.
Finally, all participants were asked about means that could be help‐
ful in disseminating more information about importance of using
sunscreen. Figure 1 shows summary of main questions asked. The
data were then analyzed using SPSS version 17. P value was con‐
sidered significant if ≤.01. The study was approved by the local IRB
(746‐2018), grant number 2018‐531.
3 | R E S U LT S
A total of 2000 participants were included in this study. Average
age for participants was 27.9 years. There were more female partici‐
pants in the study (65.3%) compared to males (34.7%). Darker skin
color was the predominant type with types 3, 4, and 5 accounting
for 79.3% of study participants. A total of 1134 (56.7%) study cohort
reported using sunscreen. Males used sunscreen much less than fe‐
males; and only 25.3% of males were using sunscreen, while 73.1%
of females were using sunscreen (P ≤ .001). About 60% of younger
participants below the age of 40 years used sunscreen, while only
38.1% of those above the age of 40 used sunscreen (P  =  ≤0.001;
Table 1).
The questionnaire was designed to measure awareness and
knowledge about use of sunscreen in three major aspects: correct
use of sunscreen, general knowledge about sunscreen, and the main
reasons for stopping use of sunscreen.
In terms of correct use of sunscreen (part 1 of questionnaire),
52.4% of participants said they were given instructions about the
use of sun block when it was prescribed to them while remainder
were not. Only 28.6% read the sunscreen leaflet to get the proper
instructions. The vast majority (71.9%) used sunscreen once daily
(typically before going out in the morning), 26.1% used the cream
2‐3 times daily, while 2% used the sun block more than 3 times a
day. In terms of using sunscreen indoor, 87% did not use sunscreen
while indoor. When participants were asked how long they applied
sunscreen before going out of their homes, around 45% said they
applied sunscreen 15‐30  minutes, while 12% applied sunscreen
just immediately before going out, whereas 43% applied sun‐
screen within 5‐10  minutes prior to leaving house. Participants
F I G U R E 1   A three‐part questionnaire
designed to assess sunscreen use among
Jordanians (cohort = 2000)
AL‐QARQAZ et al. |
      1133

TA B L E 1   The use of sunscreen according to sex and age than half (62%) of the participants were aware of the need to use
sunscreen in different skin types including dark skin, whereas
Parameter Yes (%) No (%) P value
28.6% thought only people with lighter skin colors need to use
Using sunscreen 1134 (56.7) 866 (43.3%) >.05
sunscreen. A small percentage (4.4%) had a misconception that
Female and using 955 (73.1%) (26.9%) <.001
only people with dark skin colors need to use sunscreen. inter‐
sunscreen
estingly, a significant proportion (46.3%) of participants thought
Male and using 226 (25.3%) 74.7%
children should not use sunscreen, and furthermore, 13% of study
sunscreen
participants thought sunscreen could have harmful effects on skin
<40 y age using (60%) 40% <.001
sunscreen with long‐term use.
In this study, we tried to examine the reasons behind stopping
≥40 y age using (38.1%) 61.9%
sunscreen the use of sunscreen as around 24% discontinued using sunscreen.
Our data indicate that the main reasons for stopping use of sun‐
screen include mainly side effects, cost, and lack of compliance
were asked if they knew how much sunscreen is needed; a small
(Figure 2). Among participants using sunscreen (n  =  1134), around
percentage (3%) knew how much they needed while the remain‐
15.6% reported having side effect that they thought was related to
der (97%) did not know. Finally, when asked about reapplication
the sunscreen. The most common reported side effects are shown
of sunscreen after washing/wiping skin, 19.2% said they would
in Figure 3.
usually reapply the cream, whereas 80.8% of participants did not.
We asked all participants to give their opinions regarding best
As for general knowledge about sunscreen, participants were
means to increase awareness of using sunscreen. Internet, doctors,
asked several questions that measure how much information and
TV, and pharmacists were the most common suggested sources for
misconceptions they had on sunscreen including where did they
providing more awareness of sunscreen (Figure 4).
first learn about sunscreen, appropriate strength of sunscreen,
the need to use sunscreen in children, use of sunscreen in differ‐
ent seasons of the year, the need to use indoor, where to apply
4 | D I S CU S S I O N
sunscreen, the need of sunscreen for people of dark skin, and
whether sunscreen could be harmful to skin. The data from the
The importance of using sunscreen in addition to other measures of
questionnaire show that around one‐third (32.2%) of participants
sun avoidance and protection (proper clothes, glasses, and hats) can‐
learned about sunscreen from a friend, 29.7% from a healthcare
not be overemphasized. However, it seems that despite the efforts
professional, and 17.6% first learned about sunscreen from media
put toward making public aware of sun protection, it seems that the
resources (TV, Internet, social networks). More than half partici‐
actual state indicates huge deficiency in this regards. Several studies
pants were not aware of the appropriate strength of different sun‐
have indicated that the use of sunscreen is still very short of achiev‐
screen. We also noticed that there is a misconception on the need
ing correct standards.12,15,16
to use sunscreen during winter months, since 40% of participants
In people of skin color (POC), it seems that awareness about
did not think sunscreen was needed during winter. Similarly, 70.6%
sunscreen is even more lacking.17,18 Despite having lower risk for
of participants thought sunscreen was not needed while indoor.
