Public Awareness of Sun Exposure Risks and Photoprotection for Preventing Pigmentary Skin Disorders in Saudi Arabia

UVR is a primary environmental factor from sunlight, categorized into UVA, UVB and UVC based on wavelength [1,2]. While the ozone layer blocks UVC, both UVA and UVB reach the Earth's surface and affect the skin. UVB is primarily absorbed by the epidermis, causing sunburn and DNA damage, whereas UVA penetrates deeper into the dermis, contributing to long-term issues like photoaging and pigmentary changes [1,2]. Visible light, particularly in the blue-violet spectrum, also exacerbates pigmentation disorders, especially melasma in darker skin types [3,4]. Hormonal factors can also play a role [3,4].

The Effects of UVR

Cumulative UVR exposure accelerates the degradation of collagen and elastin, leading to wrinkles and hyperpigmentation and significantly raises the risk of skin cancers, including BCC, SCC and melanoma [5]. Both UVB and UVA contribute to cancer development through distinct but overlapping pathways; UVB causes mutations in the p53 tumor suppressor gene, while UVA induces oxidative stress [5].

Photoprotection & Challenges

Universal photoprotection is recommended and includes avoiding peak sun hours, wearing protective clothing and applying broad-spectrum sunscreen [6-8]. However, sunscreen use is often suboptimal. People commonly apply inadequate amounts, miss critical areas and fail to reapply after activities like swimming [9]. The WHO advises reapplying every two hours but individuals often apply only 25-50% of the recommended quantity, significantly reducing effectiveness [9].

Recent Advances and Gaps

Enhanced sunscreens now contain antioxidants and botanical agents that neutralize Reactive Oxygen Species (ROS) and offer additional defense against inflammation and pigmentation [10-13]. Despite these advancements, public awareness remains insufficient, particularly in high-irradiance regions like Saudi Arabia [14]. A study in Jazan Province found that while women and those with higher education levels have better knowledge, misconceptions and cosmetic concerns hinder consistent use [14].

This study, therefore, aims to identify these knowledge gaps and promote evidence-based sun protection behaviors, particularly in Saudi Arabia regions with a high UV index, to reduce the incidence of pigmentary disorders and UV-induced skin damage. (Paraphrased).

Study Population

This was a cross-sectional study conducted to assess public awareness of sun exposure risks and photoprotection for preventing pigmentary skin disorders in Saudi Arabia. The study targeted all parts of the Kingdom of Saudi Arabia (central, eastern, western, northern and southern regions). The study population consisted of individuals residing in Saudi Arabia, including both Saudi citizens and expatriates. The sample included individuals of different age groups, genders and occupational backgrounds, with a focus on those frequently exposed to sunlight or at risk of developing pigmentary skin disorders.

The sample size was calculated using the following formula:

n = Z² P(1-P)/d²

(1.96)^2*(0.5)(1-0.5)/(0.05)² = 384

Where:

n = The sample size

Z = The statistic corresponding to level of confidence = 1.96

P = Expected prevalence (that could be obtained from similar studies or a pilot study conducted by the researchers) = 0.5

d = Precision (corresponding to effect size) = 0.05

Data Collection

The study took approximately 6 months for data collection, analysis and report writing. The research team used an online, semi-structured, self-administered questionnaire to gather data. The survey, created with (Google Forms), its link was distributed through social media platforms, specifically WhatsApp and Facebook groups obtained from friends, acquaintances and relatives. The distribution included males and females over the age of 18 with different educational backgrounds. The data were collected through a pre-tested and pre-designed online questionnaire. The participants' responses were numbered sequentially for each question (1, 2, 3, etc.). Part of the questionnaire included demographic data of the participants and the other part included questions related to their awareness of sun exposure risks and photoprotection for preventing pigmentary skin disorders.

Statistical Analysis

The collected data were checked for completeness and coded in an Excel sheet. The data were analyzed using IBM SPSS Statistics for Windows, Version 27.0 (Released 2020; IBM Corp., Armonk, New York, United States). A descriptive statistical analysis was conducted for all of the variables. Continuous variables were presented as a median and interquartile range, while categorical variables were expressed as numbers and percentages. Analysis of variance (ANOVA) was test the significant difference at P<0.05 among knowledge, barrires and misconcepts and awareness. Since the data do not follow a normal distribution, the researcher used nonparametric tests such as the Mann-Whitney test and the Kruskal-Willis test to test the extent to which the study dimensions differ according to demographic variables. In addition the correlation coefficient among knowledge, barrires and misconcepts and awareness was processed using Correlation Spearman's test at p<0.05 [15].

