# Sun Exposure Behaviors and Knowledge Among the At-Risk Population: Results From an International Survey, the HELIOS Project

Thierry Passeron, Brigitte Dreno, Susana Puig, Chee Leok Goh, Hee Young Kang, Fatimata Ly, Akimichi Morita, Jorge Ocampo Candiani, Sergio Schalka, Liu Wei, et al.

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Thierry Passeron, Brigitte Dreno, Susana Puig, Chee Leok Goh, Hee Young Kang, et al. Sun Exposure Behaviors and Knowledge Among the At-Risk Population: Results From an International Survey, the HELIOS Project. Photodermatology, Photoimmunology & Photomedicine, 2024, 40 (6), pp.e13014. 10.1111/phpp.13014. inserm-04788306

HAL Id: inserm-04788306

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LETTER

OPEN ACCESS

# Sun Exposure Behaviors and Knowledge Among the At-Risk Population: Results From an International Survey, the HELIOS Project

Thierry Passeron<fnref n="1" />,² | Brigitte Dreno³ | Susana Puig⁴ | Chee Leok Goh⁵ | Hee Young Kang⁶ | Fatimata Ly⁷ |

Akimichi Morita⁸ Ⓓ | Jorge Ocampo Candiani⁹ Ⓓ | Sergio Schalka¹⁰ Ⓓ | Liu Wei¹¹ | Anne-Laure Demessant-Flavigny¹² |

Caroline Le Floc'h¹² | Delphine Kerob¹² | Henry W Lim¹³ | Jean Krutmann¹⁴,¹⁵ Ⓓ

**Correspondence:** Thierry Passeron (passeron@unice.fr)

**Received:** 1 August 2024 | **Revised:** 21 October 2024 | **Accepted:** 29 October 2024

**Funding:** This study was supported by La Roche Posay.

**Keywords:** epidemiology | photoprotection | risk assessment | sunburn/prevention and control | sunlight adverse effects | survey

Large-scale prevention campaigns have significantly enhanced public awareness of the risks of excessive exposure to sunlight and its association with skin cancers. However, changing behavior remains a significant challenge for the general population [1] particularly in vulnerable groups with a personal history of skin cancer [2] or medication-induced sun sensitivity [3]. In organ transplantation recipients (OTRs), over half develop skin cancer due to long-term immunosuppressive therapy and excessive UV radiation [4].

A recent study by Daniela L. Domínguez Bueso et al. [5] concluded that a significant proportion of skin cancer survivors in the US still do not engage in frequent sun protection behavior. We aim to expand this perspective globally and evaluate the behaviors, attitudes toward sun exposure and knowledge among individuals at increased risk of sunlight-related damage.

The Helios project is based on data from an extensive survey conducted from 28 September to 18 October 2021 using an

Ipsos Panel with 17,001 participants from 17 countries spanning five continents [6]. This subanalysis focused on two primary “at-risk” population (N=2114): those with a history of skin cancer or immunosuppressant use—for their condition or after an organ transplant—referred to as the skin cancer/ ImmunoSuppressant (SK/IS) subpopulation (n=1731, of whom 434 OTRs) and those with a history of photodermatoses or photosensitive treatments—the P/PT subpopulation (n=1047).

Statistical analyses were based on frequency tables, means, standard deviations, 95% confidence intervals, and two-sided chi-square tests with a 0.05 significance level to compare different subgroups [6].

The at-risk population represented 12% (n=2114) of the overall population (N=17,001), including SK/IS subpopulation (10%, n=1731) and the P/PT subpopulation (6%, n=1047) (Tables 1 and 2).

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

© 2024 The Author(s). *Photodermatology, Photoimmunology & Photomedicine* published by John Wiley & Sons Ltd.