developing skin cancer, individuals of POC are at much higher risk
When asked about the areas of skin where sunscreen should be
for developing many pigmentary disorders that require the use of
applied, 65.4% thought that face and hands are the only sites of
sunscreen. Still, many have never used sunscreen in their life time.19
application, 25.8% thought sunscreen is used on face only, while
The findings of this study in a population with predominance
8.8% thought sunscreen should be applied to entire body. In terms
of dark skin color are consistent with the general trend of lack of
of the need to use sunscreen in different skin color types, more

F I G U R E 2   Showing main reasons for

stopping sun block use
 |
1134       AL‐QARQAZ et al.
awareness about proper use of sunscreen in other populations. 20-22
The findings of this study indicate a clear difference in the use of
sunscreens between males and females. Only one quarter of males
surveyed were using sunscreen. This indicates that when males are
advised to use sunscreens, there should be more emphasis about the
benefits of using screens and more discussion and that risks from
not using sunscreens are same for both genders and that sunscreens
are recommended as protective measure rather than a cosmetic one
which is more important to females. A similar trend of inadequate
use of sunscreens among POC especially males is also reported by
23,24
other studies.
The individuals using sunscreen are not getting the desired
benefits because there is clear deficiency in following the recom‐
mended standards of using sunscreen. It is recommended that in
POC, sunscreens of SPF 30 or above should be applied on dry skin at
least 15‐30 minutes prior to going outdoor and should be reapplied
every 2 hours and after activities that washout or remove the ap‐
plied sunscreen (eg, swimming, sweating, washing skin, and rubbing
18
off the sunscreen). It is worth mentioning that no clear guidance
is given on how much cream should be applied. The results of this
study show deficiency in following these recommendations. In this
F I G U R E 3   Most common reported
side effects from sunscreen use
F I G U R E 4   Means of increase
sunscreen awareness
population, around 43.3% were not using sunscreen to start with.
Another important observation was that people above age 40 years
were using sunscreen much less often than younger individuals. This
is an important finding because the incidence of skin cancers gener‐
ally increases with age.
Coming to the details of whether sunscreen is used properly
(part 1), it was clear that the majority of people are not following
proper recommendations because no instructions were given and
most did not read sunscreen leaflet. Additionally, lack of proper sun‐
screen application in terms of timing before going out, frequency of
reapplication, and amount needed clearly indicates that sunscreen
applied could have been inadequate. Having an easy guide (eg, fin‐
gertip unit) can help in better estimation of amount that needs to be
applied to cover the exposed skin surface. Moreover, the majority
used sunscreen only once throughout the day (71.9%) while it would
have been more correct to reapply the sunscreen more than 3 times
daily. Based on information from the Meteorological Department,
the average daylight hours in this area is around 12 hours daily
(range 10‐14  hours) with sunshine average around 8.8  hours daily
throughout the year. 23 Only 2% of study participants used sun‐
screen more than 3 times daily. Additionally, less than fifth (19.2%)
AL‐QARQAZ et al.
of population reapplied sunscreen after washing/wiping off skin.
Since this is a sunny area, sunscreen should be applied even indoor;
however, only 13% applied sunscreen while indoor. Similar to our
findings, other studies have also indicated that sunscreen applica‐
tion is inadequate, 25-27 and this clearly indicates need for more coun‐
seling, education, and clear written instructions on the proper use
of sunscreen.
The general knowledge (part 2) about sunscreen is clearly lack‐
ing too. This was evident among participants unaware of appro‐
priate strength of sunscreen, need to use in children, the need to
use sunscreen indoor, and the need to use sunscreen during winter
times, and the appropriate sites of application. For example, none
of participants thought that sunscreen needed to be applied to ears
and neck skin. Additionally, there were some misconceptions about
sunscreen; for example, some participants thought that sunscreen
could be harmful to their skin especially with long‐term use. Given
together, this lack of knowledge and presence of misconceptions
could be an important contributing factor to not using or stop using
prescribed sunscreen. A study has been done to assess knowledge
about labeling terminology used. However, only 8.7% of participants
knew the terminology. 28 Another study showed similar knowledge
gap about sunscreen including basic knowledge gaps and several
misconceptions. 29 It is clear that more work is needed for better in‐
forming the public about benefits of long‐term sunscreen use and
clarifying misconceptions.