Inclusion and Exclusion Criteria

Inclusion: All males and females aged 18 and above living in Saudi Arabia.

Exclusion

Individuals under 18 years old and those who did not reside in Saudi Arabia.

Ethical Considerations

Informed consent was obtained from all subjects. Ethics approval was obtained from the ethics committee of Majmaah University. Data were kept confidential and used only for the sole purpose of this study.

Socio-Demography and Sample Characteristics

The descriptive statistical analyst to the participants' sociodemographic data showed that of 500 questionnaires 305(61.0%) are responded (Table 1). The majority of the participants are; female (275: 90.2%). Of 305 participants, aged 18-35 years 175(57.4%). in the university degree and secondary school levels (195: 63.9% and 76: 24.9%), students (103: 33.8%) followed by and unemployed (87: 28.5%) and office workers (76: 24.9%). Of 305 participants and live in the northern of Saudi Arabia (188: 61.6%).

Knowledge of Sun Exposure and Skin Health (Paraphrased)

From Table 2 the descriptive statistical analysis indicated that of the 305 participants 289(93.8%) know that skin pigmentation issues like melasma and hyperpigmentation can be brought on by exposure to the sun. A 251(82.3%) recorded variety of the primary consequences of prolonged exposure to sunlight ranging from skin darkening or pigmentation, sunburn, premature aging and vitamin D deficiency. A 263(86.2%) know that the sun is essential for maintaining good health as it helps the body produce vitamin D. A 180 (59%) reported that stay out in the sun a period ranged between 10-30 minutes without protection is safe and 239(78.4%) reported that 12-3 pm is the worst time of day to be exposed to the sun. A 271(88.9%) recorded that the attributes; spending time outdoors without sun protection, having fair or light-colored skin, having a history of sunburns, living in a hot or sunny climate and taking certain medications that increase sun sensitivity raise the possibility of solar damage. A 173(57.4%) believe that sunscreen should be worn every day, even on overcast day. A112(36.7%) and 87(28.5%) think that exposure to the sun only damages the skin or can affect skin and other bodily parts, respectively. A 99(32.5%) have never experienced any issues while 98(32.1%) have developed pigmentation issues (melasma, dark spots). Eighty three (27.2%) participants always use sunscreen outside, while 112(36.7). A 158(51.8%) uses SPF 50 or higher for sun protection. A 234 (76.7%) use different protection techniques as sunscreen, sunglasses, staying in the shade, wearing protective clothes and avoiding outdoor activities during peak sun hours. A 120(39.3%) obtain the sun protection information from social media and 110(36.1%) from Healthcare professionals (doctors, dermatologists). A 183(60.0%) chooses the sunscreen purchase based on different criteria the most important criteria are based on dermatologist recommendation (56:18.4%) and SPF level (38:12.5%). A 98(32.2%) and 91(29.8%) always just buy based on brand or SPF and always check the ingredients before buying, respectively. A 212(69.5%) believe that sunscreen should be combined with other protective measures. More than half (168: 55.1%) of the respondents believed that sunscreen reduces the negative consequences of sun exposure but does not eliminate risks. A 114(37.4%) are trust sunscreen products, while 77(25.2%) shunned sunscreen because they are worried about chemicals in sunscreen. A 112(36.7%) forget to apply it, 62 (20.3%) have many reasons as they feel uncomfortable on their skin, forget to apply and prefer natural sun protection, prefer natural sun protection (e.g., shade, clothing).

