What Turkish Nurses Know and Do about Skin Cancer and Sun Protective Behavior

Skin cancer is a worldwide health problem (Gies et al., 1998; Young et al., 2005; Yurtseven et al., 2012). According World Health Organization (WHO), annually about 2 to 3 million people suffer from non-melanoma skin cancers (NMSC), whereas the number for malignant melanomas (MM) is 132,000 per year (WHO, 2003). Moreover, average annual increase of non-melanoma skin cancers has been found about 3-8% (Diepgen and Mahler, 2002; Saridi et al., 2009). Skin cancer incidence is 18.91 per 100,000 people in Turkey which makes the disease the third most commonly diagnosed type of cancer in the country (Turkeys Statistical Yearbook, 2011). Although, skin cancer is a potential threat for every individual regardless of baseline skin pigment, people with fair or freckled skin, fair or red hair, blue, green and hazel eyes belong to the highest risk group (WHO, 2003; Lens and Dawes, 2004; Gallagher, 2005). Risk factors for MM include dysplastic nevi and high number of ordinary nevi (more than 50) whereas tendency to burn and development of freckles with sun exposure are potential risk factors for the NMSC (CDC, 2002; WHO, 2003; NHS, 2011; Longo et al., 2011). Additionally, genetic predisposition plays an important role in development of MM. Some studies suggest that nearly 10% of melanoma patients have had a family history of melanoma (Gallagher, 2005; Longo


Introduction
Skin cancer is a worldwide health problem (Gies et al., 1998;Young et al., 2005;Yurtseven et al., 2012).According World Health Organization (WHO), annually about 2 to 3 million people suffer from non-melanoma skin cancers (NMSC), whereas the number for malignant melanomas (MM) is 132,000 per year (WHO, 2003).Moreover, average annual increase of non-melanoma skin cancers has been found about 3-8% (Diepgen and Mahler, 2002;Saridi et al., 2009).Skin cancer incidence is 18.91 per 100,000 people in Turkey which makes the disease the third most commonly diagnosed type of cancer in the country (Turkeys Statistical Yearbook, 2011).
Although, skin cancer is a potential threat for every individual regardless of baseline skin pigment, people with fair or freckled skin, fair or red hair, blue, green and hazel eyes belong to the highest risk group (WHO, 2003;Lens and Dawes, 2004;Gallagher, 2005).Risk factors for MM include dysplastic nevi and high number of ordinary nevi (more than 50) whereas tendency to burn and development of freckles with sun exposure are potential risk factors for the NMSC (CDC, 2002;WHO, 2003;NHS, 2011;Longo et al., 2011).Additionally, genetic predisposition plays an important role in development of MM.Some studies suggest that nearly 10% of melanoma patients have had a family history of melanoma (Gallagher, 2005;Longo

What Turkish Nurses Know and Do about Skin Cancer and Sun Protective Behavior
Isil Isik Andsoy 1 *, Asiye Gül 2 , Aysegul Oksay Sahin 3 , Hanife Karabacak 4   et al., 2011).Approximately one half of all melanomas occur in persons under 50 age.Indeed, melanoma is one of the most common cancers found in persons under 30 age (Armstrong and English, 1996).It is the most common cancer occurring among persons in the 25-29 ages and the third most common type in the 20-24 ages (CDC, 2002).
Ultraviolet radiation (UV) is the main factor behind skin cancer.UV light can initiate carcinogenesis and excessive exposure to the UV is the prime reason of melanoma and non-melanoma cancers, possibly accounting for up to 90% of all skin cancer cases (Armstrong and Kricker, 1996;Thomas, 2009;Narayanan and Saladi, 2011).Several studies reveal the correlation between the NMSC and increased sun exposure, exposure to UV light, outdoor activities, changes in clothing style, increased longevity and ozone depletion (Garvin and Eyles, 2001;Diepgen and Mahler, 2002).In another study, has found that exposure to high doses of intermittent sunlight, especially early in life, is an important risk factor for developing MM (Marks, 1999).In this sense, Karabük province of Turkey with its average temperature over 38 0C in the summer and with high rates of UV rays constitutes a risk zone for the skin cancer (Turkeys Statistical Yearbook, 2011).
With the exception of the melanoma, the skin cancers can be treated with surgical intervention.Treatment for skin cancer includes cryosurgery, curettage and electrodessication, tumor excision (Antony, 2000).The disease is an almost preventable one (WHO, 2003;Saraiya et al., 2004).Primary prevention measures such as minimizing sun exposure by changing sunbathing habits, avoiding artificial tanning devices, using sunscreen, seeking shade, using a sunscreen with appropriate sun protection factor, wearing sunglasses, and wearing protective clothing can significantly reduce the number of cases (WHO, 2003;Warren et al., 2004).Secondary prevention is based on early detection of skin cancer.Early detection involves regular skin examinations for high-risk individuals and screening programs to identify those at high risk (WHO, 2003;Geller et al., 2005;Jones et al., 2007;Lazovich et al., 2012).
Nurses are primarily responsible for preventing diseases and public health promotion.For these, they should maintain their own health.Although there are various studies on this subject in other countries (Morrison, 1996;McCormick et al., 1999;Darling and Ibbotson, 2002), no research on nurses' knowledge and their protective behaviors about skin cancer has been conducted in Turkey.This study aims to fill this gap by assessing the current knowledge level of Turkish nurses related to skin cancer and by revealing their attitudes towards sun exposure and their protective behaviors.