<footnote n="1">¹Department of Dermatology, Côte d'Azur University, Nice University Hospital Center, Nice, France | ²INSERM U1065, C3M, Côte d'Azur University, Nice, France | ³Nantes University, Univ Angers, INSERM, Immunology and New Concepts in ImmunoTherapy, INCIT, Nantes, France | ⁴Melanoma Unit, Dermatology Department, Barcelona University Hospital Clinic, Barcelona, Spain | ⁵National Skin Centre, Singapore, Singapore | ⁶Department of Dermatology, Ajou University School of Medicine, Suwon, South Korea | ⁷Department of Dermatology, Cheikh Anta Diop Dakar University, EPS Institute of Social Hygiene, Dakar, Senegal | ⁸Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan | ⁹Department of Dermatology, Medical Faculty University Hospital of Nuevo Leon, Monterrey, Mexico | ¹⁰Medcin Skin Research Center and Biochemistry Department, Chemistry Institute of Sao Paulo University, Sao Paulo, Brazil | ¹¹Department of Dermatology, The General Hospital of air Force PLA, Beijing, China | ¹²La Roche-Posay International, Levallois-Perret, France | ¹³Department of Dermatology, Henry Ford Health, Detroit, Michigan, USA | ¹⁴IUF Leibniz Research Institute for Environmental Medicine, Dusseldorf, Germany | ¹⁵Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany</footnote>
<table><caption>TABLE 1 | Characteristics of the at-risk population.</caption><thead><tr><th>Item</th><th>All (N=17,001)</th><th>At-risk (N=2114)</th><th>p</th></tr></thead><tbody><tr><td>Gender, male</td><td>49%</td><td>52%</td><td>0.001</td></tr><tr><td>Age, average (SD), years</td><td>44.5 (16.3)</td><td>48 (16.9)</td><td>&lt;0.001</td></tr><tr><td>Phototypes</td><td></td><td></td><td></td></tr><tr><td>I-II</td><td>47%</td><td>56%</td><td>&lt;0.001</td></tr><tr><td>III-IV</td><td>43%</td><td>38%</td><td>&lt;0.001</td></tr><tr><td>V-VI</td><td>10%</td><td>6%</td><td>&lt;0.001</td></tr><tr><td>Do you have your moles checked by a dermatologist?</td><td></td><td></td><td></td></tr><tr><td>At least once a year (ST)</td><td>16%</td><td>49%</td><td>&lt;0.001</td></tr><tr><td>Perception of skin tan and associated risks</td><td></td><td></td><td></td></tr><tr><td>Would you say, ... (ST, yes)</td><td></td><td></td><td></td></tr><tr><td>Exposure to the sun can cause skin health problems</td><td>88%</td><td>90%</td><td>0.001</td></tr><tr><td>Exposure to the sun accelerates skin aging</td><td>81%</td><td>87%</td><td>&lt;0.001</td></tr><tr><td>You cannot imagine coming back from holidays without being tanned</td><td>49%</td><td>59%</td><td>&lt;0.001</td></tr><tr><td>A tan makes a person look healthy</td><td>64%</td><td>72%</td><td>&lt;0.001</td></tr><tr><td>Value of photoprotection</td><td></td><td></td><td></td></tr><tr><td>According to you, is the risk of developing skin cancer very much, a little, not really or not at all linked to...?</td><td></td><td></td><td></td></tr><tr><td>A lack of protection during exposure to the sun</td><td>76%</td><td>83%</td><td>&lt;0.001</td></tr><tr><td>Chronic exposure to the sun</td><td>74%</td><td>82%</td><td>&lt;0.001</td></tr><tr><td>History of severe sunburn during childhood or adolescence</td><td>62%</td><td>77%</td><td>&lt;0.001</td></tr><tr><td>How much do you regret not having better protected yourself from the sun in the past? (Yes, ST)</td><td>57%</td><td>79%</td><td>&lt;0.001</td></tr><tr><td>Photoprotection measure</td><td></td><td></td><td></td></tr><tr><td>In general, you protect yourself from the sun ...</td><td>23%</td><td>40%</td><td>&lt;0.001</td></tr><tr><td>All year round, whatever the season (ST)</td><td></td><td></td><td></td></tr><tr><td>When you are exposed to the sun, do you use</td><td></td><td></td><td></td></tr><tr><td>All practices<sup>a</sup> systematically or often (ST)</td><td>12%</td><td>27%</td><td>&lt;0.001</td></tr><tr><td>When you are exposed to the sun, how often do you apply your sunscreen?</td><td></td><td></td><td></td></tr><tr><td>Base (individuals using sunscreen, even rarely)</td><td>n=13,434</td><td>n=1903</td><td></td></tr><tr><td>Every two hours or More often (after each bath/after sweating) (ST)</td><td>26%</td><td>26%</td><td>—</td></tr><tr><td>When your skin is getting tanned, do you keep applying your sunscreen?</td><td></td><td></td><td></td></tr><tr><td>With a reduced frequency or protection factor (ST)</td><td>44%</td><td>38%</td><td>&lt;0.001</td></tr><tr><td>What is the level of UVB protection of the sunscreen you are using most often? High or very high (ST)</td><td>65%</td><td>66%</td><td>—</td></tr><tr><td>Value of photoprotection</td><td></td><td></td><td></td></tr><tr><td>According to you, is the risk of developing skin cancer very much, a little, not really or not at all linked to...?</td><td></td><td></td><td></td></tr><tr><td>History of severe sunburn during childhood or adolescence</td><td>62%</td><td>77%</td><td>&lt;0.001</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 1 | Continued</caption><thead><tr><th>Item</th><th>All (N=17,001)</th><th>At-risk (N=2114)</th><th>p</th></tr></thead><tbody><tr><td>A lack of protection during exposure to the sun</td><td>76%</td><td>83%</td><td>&lt;0.001</td></tr><tr><td>Chronic exposure to the sun</td><td>74%</td><td>82%</td><td>&lt;0.001</td></tr><tr><td>How much do you regret not having better protected yourself from the sun in the past? (Yes, ST)</td><td>57%</td><td>79%</td><td>&lt;0.001</td></tr><tr><td>Knowledge of sunrays</td><td></td><td></td><td></td></tr><tr><td>How well, if at all, do you feel you understand: (Well, ST)</td><td></td><td></td><td></td></tr><tr><td>The differences between UVB and UVA</td><td>30%</td><td>46%</td><td>&lt;0.001</td></tr><tr><td>SFP</td><td>46%</td><td>62%</td><td>&lt;0.001</td></tr><tr><td>UVA index</td><td>32%</td><td>50%</td><td>&lt;0.001</td></tr><tr><td>Visible light</td><td>48%</td><td>62%</td><td>&lt;0.001</td></tr><tr><td>IR light</td><td>51%</td><td>61%</td><td>&lt;0.001</td></tr><tr><td>Knows at least one element</td><td>75%</td><td>88%</td><td>&lt;0.001</td></tr></tbody></table>