Table 1: Data and Samples Characteristics

Barriers and Misconceptions (Paraphrased)

For barriers and misconceptions characters, 205(67.2%) participants don't believe that sun protection is just necessary for those with lighter skin and 225(73.8%) think that those with light and dark skin need sun protection (Table 3). Of the 305 participants, 205(67.2%) believed that sun exposure is harmful year-round. In addition, 226(74.1%) think that UV rays can still penetrate windows and shade, while 39(12.7%) believed that shade or glass completely blocks UV rays. A 69(22.6%) believed that one application of sunscreen is enough to provide adequate protection throughout the day while the majority of them believed that sunscreen should be reapplied regularly. A 187(61.3%) believed that they can still get enough vitamin D with using sunscreen. A 192(63.0%) participants think that tanning increases sun damage and skin cancer risk, while low count (34: 11.1%) believed that tanning protects the skin from future sunburn. Hundred and thirty seven (44.9%) participants believe that conventional sunscreen is more effective and 108(35.4%) don't shore but 60(19.7%) believed that SPF-containing moisturizers or makeup offer the same degree of sun protection as conventional sunscreen. A 116(38.0%) of 305 participants think that using SPF as SPF 50+ provides all-day protection, while 96(31.5%) believed that sunscreen should still be reapplied regularly and 93(30.5%) are not shore. A 172(56.4%) believed that sunburn in not the only indication of UV damage but damage can occur without visible sunburn. A 17.0 and 14.8% of the participants received advice that they don't need for use sunscreen every day from friends/family and social media represents, while, 208(68.2%) know that sunscreen is important. A 58.7% believed that sunscreen should be used daily. A 198(64.9%) and 32 (10.5%) are motivated to use sunscreen more frequently especially doctors or dermatologist recommendations, more public awareness campaigns (27: 8.9%) and more affordable sunscreen options (22: 7.2%).

Table 2: Descriptive Analysis of the Knowledge of Sun Exposure and Skin Health Characters of the Participants

Table 2: Continue

Recommendations and Awareness (Paraphrased)

The results of the descriptive statistical analysis in Table 4 showed that 288(94.4%) of the sample believe that Saudi Arabia should launch more sun protection awareness campaigns. Two hundred and forty of all participants represent 78.7% chose different strategies to raise awareness as social media campaigns (13.4%), education programs, advertisements on TV and radio, free distribution of sunscreen samples and awareness programs in hospitals and clinics. Of 305 participants, 274 (89.8%) are interested receiving more information about sun protection and skin health. A 191 (62.7%) of participants reported that Saudi Arabians need more awareness about the dangers of sun exposure and the significance of sun protection. Most of the participants (201: 65.9%) have never received formal sun protection course but 57(18.7%) and 47(15.4%) received formal course through a healthcare professional or learned in the school/university, respectively. The majority of participants represented by 150(50%) felt that public awareness initiatives about sun protection should be take place in schools and universities, hospitals and clinics, social media platforms shopping malls and public places. A 242(79.3%) of the participants believe that greater public education regarding sun protection should come from dermatologists and other medical professionals through providing more guidance. One hundred and seventy seven (58.0%) showed that mobile applications is helpful as it offers individualized sun protection advice as well as daily UV index alerts. Of the 305 participants a 147(48.2%) would support the nationwide initiative to encourage sun protection practices, like "Sunscreen Day" and 68(31.5%) participants reported that their support for this initiative will be conditional upon providing free sunscreen samples.

Table 3: Descriptive Analysis of the Barriers and Misconceptions Characters of the Participants

Table 4: Descriptive Analysis of the Recommendations and Awareness Characters of the Participants

The Differences in the Study's Variables According to Socio-Demography Characteristics

The major hypothesis is that there are statistically significant differences in the study's variables according to (Gender, Age, Education Level, occupation, region). Statistically significant differences in the study's variables according to the Gender are conducted used the Mann-Whitney test to variance analysis. Table 5 shows that the level of significance for the dimension (Sun Protection Practices) according to Gender is less than 0.05 (sig.<0.05), which mean that there's significant difference in the study sample's answers to these dimensions. While the remaining dimensions are greater than 0.05 (sig.>0.05), which mean that there's no significant difference in the study sample's answers to these dimensions according to Gender.

Significant differences in the study's variables according to Age is investigated using Kruskal-Wallis test to variance analysis and age. The results in Table 6 show that the level of significance between the dimension (Knowledge of Sun Exposure and Skin Health) and age categories is less than 0.05 (sig.<0.05), which mean that there's significant difference in the study sample's answers to these dimensions according to Age. While the remaining dimensions are greater than 0.05 (sig.>0.05), which mean that there's no significant difference in the study sample's answers to these dimensions according to Age.

