A pilot study of the validity of self-reported ultraviolet radiation exposure and sun protection practices among lifeguards, parents and children

Outdoor recreation settings, such as swimming pools, provide a promising venue to assess UVR exposure and sun protection practices among individuals who are minimally clothed and exposed to potentially high levels of UVR. Most studies assessing sun exposure/protection practices rely on self-reported data, which are subject to bias. The aim of this study was to establish the feasibility of conducting a multimethod study to examine the validity of self-reported measures within a swimming pool setting. Data were collected from 27 lifeguards, children and parents in Hawaii. Each participant filled out a survey and a 4 day sun habits diary. On two occasions, researchers assessed observable sun protection behaviors (wearing hats, shirts, sunglasses), swabbed the skin to detect the presence of sunscreen, and subjects wore polysulphone dosimeters to measure UVR exposure. Overall, observed sun protection behaviors were more highly correlated with diary reports than with survey reports. While lifeguards and children reported spending comparable amounts of time in the sun, dosimeter measures showed that lifeguards received twice as much UVR exposure. This study demonstrated the feasibility of implementing a multimethod validity study within a broader population of swimming pools.     

Solar UVR exposure, concurrent activities and sun-protective practices among primary schoolchildren

Comprehensive measures of ultraviolet radiation (UVR) exposure, concurrent activities and sun-protective practices are needed to develop and evaluate skin cancer prevention and sun protection interventions. The UVR exposures of 345 primary schoolchildren at 23 schools around New Zealand were measured using electronic UVR monitors for 1-week periods over 12 weeks in 2004 and 2005. In addition, ambient UVR levels on a horizontal surface were measured on-site at each school. Children completed activity diaries during the period UVR measurements were made and provided information on their indoor and outdoor status and clothing and sun protection worn. Mean total daily UVR exposure (7:00-20:00 h NZST + 1) at the body location where the UVR monitors were worn was 0.9 SED (standard erythemal dose, 1 SED = 100 J m(-2)). This was 4.9% of the ambient UVR on a horizontal surface. Mean time spent outdoors was 2.3 h day(-1). Differences in children's UVR exposure could be explained in part by activity, where outdoor passive pursuits were associated with higher UVR exposure rates than outdoor active and outdoor travel pursuits. Compared with older children, the activities of younger children, although labeled the same, resulted in different UVR exposures, either as a result of reporting differences or a real difference in UVR exposure patterns. UVR exposure rates were generally higher on weekdays compared with the weekend, confirming the important role of school sun protection and skin cancer prevention programs. High UVR exposure activities included physical education, athletics and lunch break.     

Agreement between diary records of time spent outdoors and personal ultraviolet radiation dose measurements

Little is known about the validity of self-recorded sun exposure and time spent outdoors for epidemiological research. The aims of the current study were to assess how well participants' self-recorded time outdoors compared to objective measurements of personal UVR doses. We enrolled 124 volunteers aged 40 and above who were identified from targeted subgroups of US radiologic technologists. Each volunteer was instructed to wear a polysulfone (PS) dosimeter to measure UVR on their left shoulder and to complete a daily activity diary, listing all activities undertaken in each 30 min interval between 9:00 A.M. and 5:00 P.M. during a 7 day period. In a linear regression model, self-recorded daily time spent outdoors was associated with an increase of 8.2% (95% CI: 7.3-9.2%) in the personal UVR exposure with every hour spent outdoors. The amount of self-recorded total daily time spent outdoors was better correlated with the personal daily UVR dose for activities conducted near noon time compared to activities conducted in the morning or late afternoon, and for activities often performed in the sun (e.g. gardening or recreation activities) compared to other outdoor activities (e.g. driving) in which the participant is usually shaded from the sun. Our results demonstrated a significant correlation between diary records of time spent outdoors with objective personal UVR dose measurements.     