Abbreviations: DK, do not know; ISD, immunosuppressive drugs; OTR, organ transplant recipient; PSD, photosensitive drugs; SD, standard deviation; ST, subtotal; UVA (UVB), ultraviolet A (B) sun rays.

The at-risk population adopted safer protection measures than the overall population. In particular, 40% declared they used sun protection throughout the year in contrast to 23% of the total population. This was particularly true in the SK/IS population compared with the P/PT population (41% vs. 25%, respectively). Moreover, 27% of at-risk individuals reported using all protective measures systematically or often, compared with 12% in the total population. Once again, a difference was observed between the two subpopulations: 28% of the SK/IS population and 35% of the P/PT population reported using the full range of protective measures systematically or often.

In terms of medical surveillance, 49% of the at-risk population (51% for both SK/IS and P/PT) had their moles checked at least once a year by a dermatologist, which is much higher than in the general population (16%).

Overall, the at-risk population was more likely to acknowledge the connection between ineffective photoprotection behaviors and the risk of developing skin cancer, such as the lack of protection during sun exposure (83% vs. 76%), chronic exposure (82% vs. 74%) and severe sunburns during childhood or adolescence (77% vs. 62%). This population also expressed more regret about their poor level of sun protection in the past than the total population (79% vs. 57% of the general population).

In the SK/IS and P/PT subpopulations, tanning and holiday activities were often combined, with 59% and 71%, respectively stating that it was inconceivable to return from holiday without a tan.

While the majority of the at-risk population had some knowledge about at least one aspect of sunlight (88% among at-risk vs. 75% of the total population), many misunderstandings still remain. In comparison to the total population, where 30% had some understanding of the difference between UVA and UVB,

a higher yet still minority portion of the at-risk population (46%) was familiar with the difference. This trend was mirrored in other sunlight-related notions: 62% and 50% of at-risk individuals understood SFP and UVA indexes, respectively (versus 46% and 32% of the total population, respectively).

The populations studied, who are at an increased risk of sunlight-related skin damage, including skin cancers, exhibited suboptimal adherence to photoprotection measures given their health status. Although it exceeds that of the general population, photoprotection levels remain relatively low among these at-risk populations. However, individuals at-risk were in a position to receive superior dermatological advice.

In line with the conclusions drawn by Daniela L. Domínguez Bueso et al. [5] in a US population, the results of this international survey suggest both the overall at-risk population and the SK/IS subpopulation including individuals with a history of skin cancer, exhibit safer attitudes towards sunlight exposure, except in terms of the frequency of sunscreen application. However, the frequent application of sunscreen item was assessed differently in both studies, which may lead to varying interpretations by the participants. Additionally, it is worth acknowledging the potential biases inherent in declarative surveys, such as cognitive and memory biases, as well as social desirability bias, which may affect both studies.

Prevailing misconceptions suggest that at-risk populations often underestimate their individual risks in favor of the immediate psychological benefits of intentional tanning. It is noteworthy that this attitude was particularly prevalent among at-risk individuals and has been reported even among those with a personal history of melanoma, for whom the immediate psychological benefit of tanning outweighs the long-term consequences of exposure to sunlight [7]. This highlights the critical role of dermatologists and general practitioners in providing comprehensive education and guidance [8].