Study design
The study was conducted as a descriptive crosssectional design.

Setting and sample
The study was carried out at Karabük State Hospital and Safranbolu State Hospital which are located at the Western Black Sea Region of Turkey from March 11 to May 30, 2013.Two hundred and forty-six nurses work at the Karabük State Hospital and 70 nurses at the Safranbolu State Hospital.Six nurses did not want to participate in the study.Hence, the study was conducted with the participation of 310 nurses (98.1% response rate).

Data collection
The questionnaire was developed by researchers after a review of the literature (McCormick et al., 1999;Darling and Ibbotson, 2002;Miles et al., 2005;Johns et al., 2007;Saridi et al., 2009;Lindow and Shelestak, 2011;Yurtseven et al., 2012;Ramezanpour et al., 2013).The questionnaire was composed of three parts; The first part included 18 questions to reveal general characteristics of the nurses.The second part included 14 questions to find out the degree of their knowledge on risk factors about skin cancer.The high score indicates a low level of knowledge The final part consisted of 33 questions to determine the practices of the nurses related to protection from harmful effects of the sun.12 of the questions at the final part were related with the daily behaviors of the participants, 14 were about sunscreen usage and 5 were on behaviors related to their subjection to sunlight.
A pilot questionnaire was conducted over 15 nurses in order to identify and eliminate bias in the questionnaire design and minor revisions were made afterwards.Data obtained during the pilot study was included in study results.

Statistical analysis
Statistical analysis of the data was performed frequency and percentage were calculated for all responses in the survey.Data analysis was performed using the student T tests ANOVA, and correlation analyses were used.Results had 95% confidence interval with p <0.05, indicating statistical significance.

Ethical considerations
Ethical permission for the study was obtained with approval of appropriate management authority prior to data collection.The researcher followed the principles of the Declaration of Helsinki and received oral consent of participants.Participation in the survey was voluntary and nurses were free to withdraw from the study at any time.Nurses were exposed to minimal, if any, risk during participation.Each interview took approximately 15-20 minutes and nurses received no benefits for their participation.Interviews were anonymous and data remained confidential throughout the study.

Results
Socio-demographic characteristics of nurses 310 of the 316 nurses (98.1%) working in Karabük and Safranbolu state hospitals agreed to participate in the survey whereas 6 nurses (0.9%) refused to participate.Table 1 shows the socio-demographic characteristics of the nurses.91.6% (n=284) of the participants were female whereas 8.4% (n=26) were male.The mean age of the nurses was 30.26±6.89.69% (n=214) of the nurses are married and 96.1% (n=298) had graduated bachelor's degree.83.9% (n=260) of them did not have any chronic illness.4.8% (n=15) of the nurses had a family member with skin cancer and 41.3% (n=128) of them had been sunburnt.A clear majority of the participants (n=128) have been sunburnt at least once.Regarding their skin types, 70% (n=217) of the participants had fair skin.The majority had brown/ black hair (89.1%, n=276)) and dark eyes (77.1%, n=239).77.4% (n=240) of the nurses had birthmark.91.6% (n=284) had nevi and 93.7% (n=266) of the participants with nevi had nevus less than 50.

Nurses' knowledge of skin cancer
It has been found that that a clear majority of the participants had given true answers to questions on skin cancer.The wrong answers that the participants gave included 'some viruses can cause skin cancer', 'skin cancer can easily be diagnosed', 'people with more than 50 nevi may be under higher risk of skin cancer', and 'people with birthmark may be at risk for skin cancer'.Two hundred fifty of the participants replied 'I do not see myself at skin cancer risk and there is nothing I can do to prevent skin cancer' (Table 2).
Table 3   behaviour of protection (p=0.087)from it.There was not any statistical meaningful difference between the variables of age, education, skin cancer family history, having been sunburnt , skin tone, eye color, hair color and existence of nevi conditions and the point averages for the knowledge of the risk factors for skin cancer.