Ultraviolet radiation exposure of children and adolescents in Durban,South Africa

The solar ultraviolet radiation (UVR) exposure of 30 children and adolescents in three age groups (4-6 years, 7-9 years and 13-14 years) was measured for 1 week in late summer (February-March) in Durban, South Africa, using UVR-sensitive polysulfone film badges (PSFB) attached to the lapel region of the body. The mean and median values for all ages over the study period were 2.0 and 1.2 standard erythemal dose (SED) units, respectively, where 1 SED = 100 J x m(-2). Individual PSFB doses were analyzed as a function of age, gender and behavior. No significant statistical differences were found between different age groups; however, there was a statistical difference between males and females, with males generally receiving higher PSFB doses. Subjects completed UVR exposure journals documenting their time outdoors, shade versus sun conditions, nature of their activities, clothing worn and their use of sunscreen for each day of the study. Activity patterns were noted as the most important factor influencing individual UVR dose. Ambient erythemal UVR was measured by a Yankee Environmental Systems UVB pyranometer, and a relationship between ambient UVR and individual UVR dose was derived. On average, subjects received a dose of 4.6% of the total daily erythemal UVR. Based on this factor, the potential dose of an individual over a full annual cycle was estimated. Accordingly, there were 139 days during the year when an individual with skin type I (light skin) would be likely to experience minimal erythema and 97 and 32 days for individuals with skin types II and III, respectively.     

Schoolyard Shade and Sun Exposure: Assessment of Personal Monitoring During Children's Physical Activity

Childhood exposure to ultraviolet radiation (UVR) is a major risk factor for the development of melanoma later in life. However, it is challenging to accurately determine personal outdoor exposure to UVR, specifically erythemally weighted UVR (UV_Ery), due to technological constraints, variable time–activity patterns, and the influence of outdoor environmental design. To address this challenge, this study utilized mobile and stationary techniques to examine the UV_Ery exposures of 14 children in a schoolyard in Lubbock, TX, in spring 2016. The aims of the study were to examine the influence of artificial shade on personal UV_Ery exposures and to assess full sun exposure ratios (ERs) within the same playground microenvironment. On average, personal wrist dosimeters worn during play in the sun measured 18% of the total onsite UV_Ery measured by a stationary UV pyranometer. Shade was found to significantly reduce the personal UV_Ery exposures by 55%, UVB_{280–315 nm} exposures by 91%, and the overall solar radiation by 84%. Substantial benefits can be garnered through focused design of children's recreational space to utilize shade—both natural and artificial—to reduce UVR exposures during play, and to extend safe outdoor stays. Finally, although the wrist is a practical location for a dosimeter, it often underestimates full exposures, particularly during physical activity.     

Constitutive and Relative Facultative Skin Pigmentation among Victorian Children Including Comparison of Two Visual Skin Charts for Determining Constitutive Melanin Density

Our aim was to examine the association between ethnicity, phenotype, sun behavior and other characteristics, and constitutive and relative facultative skin pigmentation. A total of 191 participants were recruited, with a mean age of 7.6 years (SD 3.4), during 2009–2011 from Maternal and Child Health Centres (MCHC) and schools in Melbourne, Australia. Parental questionnaire data were obtained on sun behavior and examination consisted of noting the child's natural skin, hair and eye color, ethnicity, nevi count and spectrophotometric melanin density (MD). Constitutive skin pigmentation was estimated from buttock MD. Relative facultative skin pigmentation was estimated by hand compared with buttock absorption. Ethnicity, hair color and skin color were associated with constitutive and facultative skin pigmentation on univariate analysis. Higher ambient ultraviolet radiation (UVR) in the past month, greater freckling, greater nevi and increased sun exposure over the past year were related to darker facultative skin pigmentation. Sun exposure over the life course was not. The two skin charts accounted for 39.7% and 21.4% of buttock MD, respectively. Relative facultative skin pigmentation is associated with recent UVR levels, not life‐course sun exposure. Relative facultative skin pigmentation may not be a useful measure of sun exposure over the early life course. Skin color charts can be used to assess constitutive skin pigmentation if spectrophotometry is not available.     

Correlation between Objective Measures of Sun Exposure and Self-Reported Sun Protective Behavior and Attitudes in Predominantly Hispanic Youth