We tried to get more insight about reasons that contribute to
stop using the sunscreen (part 3). The most common reported rea‐
sons were having side effects, cost, poor compliance, lack of im‐
provement, and not knowing that sunscreen needs to be used long
term. The most common reported side effects were as follows: did
not like the texture of sunscreen on the skin, irritation, developing
acne lesions, increase sweating, darkening of skin, and others.
Sun protection awareness campaigns have been employed in
several countries especially Australia and the United states. This has
resulted in more frequent use of sunscreens.30 The campaigns ad‐
dressed different behaviors of sun exposure and the proper use of
sunscreens. Similar campaigns should be initiated to increase aware‐
ness about proper use of sunscreens among Jordanians. Special em‐
phasis should be given to encourage males and younger age groups
to use sunscreens. Such campaigns can be used to better inform in‐
dividuals about risks of unprotected sun exposure and the benefits
of proper use of sunscreens, including skin cancer reduction, skin
aging, and role in treatment of various conditions associated with
pigmentary change that is especially relevant to POC. Additionally,
specific details should be given about managing possible side effects
and trying various brands of sunscreens, for example, using non‐
comedogenic brands in younger individuals. The person prescribing
sunscreen should also stress that the use of sunscreen is not only for
treatment of a specific condition, rather this is required as preven‐
tive long‐term measure. When a patient uses sunscreen, it should be
clarified that even without seeing improvement in their condition, it
may be due to inadequate use of sunscreen or a need to add in other
treatment lines to control the skin condition.
|
      1135
In this digital age, the utilization of Internet, mobile app, and social
media as our study showed would be a good means to reach many
young individuals in order to maximize the awareness about sunscreen.
5 | CO N C LU S I O N S
This study in POC indicates huge lack of awareness about sun‐
screen use. The use of sunscreen is inadequate and does not meet
recommended standards. General knowledge about sunscreen is
also deficient which contributes to inadequate use and suboptimal
protection. Proper counseling for individuals could increase com‐
pliance, avoid stopping sunscreen, and reduce side effects from
sunscreen. All resources including Internet, TV, awareness cam‐
paigns, clinics, and pharmacists have a significant role in increasing
awareness of sun protection and correct use of sunscreen. Having
a printed sheet with all needed information including a guide on
amount estimation (eg, fingertip unit) may improve the proper use
of sunscreen.
AC K N OW L E D G M E N T
This work was funded and supported by deanship of research at Jordan
University of Science and Technology. We would like also to thank Dr
Enas Al Haje for her help in recruiting participants for this study.
C O N FL I C T O F I N T E R E S T
The authors declare they have no conflict of interest.
ORCID
Firas Al‐Qarqaz  https://orcid.org/0000-0003-4876-7406
REFERENCES
1. Holick M. Sunlight and vitamin D for bone health and prevention
of autoimmune diseases, cancers, and cardiovascular disease. Am J
Clin Nutr. 2004;80(6):1678S‐1688S.
2. Sassi F, Tamone C, D'Amelio P. Vitamin D: nutrient, hormone, and
immunomodulator. Nutrients. 2018;10(11):1656.
3. Yu J, Lavoué J, Parent MÉ. Sunlight exposure during leisure activ‐
ities and risk of prostate cancer in Montréal, Canada, 2005–2009.
BMC Public Health. 2014;14(1):756.
4. Mead MN. Benefits of sunlight: a bright spot for human health.
Environ Health Perspect. 2008;116(4):A160‐A167.
5. Reeves GM, Nijjar GV, Langenberg P, et al. Improvement in de‐
pression scores after 1 hour of light therapy treatment in
patients with seasonal affective disorder. J Nerv Ment Dis.
2012;200(1):51‐55.
6. Kent ST, Cushman M, Howard G, et al. Sunlight exposure and car‐
diovascular risk factors in the REGARDS study: a cross‐sectional
split‐sample analysis. BMC Neurol. 2014;14:133.
7. Watson M, Holman DM, Maguire‐Eisen M. Ultraviolet radiation
exposure and its impact on skin cancer risk. Semin Oncol Nurs.
2016;32(3):241‐254.
 |
1136       AL‐QARQAZ et al.
8. Lomas A, Leonardi‐Bee J, Bath‐Hextall F. A systematic review of
worldwide incidence of nonmelanoma skin cancer. Br J Dermatol.
2012;166:1069‐1080.
9. Wu S, Han J, Laden F, Qureshi AA. Long‐term ultraviolet flux, other
potential risk factors, and skin cancer risk: a cohort study. Cancer
Epidemiol Biomarkers Prev. 2014;23(6):1080‐1089.
10. Doran CM, Ling R, Byrnes J, et al. Benefit cost analysis of three
skin cancer public education mass‐media campaigns implemented
in New South Wales, Australia. PLoS ONE. 2016;11(1):e0147665.