Statistically, significant differences in the study's variables according to education level, the Kruskal-Wallis test to variance analysis is used. Table 7 shows that the level of significance for the dimensions (Knowledge of Sun Exposure and Skin Health and Barriers and Misconceptions) is less than 0.05 (sig.<0.05), which mean that there's significant difference in the study sample's answers to these dimensions according to education level. While the remaining dimensions are greater than 0.05 (sig.>0.05), which mean that there's no significant difference in the study sample's answers to these dimensions according to education level.

Table 5: The Results of the Variance Analysis of the Study's Variables According to the Gender

Table 6: The Result of the Variance Analysis of the Study's Variables According to Age

Table 7: The Result of the Variance Analysis of the Study's Variables According to Education

Statistically significant differences in the study's variables according to occupation, the Kruskal-Wallis test to variance analysis is used. Table 8 shows that the level of significance for the dimension (Knowledge of Sun Exposure) is less than 0.05 (sig.<0.05), which mean that there's significant difference in the study sample's answers to these dimensions according to occupation. While the remaining dimensions are greater than 0.05 (sig.>0.05), which mean that there's no significant difference in the study sample's answers to these dimensions according to occupation.

The Kruskal-Wallis test to variance analysis shows that the level of significance for the dimensions (Sun Protection Practices and Recommendations and Awareness) is less than 0.05 (sig.<0.05), which mean that there's significant difference in the study sample's answers to these dimensions according to region. While the remaining dimensions are greater than 0.05 (sig.>0.05), which mean that there's no significant difference in the study sample's answers to these dimensions according to region (Table 9).

Table 8: The Result of the Variance Analysis of the Study's Variables According to Occupation

Table 9: The Result of the Variance Analysis of the Study's Variables According to Region

Table 10: Spearman's Correlation Coefficient Among the Study Variables

**Correlation is significant at the 0.01 level

Correlation Coefficient Among the Participant's Responses to Questions of the Three Studied Variables

The Table 10 showed the correlation spearman, among the knowledge of sun exposure and skin health, barriers and misconceptions and recommendations and awareness variables. Significant positive correlation was recorded between knowledge of sun exposure and skin health and barriers and misconceptions variables (r = 0.374) at p<0.01. Also between knowledge of sun exposure and skin health, barriers and misconceptions and recommendations and awareness variables at p<0.01 (r = 0.349). Also, significant correlation at p<0.01 (r = 0.413) between barriers and misconceptions and recommendations and awareness variables.

Stressors such as solar ultraviolet radiation (UVR) can affect skin health [15,16] Among these risk factors, skin damage induced by solar UVR is an escalating problem in dermatology, along with an increased incidence of skin cancer, especially non-melanoma skin cancer [15].

Knowledge, wright concepts, attitudes and practices to sun exposure risks reveal important insights about public awareness and behaviors to skin health, include skincare various practices. Skin problems significantly effect on individuals' health [17], especially in older adults, as the skin structural changes [18]. The most essential functions of the skin are maintenance of water, electrolytes and protein retention [19], acting as a barrier from external environment to internal tissues [20,21], sweat and vitamin D excretion, absorbing the beneficial dose of UV, regulating temperature and autonomic/immunologic actions.

This study evaluated the knowledge, misconcepts, practices and awareness of participants from Saudi Arabia to sun exposure risk. The results of the participated sample show that these populations need to be done to provide more education individuals within these population groups that should aid to improve their knowledge, correct the misconcepts, behavior towards skincare and encourage them to follow wright practices that will offer them opportunities for healthier lives.

Five hundred questionnaires were sent electronically to 500 individuals, with the target of 384 responses. The results showed that 305(61%) individuals responded. Therefore, the study didn't achieved a response rate. This may be due to the lack of interest of a large part (49%) of the sample.

The Participants' sociodemographic characters indicated that the most respondents are female which 1.5 duplicate is more than that recorded in Jazan area [21]. This result may be indicated a bias or may be they are the most interested for skin healthcare. In addition, the majority of respondents were young adults (78.3%) with a high level of education (97.0%), primarily living in the central region of Saudi Arabia, which is an area with higher socioeconomic status and education. The present data indicated a bias to these categories, also indicated that these data is normal for these categories (paraphrased).