Melanoma incidence is increasing, with poor prognosis cases growing faster in California Hispanics than in non-Hispanic whites. Ultraviolet Radiation (UVR) exposure as a child has been found to disproportionately increase the risk of melanoma. To determine correlates of UVR exposure in this high-risk population, we conducted a study in predominately Hispanic 4th and 5th grade classrooms in Los Angeles County, a high UVR environment, during the spring. To address potential reporting bias, electronic UV dosimeters were utilized to objectively measure the association between UVR exposure and constructs (acculturation, sun protective behavior and knowledge, family interventions) obtained on baseline questionnaires (n = 125). Tanning attitude (wanting to get a tan) was associated with lower median time spent outside (1.73 min versus 22.17, AUC 82.08, Sensitivity 0.78, Specificity 0.73) and standard erythemal dose (SED) on weekends, but positively associated with sun protective knowledge. Sun protective knowledge and family discussion of sunscreen were also inversely associated with objectively measured time outside. Students spent a median 30.61 (IQR 19.88) minutes outside per day (SED 0.30, IQR 0.20), with only 35.70% of it occurring in nonschool hours. We determined the majority of UVR exposure in this population occurs at school, providing valuable guidance for future interventions.     

Sun Exposure at School

There is strong evidence that sun exposure during childhood and adolescence plays an important role in the etiology of skin cancer, in particular cutaneous melanoma. Between the age of 6 and 18, most children and adolescents will spend around 200 days per year at school and may receive a substantial fraction of their daily total solar ultraviolet radiation (UVR) exposure while at school. This study estimated the average daily erythemally effective dose of 70 grade 8 students from a high school in Townsville during 5 school days in July 1998. Through UV measurements of shade locations at the school and a combination of frequency counts and a questionnaire of grade 8 students, it was possible to determine the fraction of solar UVR reaching under the shade structures during lunch breaks and routine outdoor activities. Also, a routinely operating UV-Biometer provided the annual variation of the daily dose that was used to calculate exposure levels for the 70 students. Our results suggest that up to 47% of the daily total dose fell within the time periods where students were outdoors during school hours. For students not seeking shade structures during the breaks (which usually was the case when involved in sport activities such as basketball or soccer), the average daily dose could have been as high as 14 SED (standard erythemal dose). Using results from the questionnaire of 70 grade 8 students, their average annual dose while at school was 414 SED or 2 SED per school day. However, the distribution of average daily erythemal effective dose per grade 8 student over the whole year showed that on 31% of all school days in 1998, this dose was exceeded. Because most previous attempts to change arguably poor sun-protective behavior of young Australian children and adolescents at school showed little success, one way of decreasing the amount of harmful UVR reaching unprotected skin is the more careful design of shade structures at schools.     

A Case–Sibling Assessment of the Association Between Skin Pigmentation and Other Vitamin D-related Factors and Type 1 Diabetes Mellitus

Fair skin pigmentation has been associated with a higher risk of type 1 diabetes mellitus (T1DM). The aim is to compare children with T1DM directly to a sibling in relation to their skin pigmentation in sun-exposed and unexposed sites, past sun exposure and methylation of the VDR gene promoter. The sample consisted of children with T1DM attending a diabetes outpatient clinic and siblings (total n  = 42). Cutaneous melanin density was estimated using a spectrophotometer. Parental report on past sun exposure was obtained. DNA methylation analysis of the VDR gene promoter was conducted. Matched data analysis was performed comparing each case directly to their sibling. Cases were significantly more likely to have lighter skin pigmentation at the upper arm (AOR 0.69 [95% CI: 0.52, 0.90]; P  = 0.01). Low infant sun exposure was imprecisely associated with a two-fold increase in T1DM risk (AOR 2.43 [95% CI: 0.91, 6.51]; P  = 0.08 for under 1 h of winter sun exposure per leisure day). The VDR gene promoter was completely unmethylated in both cases and siblings. The previously demonstrated association between light skin pigmentation and T1DM risk was evident even in this comparison across sibling pairs. Further work on past UVR exposure and related factors such as skin pigmentation is required.     

Estimating Sun Exposure of Children in Day Care Nurseries in South Oxfordshire,UK

Exposure to ultraviolet radiation and sunburn during childhood and adolescence is linked to increased risks of melanoma and basal cell carcinoma later in life. Infants and toddlers are thought to be unusually vulnerable to UVR because of lower levels of melanin, a thinner stratum corneum and a higher surface area/body mass ratio. The aim of this study was to assess variations in the available erythema effective radiant doses to young children in day care nurseries in South Oxfordshire, UK over 7 years between 2008 and 2014. The data were analyzed in three distinct seasons according to a series of realistic exposure scenarios taking into account nursery routines. The results indicate the time of year when high doses are to be expected and provide strong support for arguments in favor of raising public awareness of sun protection earlier in the year.     