Nurses' protective behaviors about skin cancer
The analysis of data indicates that most nurses had a good protective behavior about skin cancer in terms of items listed in Table 4.In general, percentages of "positive behaviors" responses for all the knowledge items are higher than "negative behaviors" and "those who don't know" answers.However the nurses did not have sufficient positive behaviors regarding skin cancer which is reflected in the rates of answers to the statements "I use sun hat when I go out" (n=41), "I do not go swimming between 11 am and 4 pm" (n=96), "I use sun cream every half an hour when I am at the beach" (n=107), "I do not go out between 10 am and 4 pm" (n=141), "When I go outside, I use sunshade" (n=54), "When I am exposed to sun light, I use at least factor 15 sunscreen" (n=143), "I have been using sunscreen since my childhood" (n=78), "when shopping, I firstly pay attention to the perfume of the sunscreen" (n=61), "I use sunscreen only when I am sunburnt" (n=65).

Discussion
This study aimed to assess about nurses' knowledge and protective behavior towards skin cancer.Most of them had fair skin color.The majority had brown/black hair and dark eyes.Less than half of nurses had been sunburnt.Approximately three quarters had birthmark, most of them had nevi and the majority of those with nevi had less than 50 nevi.As noted in other studies (Davis et al., 2002;Argyriadou et al., 2005;Halpern and Kopp, 2005;Yurtseven et al., 2012), these findings may be indicated a moderate risk for development of skin cancer (WHO, 2003).The literature suggests that the nurses with fair hair and colored-eyes which constitute a minority in the sample are under higher risk of skin cancer compared to other nurses (CDC, 2002;WHO, 2003;NHS, 2011).In addition, although they have lower risk of skin cancer people with dark skins are also exposed to ultraviolet light and negative consequences for eyes and immunity system.WHO stated that 20% of these people go blind due to being exposed to ultraviolet light.Thus, not only people with fair skin but all people should be protected from negative effects of sun (CDC, 2002;WHO, 2003).Nurses with more nevi are at a high risk compared to others.Those with sunburnt that has turned into bulla are two times more likely to be under risk compared to those with no sunburnt.Scholarly works have also asserted that family history of skin cancer increases risks for individuals (WHO, 2003;Gallagher,. 2005;Longo et al., 2011).Since nearly half of the nurses have had blister due to sunburnt, they are prone to risks in terms of skin cancer.
The majority of the nurses have answered the question on skin cancer correctly.However, the respondents gave less correct answers to the questions of "some viruses can cause skin cancer", "skin cancer diagnosis can be easy", "people with more than 50 nevi are under higher risk of skin cancer" and "people with birthmark may be at risk for skin cancer".Studies on nurses and other populations have revealed that nurses and other populations have inadequate knowledge on skin cancer (Morrison, 1996;McCormick et al., 1999;Darling and Ibbotson, 2002;Halpern and Kopp, 2005;Romenzanpaur et al., 2012).Higher rate of correct answers by respondents in our study reveals that the participants have an adequate level of knowledge on the subject.However, although the nurses are not expected to have full knowledge of the risk factors of skin cancer, their inadequate knowledge provides a barrier for early diagnosis of skin cancer and for increasing public consciousness related to prevention of skin cancer.
Most of the nurses stated that they did not perceive themselves under skin cancer risk and that there was nothing that they could do to prevent skin cancer.Hall et al.(1997) found that 20.3% of the adult participants considered themselves under high risk potential of skin cancer whereas 24.8% of them did not perceive any risk potential.Mackie (2004), stated that participants of his study were worried about skin cancer.Thus, compared to other studies, the participants of the current study were less worried about skin cancer risk.This situation might stem from the relative absence of informative campaigns of media and educational institutions in Turkey for promoting consciousness related to skin cancer and negative influences of the sunlight.
The nurses' mean score of their knowledge was statistically significantly different with respect to gender Women were more likely to report higher knowledge score than males.These results are consistent with findings of other studies (Kristijanson et al., 2004;Cinar et al., 2009;Romezanpour et al., 2012).On the contrary, Yurtseven et al. (2012) and Manne et al. (2011) have found statistically meaningful relationship between skin cancer history in family members and knowledge level.On the other hand, Darling and Ibbotson (2002), has found no significant relationship between gender and knowledge level in his study on nurses.This might be a consequence of the fact that our participants were predominantly female.