11. Iannacone MR, Green AC. Towards skin cancer prevention and
early detection: evolution of skin cancer awareness campaigns in
Australia. Melanoma Manag. 2014;1(1):75‐84.
12. Nahar VK, Wilkerson AH, Ghafari G, et al. Skin cancer knowl‐
edge, attitudes, beliefs, and prevention practices among medical
students: a systematic search and literature review. Int J Womens
Dermatol. 2018;4(3):139‐149.
13. Yan S, Xu F, Yang C, et al. Demographic differences in sun protec‐
tion beliefs and behavior: a community‐based study in Shanghai,
China. Int J Environ Res Public Health. 2015;12(3):3232‐3245.
14. Grandahl K, Ibler KS, Laier GH, Mortensen OS. Skin cancer risk per‐
ception and sun protection behavior at work, at leisure, and on sun
holidays: a survey for Danish outdoor and indoor workers. Environ
Health Prev Med. 2018;23(1):47.
15. von Schuckmann LA, Wilson LF, Hughes M, et al. Sun protection
behavior after diagnosis of high‐risk primary melanoma and risk of
a subsequent primary. J Am Acad Dermatol. 2019;80(1):139‐148.
16. Şenel E, Süslü I. Knowledge, attitudes, and behaviors regard‐
ing sun protection, effects of the sun, and skin cancer among
Turkish high school students and teachers. Dermatologica Sinica.
2015;33(4):187‐190.
17. AlGhamdi KM, AlAklabi AS, AlQahtani AZ. Knowledge, atti‐
tudes and practices of the general public toward sun exposure
and protection: a national survey in Saudi Arabia. Saudi Pharm J.
2015;24(6):652‐657.
18. Cestari T, Buster K. Photoprotection in specific populations: chil‐
dren and people of color. J Am Acad Dermatol. 2017;76(3S1):S110
‐S121.
19. Pichon LC, Corral I, Landrine H, Mayer JA, Norman GJ. Sun‐pro‐
tection behaviors among African Americans. Am J Prev Med.
2010;38(3):288‐295.
20. Al Robaee AA. Awareness to sun exposure and use of sunscreen by
the general population. Bosn J Basic Med Sci. 2010;10(4):314‐318.
21. Ziehfreund S, Schuster B, Zink A. Primary prevention of keratino‐
cyte carcinoma among outdoor workers, the general population
and medical professionals: a systematic review updated for 2019.
J Eur Acad Dermatol Venereol. 2019;33(8):1477-1495.
22. Agbai ON, Buster K, Sanchez M, et al. Skin cancer and photopro‐
tection in people of color: a review and recommendations for phy‐
sicians and the public. J Am Acad Dermatol. 2014;70(4):748‐762.
23. Pengpid S, Peltzer K. Sun protection use behaviour among
University students from 25 low, middle income and emerging
economy countries. Asian Pac J Cancer Prev. 2015;16(4):1385‐1389.
24. Cestari T, Buster K. Photoprotection in specific populations: chil‐
dren and people of color. J Am Acad Dermatol. 2017;76(3):S110
‐S121.
25. Weather atlas. Amman, Jordon: Jordan Meteorological Department;
2018. https​://www.weath​er-atlas.com/en/jorda​n/irbid-climate
26. Yang HP, Chen K, Ju M, Chang BZ, Wang LY, Gu H. A study of
the way in which dermatologists and photosensitive patients
apply sunscreen in China. Photodermatol Photoimmunol Photomed.
2009;25(5):245‐249.
27. Heerfordt IM. Sunscreen use at Danish beaches and how to im‐
prove coverage. Dan Med J. 2018;65(4):pii: B5476.
28. Prado G, Svoboda RM, Teplitz RW, Farberg AS, Rigel DS. Patient
knowledge of FDA‐mandated sunscreen labeling terminology: a
cross‐sectional survey. Photodermatol Photoimmunol Photomed.
2018;35(3):141‐147.
29. Agarwal SB, Godse K, Patil S, Nadkarni N. Knowledge and attitude
of general population toward effects of sun exposure and use of
sunscreens. Indian J Dermatol. 2018;63(4):285‐291.
3 0. Koch S, Pettigrew S, Hollier LP, et al. Trends in Australian adoles‐
cents' sun‐protection behaviours: implications for health cam‐
paigns. Aust N Z J Public Health. 2016;40(5):468‐473.
How to cite this article: Al‐Qarqaz F, Marji M, Bodoor K,
Al ALshiyab D, Muhaidat J, Al Ghamdi S. Awareness about
proper use of sunscreen in people of color: A Jordanian‐
based survey. J Cosmet Dermatol. 2020;19:1131–1136.
https​://doi.org/10.1111/jocd.13120​