<footnote>ªAll practices: wearing protecting clothing, hat/cap and sunglasses, seeking shade, refraining from sun exposure during the peak UV index, applying sunscreen.</footnote>
<table><caption>TABLE 2 | Characteristics of the at-risk subpopulations SK/IS and P/PTª.</caption><thead><tr><th>Item</th><th>SK/IS (n=1731)</th><th>P/PT (n=1047)</th><th>p</th></tr></thead><tbody><tr><td>Gender, male</td><td>53%</td><td>54%</td><td></td></tr><tr><td>Age, average (SD), years</td><td>49 (17.1)</td><td>42.2 (15.4)</td><td>&lt;0.001</td></tr><tr><td>Phototypes</td><td></td><td></td><td></td></tr><tr><td>I-II</td><td>57%</td><td>54%</td><td>—</td></tr><tr><td>III-IV</td><td>37%</td><td>38%</td><td>—</td></tr><tr><td>V-VI</td><td>6%</td><td>8%</td><td>0.04</td></tr><tr><td>Do you have your moles checked by a dermatologist?</td><td></td><td></td><td></td></tr><tr><td>At least once a year (ST)</td><td>51%</td><td>51%</td><td>—</td></tr><tr><td>Perception of skin tan and associated risks</td><td></td><td></td><td></td></tr><tr><td>Would you say, ... (ST, yes)</td><td></td><td></td><td></td></tr><tr><td>Exposure to the sun can cause skin health problems</td><td>90%</td><td>87%</td><td>0.001</td></tr><tr><td>Exposure to the sun accelerates skin aging</td><td>88%</td><td>83%</td><td>&lt;0.001</td></tr><tr><td>You cannot imagine coming back from holidays without being tanned</td><td>59%</td><td>71%</td><td>&lt;0.001</td></tr><tr><td>A tan makes a person look healthy</td><td>73%</td><td>75%</td><td>—</td></tr><tr><td>Value of photoprotection</td><td></td><td></td><td></td></tr><tr><td>According to you, is the risk of developing skin cancer very much, a little, not really or not at all linked to...?</td><td></td><td></td><td></td></tr><tr><td>A lack of protection during exposure to the sun</td><td>84%</td><td>81%</td><td>0.04</td></tr><tr><td>Chronic exposure to the sun</td><td>82%</td><td>79%</td><td>0.05</td></tr><tr><td>History of severe sunburn during childhood or adolescence</td><td>78%</td><td>75%</td><td>—</td></tr><tr><td>How much do you regret not having better protected yourself from the sun in the past? (Yes, ST)</td><td>80%</td><td>83%</td><td>0.05</td></tr><tr><td>Photoprotection measure</td><td></td><td></td><td></td></tr><tr><td>In general, you protect yourself from the sun ...</td><td>41%</td><td>25%</td><td>&lt;0.001</td></tr><tr><td>All year round, whatever the season (ST)</td><td></td><td></td><td></td></tr><tr><td>When you are exposed to the sun, do you use</td><td>28%</td><td>35%</td><td>&lt;0.001</td></tr><tr><td>All practices<sup>b</sup> systematically or often (ST)</td><td></td><td></td><td></td></tr><tr><td>When you are exposed to the sun, how often do you apply your sunscreen?</td><td></td><td></td><td></td></tr><tr><td>Base (individuals using sunscreen, even rarely)</td><td>n=1563</td><td>n=949</td><td></td></tr><tr><td>Every 2h or More often (after each bath/after sweating) (ST)</td><td>26%</td><td>22%</td><td>0.02</td></tr><tr><td>When your skin is getting tanned, do you keep applying your sunscreen?</td><td></td><td></td><td></td></tr><tr><td>With a reduced frequency or protection factor (ST)</td><td>38%</td><td>38%</td><td>—</td></tr><tr><td>What is the level of UVB protection of the sunscreen you are using most often? High or very high (ST)</td><td>66%</td><td>60%</td><td>&lt;0.001</td></tr><tr><td>Value of photoprotection</td><td></td><td></td><td></td></tr><tr><td>According to you, is the risk of developing skin cancer very much, a little, not really or not at all linked to...?</td><td></td><td></td><td></td></tr></tbody></table>

(Continues)
fees from L'Oréal, grants and personal fees from Lycored, grants and personal fees from Mary Kay, grants and personal fees from Mibelle, grants and personal fees from Procter & Gamble, grants and personal fees from Repairogen, grants and personal fees from RepliCel, grants and personal fees from Skinceuticals, grants and personal fees from SkinMedica, an Allergan Company, grants and personal fees from Stada, grants and personal fees from Symrise, grants and personal fees from Unilever, grants and personal fees from Vichy, grants and personal fees from Walgreen-Boots- Alliance, outside the submitted work.

## Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Thierry Passeron

Brigitte Dreno

Susana Puig

Chee Leok Goh

Hee Young Kang

Fatimata Ly

Akimichi Morita

Jorge Ocampo Candiani

Sergio Schalka

Liu Wei

Anne-Laure Demessant-Flavigny

Caroline Le Floc'h

Delphine Kerob

Henry W Lim

Jean Krutmann

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