Most nurses had a good protective behavior about skin cancer.But it is insufficient for going out in midday, swimming in midday and using hat, umbrella and sun cream.WHO stated that the most important protective behaviors for skin cancer are limiting time in the midday sun (11am to 4pm), seeking shade, wearing protective clothing, wearing a hat, using sunscreen with sun protection factor (SPF) more than 15, and using sunglasses (WHO, 2003;Warren et al., 2004).Hall et al. (1997) has found that rate for usage of protective clothing and staying in shadow ranged between 28% and 32%.On the other hand, Mackie (2004) has found that one-third of the participants did not use or rarely used protective clothing and items when they were outside.He also found that rates of using hat ranged from 18% to 52%, protective clothing from 0% to 34%, and staying indoor from 11% to 32%.It might be asserted that the participants of our study have slightly higher rates in terms of usage of protective items and clothing and hat.In another study, DOI:http://dx.doi.org/10.7314/APJCP.2013.14.12.7663Turkish Nurses and Skin Cancer Protection Knowledge and Behaviour Darling and Ibbotson (2002) found that 57% of the nurses used sunscreen with SPF.This rate was found as 50% in the study of Saridi et al. (2009).Devos et al.(2003) found lower rates of usage of sunscreen with SPF.On the other hand Davis et al. (2002) found that rate of sun protectors was 39%.This rate was found as 26% in the study of Halpern and Kopp (2005).They also found that the rate was lower for those working outdoors (Halpern and Kopp 2005).Yurtseven et al. (2012) reported that usage of umbrella was low whereas other protective measures were high.However, Argyriadou et al. (2005) found 90% usage of sun protector items.Morrison (1996), stated that nurses felt the necessity of using sun protectors when they travelled abroad.Although the participants in the listed studies varied in terms of their educational background and professions, our study has been conducted over nurses with university degrees.This might be an explanatory factor for the differences and for more usage of some of the protective behaviors.However, it has been found that the nurses that participated in this study did not sufficiently employ protective measures, especially sunhats, umbrellas and ideal application of sunscreens.Given the fact that non melanoma skin cancer mostly develops in the faces of individuals, we might reach to the conclusion that attention should be directed to the importance of protective measures and cloths, including sunhats (Thompson et al., 1993;Phillips et al., 2000).In another study, it has been found that individuals with family history of skin cancer are more likely to take protective measures (Manne et al., 2011).As a conclusion, we have found that the nurses do not sufficiently employ protective behaviors.Hence, knowledge level of the nurses related to the influence of sun on skin and preventive measures for skin cancer has to be developed.Individual protective measures taken by the nurses who are seen as role models are crucial for their suggestions to their patients regarding protective measures against sun and skin cancer.Mortality and morbidity caused by skin cancer types, including melanoma can be significantly decreased by early diagnosis.It is our hope to increase awareness of nurses regarding the importance of protective measures against skin cancer.
In conclusion, the nurse specialist is able to offer extra support and guidance to patients who have, or have had skin cancer anywhere on their body.The nurse specialist is a qualified nurse with additional knowledge and experience, and works as part of the health care team offering advice and support to people with skin cancer at any stage of their treatment.Due to this, nurses should have sufficient knowledge of the skin cancer before anyone else.
Despite the limitations, the present study's findings suggest this nurse population lacks sufficient knowledge to understand and assess the importance of skin cancer risk.More sophisticated research and replication of the present study with other samples are needed to identify the barriers to adopting protective behavior and how best to change attitudes towards sun tanning by, identifying those at particularly high risk of developing skin cancer.In conclusion, it is thought that the results of this study may have a guiding quality for future studies.

Table 1 . Characteristics of Nurses
shows mean scores of nurses' knowledge about risk factors concerning knowledge of skin cancer based on some demographical characteristics.The DOI:http://dx.doi.org/10.7314/APJCP.2013.14.12.7663Turkish Nurses and Skin Cancer Protection Knowledge and Behaviour *Rheumatoid arthritis, Lumber disk…etc.

Table 2 . Knowledge about Skin Cancer
knowledge level significantly differed with respect to gender.Knowledge level was significantly higher for females (28.05±7.17)compared to males (40.96±10.55).As a result of the multivariate analysis of variance, it is understood the gender affects the level of knowledge about skin cancer (p=0.000),but does not influence the