In terms of the knowledge, most of participants well know the adverse effect of exposure to sunlight on skin pigmentation issues, primary consequences of prolonged exposure to sunlight ranging from skin darkening or pigmentation, sunburn, premature aging and vitamin D deficiency. This knowledge promotes the most respondents to use sunscreen SPF 50 and different sun protection techniques outside. Social media and healthcare professionals represented the main knowledge for sun protection. High percentages of these sources may be due to the high percentage of those have skin disease. In addition, most of the participants have information to select and buy appropriate sunscreen. Most of the participants believe that it should be combined sunscreens with other protective measures and believe that sunscreen reduces but does not eliminate risks. In spite of participants good knowledge high percentage of them forgets to apply sunscreens. Results of this study are in consistent with the findings of study. The Good knowledge of the most participants about skin sun exposure risks influence on using skin protection and this indicating high awareness for the current issue. In addition it indicated a gap between knowledge and application (paraphrased).

Regarding to barriers and misconcepts, most of most the participants have wright concepts. Where most of them believed that lighter and darker skins need sun protection, UV rays penetrate windows and shade, so most of them prefer applying sunscreen regularly as they can still get enough Vitamin D. Also, most of respondents prefer using sun screen than tanning and think that tanning increases sun risks. Dermatologists recommendations and public awareness campaigns are important factors motivate most participants to apply sun screen protections (paraphrased).

Protective measures, such as limiting outdoor activities during peak UV hours, seeking shade, wearing suitable hats and clothing and sunglasses and using sunscreen, play a crucial role in preventing and saving the skin against disorders [22,23]. Practices related to sun exposure protection varied widely from region to region and country to others, with 57.7 of the total participants is always use sunscreen is higher than the findings from a previous study in Gazan (KSA) and Peru [21,24]. This variation could be attributed to differences in socioeconomic status and level of education among the participants. Concerning proper sunscreen application, 225(73.8%) recognized that the lighter as darker-skinned peoples need to apply sunscreen repeatedly every day for and the maximum time for exposure is 10-30 minutes. These results highlight a noticeable variation between knowledge behaviors. In spite of knowing the risks of sun exposure, many participants reported inconsistent sun protection practices. This suggests a potential gap between awareness and actual application of preventive measures.

The current study also indicates that sciodemographic characteristics such as gender, age, level of education, occupation and place of residence have a significant impact on knowledge level and the awareness of participants.

There is a positive correlation between knowledge of harmful of sun exposure on skin and misconcepts and behavior toward skin protection and awareness, also, positive correlation was between behavior toward skin protection and awareness. Public education from dermatologists and finally, most of participants agreed that to be a part of a nationwide initiative to encourage sun protection practice.

In contrast to study, the current results indicate that low gap between knowledge, skin protection and awareness. This conclusion is supported by that the most of participants need to raised there awareness through different strategies. In addition, the willingness of most participants to take part in a nationwide initiative to encourage sun protection practices.

The positive significant correlation showed low gap between knowledge, skin protection and awareness may be due to the bios to category of the study sample, where 90% of participants are females, youngest ages, belonging to university degree and students.

Therefore, the sample should include approximately equal counts of people from different segments of society to clearly demonstrate the gap between the knowledge about the harmful of sun exposure and the behaviors related the use of different sunscreen methods. This will also reveal the extent to which knowledge and use of sunscreen affect awareness.

The current study showed that most participants have good knowledge about the risks of sun exposure on the skin and understand the importance of using sunscreen and other protective measures. The results also showed a positive correlation between knowledge and correct perceptions about sun exposure risks and sun protection behaviors. However, there is a need for further awareness and education to enhance knowledge and correct perceptions about sun exposure risks and sun protection behaviors among different segments of society. Especially, since there is a low gap between knowledge and actual sun protection behaviors, which requires ongoing efforts to promote awareness and adherence to sun protection behaviors. Further studies are needed with a large sample distributed along the KSA without bias to gender, age, education level, occupation and region.

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