Solar Ultraviolet Radiation Exposure of South African Marathon Runners During Competition Marathon Runs and Training Sessions: A Feasibility Study

Marathon runners spend considerable time in outdoor training for and participating in marathons. Outdoor runners may experience high solar ultraviolet radiation (UVR) exposure. South Africa, where running is popular, experiences high ambient solar UVR levels that may be associated with adverse health effects. This feasibility study explores the use of personal dosimeters to determine solar UVR exposure patterns and possible related acute health risks of four marathon runners during marathons and training sessions in Cape Town and Pretoria. Runners running marathons that started early in the day, and that did not exceed 4 hours, yielded low total solar UVR exposure doses (mean 0.093 SED per exposure period run, median 0.088 SED, range 0.062–0.136 SED; average of 16.54% of ambient solar UVR). Training sessions run during early morning and late afternoon presented similar results. Several challenges hindered analysis including accounting for anatomical position of personal dosimeter and natural shade. To assess health risks, hazard quotients (HQs) were calculated using a hypothetical runner's schedule. Cumulative, annual solar UVR exposure‐calculated acute health risks were low (HQ = 0.024) for training sessions and moderate (HQ = 4.922) for marathon runs. While these data and calculations are based on 18 person‐days, one can measure marathon runners' personal solar UVR exposure although several challenges must be overcome.     

Measurement of the UVR Exposures of Expeditioners on Antarctic Resupply Voyages†

A study to assess the potential exposure to solar UV radiation of expeditioners on Australian Antarctic resupply voyages was carried out over the Austral summers of 2004/2005 to 2006/2007. Subjects wore UVR‐sensitive polysulphone (PS) badges on the chest for the duration of their working day, which generally ranged from 5 to 10 h, but could be as long as 14 h. Measurements were carried out during unloading of two vessels while they were at the three Australian Antarctic stations. The subjects wore standard Australian Antarctic Division clothing assemblages, although the face and hands and in some cases more of the limbs were uncovered and subjected to exposure to UVR. The badges worn by the subjects received exposures ranging from 0.2 to 18 standard erythemal doses (SEDs), with a median of 3.2 SEDs. However, comparison with occupational exposure limits showed that more than 80% of the subjects’ PS badges received UVR exposures in excess of the limits while 31% received more than five times the limits. Despite sun protection being provided more than 70% of the workers reported mild erythema.     

PERSONAL DOSIMETRY OF SOLAR UV RADIATION FOR DIFFERENT OUTDOOR ACTIVITIES

Abstract Quantifying individual exposure to ultraviolet radiation (UVR) is critical to understanding the etiology of a number of diseases including nonmelanotic and melanotic skin cancers. Measurements of personal exposure to solar UVR were made in Hobart, Tasmania in February (summer) 1991 for six different outdoor activities using UVR-sensitive polysulfone (PS) film attached at seven anatomical sites. Concurrent behavioral and environmental observations were also made. To date many studies have relied on subject recall to quantify past solar UVR exposures. To gain insight into the accuracy of subject recall the measured UVR exposures received by different subjects using the PS film were compared to those calculated from personal diaries and ambient solar UVB levels from a monitoring station. In general, when UVR exposure activities took place under close supervision, good correlations were obtained between the PS badges and the ambient measurements/diaries approach. Ultraviolet radiation exposures for the field study involving 94 subjects engaged in a number of outdoor activities are presented.     

Solar Ultraviolet Radiation Exposure and Sun Protection Behaviors and Knowledge Among a High‐Risk and Overlooked Group of Outdoor Workers in South Africa

The exposure of outdoor car guards to solar ultraviolet radiation (UVR), the majority with deeply pigmented skin, to solar UVR was measured for five consecutive days during early spring (September 2017) in South Africa using electronic UVR dosimeters attached to the upper arm of each participant. The exposure of the nape of the neck, forehead, nose, cheek and hand was extrapolated from the measurements. The onsite ambient solar UVR on a flat, horizontal, unshaded surface was measured concurrently. The sun‐related knowledge, behavior and attitudes of the car guards were evaluated using questionnaires. Total personal daily solar UVR exposure as a percentage of the ambient solar UVR exposure was 24%. The exposure of car guards on several body sites was in excess of the occupational threshold limit value. Sleeved shirts and hats were the most commonly used sun protection measures (worn by 70% and 80%, respectively). Considering the high levels of solar UVR reported on most days throughout the year in South Africa, more studies quantifying the personal exposure of outdoor workers in both the informal and formal sectors are necessary.     

