Abstract 1929: Not just demographics: Urban and rural differences in skin cancer sun protection behaviors in the United States
Authors: Dona Allison C. , Jewett Patricia , Ahmed Rehana L. , Lazovich DeAnn , Vogel Rachel I. 
Published: April 2023

Introduction: Skin cancer is the most common cancer in the United States (US) and is associated with notable morbidity and mortality. There has been mixed evidence regarding whether rural vs. urban residence is an independent risk factor for skin cancer, and it is not clear to what degree these differences are driven by demographic or behavioral factors. We investigated if there are differences in skin cancer sun protection behaviors between urban and rural residents.

Methods: We used data from three (2013-2018) National Health and Nutrition Examination Survey (NHANES) cycles. Sunburns and sun exposure and behavior measures were dichotomized: 2+ hours outside during work days or non-work days, at least one sunburn in the past year (yes/no); sunscreen use, wearing long sleeves, staying in the shade (never, rarely, sometimes/most of the time, always). Urban/rural residence was measured as a 2-level indicator. We compared sunburn and sun behavior measures by rural-urban status using adjusted survey-weighted logistic regression models. Because of distribution difference by rural-urban status, we stratified by non-Hispanic (NH) white identity vs. identifying as a person of color. Odds ratios and 95% confidence intervals presented were adjusted for age, sex, income, education, body mass index, and smoking.

Results: When comparing urban vs. rural residents, both NH white individuals (42.9 vs. 29.1%, OR: 1.60 [1.27, 2.01]) and people of color (48.9 vs. 36.5%, OR: 1.54 [1.08, 2.19]) in rural communities had greater odds of spending 2+ hours outside on work days. Rural NH white residents had greater odds of spending 2+ hours outside on non-work days (64.8 vs. 72.2%, OR: 1.45 [1.12, 1.88]). Both rural NH white individuals (26.7 vs. 21.6%, OR: 0.72 [0.57, 0.89]) and rural people of color (41.1 vs. 35.5%, OR: 0.81 [0.68, 0.97]) had lower odds of staying in the shade. Rural NH white residents reported lower sunscreen use (35.1 vs. 26.0%, OR: 0.74 [0.59, 0.93]). Among people of color, rural residency was associated with greater odds of at least one sunburn in the past year (34.5 vs. 24.7%, OR: 1.60 [1.23, 2.09]). Sunburns were more frequent overall (59-61%) in NH white individuals; however, no significant differences by rural-urban residence were observed.

Conclusions: Rural residents report engaging in skin cancer preventative sun behaviors less often than urban residents. Greater sunburn frequency among rural and urban NH white individuals compared with individuals of color is consistent with higher skin cancer rates in NH white individuals. However, over 25% of people of color reported a sunburn in the past year, highlighting the importance of intervention on skin cancer risk beyond NH white individuals. Consistently less sun protection behavior across rural populations even after adjustment for demographics emphasizes that rurality should be recognized as an independent risk factor for sun risk behaviors.

Citation Format: Allison C. Dona, Patricia Jewett, Rehana L. Ahmed, DeAnn Lazovich, Rachel I. Vogel. Not just demographics: Urban and rural differences in skin cancer sun protection behaviors in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1929.