Seasonal Variation in Measured Solar Ultraviolet Radiation Exposure of Adults in Subtropical Australia

Generating accurate population-specific public health messages regarding sun protection requires knowledge about seasonal variation in sun exposure in different environments. To address this issue for a subtropical area of Australia, we used polysulphone badges to measure UVR for the township of Nambour (26° latitude) and personal UVR exposure among Nambour residents who were taking part in a skin cancer prevention trial. Badges were worn by participants for two winter and two summer days. The ambient UVR was approximately three times as high in summer as in winter. However, participants received more than twice the proportion of available UVR in winter as in summer (6.5%vs 2.7%, P < 0.05), resulting in an average ratio of summer to winter personal UVR exposure of 1.35. The average absolute difference in daily dose between summer and winter was only one-seventh of a minimal erythemal dose. Extrapolating from our data, we estimate that ca. 42% of the total exposure received in the 6 months of winter (June–August) and summer (December–February) is received during the three winter months. Our data show that in Queensland a substantial proportion of people’s annual UVR dose is obtained in winter, underscoring the need for dissemination of sun protection messages throughout the year in subtropical and tropical climates.     

Comparing Handheld Meters and Electronic Dosimeters for Measuring Ultraviolet Levels under Shade and in the Sun

This study aimed to compare the validity, reliability and practicality of alternative portable methods for measuring erythemal UVR levels in passive recreation areas in public parks. UVR levels were measured for point in time comparisons between Solarmeter 6.5 handheld meters and time‐stamped electronic dosimeters in a large central park in Melbourne, Australia. Observations were made at 20 locations in the park by two research assistants under two conditions: (1) matched shade (2) contrasting shade—no shade. Comparisons were also made with scientific instruments on the UVR monitoring station rooftop and by remotely selecting UV records and forecasts on cloud‐free dates of park observations. There was good agreement between the portable UVR instruments in the park setting as confirmed via Bland Altman plots, while the dosimeter appeared less sensitive to change in shade conditions. The rooftop measurements showed that the Solarmeter 6.5 UVR readings were comparable to those of the adjacent rooftop instruments. The practicalities of using the dosimeters and Solarmeters for behavioral studies are discussed. These findings provide a basis for use of the Solarmeter 6.5 to measure changes in UVR levels due to different environmental conditions with relative accuracy for intervention studies in outdoor settings.     

Vitamin D Level in Summer and Winter Related to Measured UVR Exposure and Behavior

The influence of the summer UVR exposure on serum-25-hydroxyvitamin D (25(OH)D) in late summer and winter was investigated in an open study on 25 healthy, adult volunteers. The UVR exposure dose in standard erythema dose (SED) was monitored continuously during a summer season with personal, electronic wristwatch UVR dosimeters and sun exposure diaries. Constitutive and facultative skin pigmentation was measured in September. 25(OH)D was measured in September and February and was in mean 82 nmol/L ± 25 (mean ± SD) in September and 56 nmol/L ± 19 (mean ± SD) in February. The received cumulative UVR dose measured during a mean of 121 days was 156 SED ± 159 (mean ± SD). The following UVR exposure parameters correlated with 25(OH)D in September and February, respectively: (1) The cumulative UVR dose ( r  = 0.53; P  < 0.01) and ( r  = 0.43; P  = 0.03); (2) Mean daily hours with UVR measurements monitored by the dosimeter ( r  = 0.64, P  = 0.001) and ( r  = 0.53; P  = 0.007); (3) Days "with sun-exposed upper body" ( r  = 0.58, P  = 0.003) and ( r  = 0.50; P  = 0.01); (4) Facultative pigmentation ( r  = 0.47; P  < 0.02) and ( r  = 0.7; P  < 0.001); (5) Constitutive pigmentation ( r  = 0.06, n.s.) and ( r  = 0.43, P  = 0.03). Neither days "sunbathing" nor days with "sunscreen applied" correlated with 25(OH)D. The fall in 25(OH)D during winter was dependent on the entry value.     

Measuring Exposure to Solar Ultraviolet Radiation Using a Dosimetric Technique: Understanding Participant Compliance Issues

Personal ultraviolet dosimeters have been used in epidemiological studies to understand the risks and benefits of individuals' exposure to solar ultraviolet radiation (UVR). We investigated the types and determinants of noncompliance associated with a protocol for use of polysulphone UVR dosimeters. In the AusD Study, 1002 Australian adults (aged 18–75 years) were asked to wear a new dosimeter on their wrist each day for 10 consecutive days to quantify their daily exposure to solar UVR. Of the 10 020 dosimeters distributed, 296 (3%) were not returned or used (Type‐I noncompliance) and other usage errors were reported for 763 (8%) returned dosimeters (Type‐II noncompliance). Type‐I errors were more common in participants with predominantly outdoor occupations. Type‐II errors were reported more frequently on the first day of measurement; weekend days or rainy days; and among females; younger people; more educated participants or those with outdoor occupations. Half (50%) the participants reported a noncompliance error on at least 1 day during the 10‐day period. However, 92% of participants had at least 7 days of usable data without any apparent noncompliance issues. The factors identified should be considered when designing future UVR dosimetry studies.     

Validation of Brief Questionnaire Measures of Sun Exposure and Skin Pigmentation Against Detailed and Objective Measures Including Vitamin D Status

Self‐reported sun exposure is commonly used in research, but how well this represents actual sun exposure is poorly understood. From February to July 2011, a volunteer sample (n = 47) of older adults (≥45 years) in Canberra, Australia, answered brief questions on time outdoors (weekdays and weekends) and natural skin color. They subsequently maintained a sun diary and wore an ultraviolet radiation (UVR) digital dosimeter for 7 days. Melanin density was estimated using reflectance spectrophotometry; lifetime sun damage was assessed using silicone casts of the back of the hand; and serum 25‐hydroxyvitamin D (25(OH)D) concentration was assayed. Questionnaire‐reported time outdoors correlated significantly with diary‐recorded time outdoors (Spearman correlation r_s = 0.66; 95% CI 0.46, 0.80; P < 0.001) and UVR dosimeter dose (r_s = 0.46; 95% CI 0.18, 0.68; P = 0.003), but not 25(OH)D concentration (r_s = 0.24; 95% CI ?0.05, 0.50; P = 0.10). Questionnaire‐reported untanned skin color correlated significantly with measured melanin density at the inner upper arm (r_s = 0.49; 95% CI 0.24, 0.68; P < 0.001). In a multiple linear regression model, statistically significant predictors of 25(OH)D concentration were self‐reported frequency of physical activity, skin color and recent osteoporosis treatment (R² = 0.54). In this study, brief questionnaire items provided valid rankings of sun exposure and skin color, and enabled the development of a predictive model for 25(OH)D concentration.     

Sun Exposure and Vitamin D Status as Northeast Asian Migrants Become Acculturated to Life in Australia

Vitamin D deficiency is more common in Northeast‐Asian immigrants to western countries than in the local population; prevalence equalizes as immigrants adopt the host country's culture. In a community‐based study of 100 Northeast‐Asian immigrants in Canberra, Australia, we examined predictors of vitamin D status, its association with indicators of acculturation (English language use; time since migration) and mediators of that association. Participants completed a sun and physical activity diary and wore an electronic ultraviolet radiation (UVR) dosimeter for 7 days. Skin colour was measured by reflectance spectrophotometry. Serum concentrations of 25‐hydroxyvitamin D (25(OH)D) and cardio‐metabolic biomarkers were measured on fasting blood. In a multiple linear regression model, predictors for 25(OH)D concentration were season of blood collection, vitamin D supplementation, UVR exposure, body mass index, physical activity and having private health insurance (R² = 0.57). Greater acculturation was associated with lower risk of vitamin D deficiency (de‐seasonalized 25(OH)D level <50 nmol L^?1) (Adjusted Odds Ratio (AOR): 0.22 [95%CI 0.04–0.96]); this association was statistically mediated by physical activity and time outdoors. Vitamin D deficiency was associated with higher total cholesterol levels (>5.0 mmol L^?1) (AOR: 7.48 [95%CI 1.51–37.0]). Targeted public health approaches are required to manage the high prevalence of vitamin D deficiency in migrants retaining a traditional lifestyle.