Men’s Attitudes and Behaviors About Skincare and Sunscreen Use Behaviors

Skin cancer is the most commonly diagnosed cancer in the United States. More than five million Americans are diagnosed annually, and 20% will develop skin cancer by the age of 70.^1,2 While non-melanoma skin cancers (NMSC) such as basal and squamous cell are more common, men, regardless of race and ethnicity, are disproportionately affected compared to women, developing both melanoma and NMSC at higher rates. Research shows that men are more prone to UV-induced immune suppression, and their skin does not respond as well as women to environmental stressors like UVR.^3,4 The American Cancer Society predicts that men will fall victim to 60% of new skin cancer cases (excluding NMSC) and will comprise near 70% of death from these cancers in 2019.¹ In 2020, >100,000 new cases and 6,800 deaths will likely occur from melanoma in the U.S..⁵ Most melanoma cases are preventable through reduced sun exposure, including avoiding indoor tanning and applying broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or greater, wearing protective clothing, seeking shade, and avoiding midday exposure.¹ In 2014, the Surgeon General called for increased public awareness and preventative skin cancer measures. Despite these efforts, men are less likely than women to use sunscreen.⁶ Although prior literature exists examining general consumer preferences regarding^7,8 and motivations for use,⁹ limited research focuses specifically on men's behaviors (ie, daily or weekly sunscreen use) surrounding skin cancer prevention. Our objective in this study involved assessing men's use of and motivations for regularly applying sunscreen, as well as preferred skincare product characteristics that could facilitate or hinder using sunscreen regularly.

Recruitment and Eligibility Participants were recruited using Amazon Mechanical Turk (MTurk), a commonly used online data collection and research marketplace.^10-12 MTurk has thousands of active participants' known as MTurk Worker's around the world that complete small tasks or surveys for financial compensation. Participants were informed that there was a skincare survey for which they may qualify. If deemed eligible, participants could complete a 15-minute questionnaire and receive a $3.00 Amazon credit as an incentive. Participant eligibility criteria included: 1) being a member/user of MTurk, 2) falling between ages 20-70, 3) having a yearly income > $40,000, 4) having completed at least a High School Diploma, and 5) living in the United States. In order to include a higher proportion of certain groups, including men, people who identify as LGBT, and older men, surveys were posted in waves, and eligibility criteria were restricted to include more people of certain groups than would have been included from a pure convenience sample from MTurk. We purposely targeted at least 100 men per age group in the following age groups: 18–24, 25–34, 35–44, 45–54, and 55– 70. Participants were prevented from participating in the survey more than once by issuing a qualification in MTurk to everyone that participated in each round of the survey and preventing anyone with that qualification from participating again. Including as many participants as possible from particular demographic groups ensured that there were enough participants in each of these groups to provide a meaningful subsample to include in analyses. This study protocol was evaluated by the Advarra IRB and was determined to be exempt from IRB oversight. Study Procedures The online survey was programmed in Survey Monkey and distributed through MTurk. MTurk workers deemed eligible provided consent via an electronic consent form at the beginning of the survey. The survey was designed to collect observational data about men’s use of sunscreen, motivation to use sunscreen, and product preferences, and began with a brief demographic questionnaire. Three attention check questions were included within the survey to ensure quality of the data. Measures Our survey instrument was developed as a collaboration within the study team and with input from outside experts in measurement, survey creation and methodology. Where possible, survey questions were drawn from large, high quality national surveys.^13-18 At the beginning of the survey, all potential participants were asked their age, gender, income, education, sexual orientation, ethnicity, and state of residence. Participants that were eligible for the survey then viewed a short consent form. As part of the survey, participants were asked to indicate how frequently they use common skincare products, including sunscreen, to assess use and other possible products that could include sun protection to increase use of sunscreen. Participants were asked what might change their willingness to use sunscreen: characteristics that may motivate them to use daily sunscreen, what they care most about in a sunscreen, what would deter them from using a daily sunscreen, and how important certain characteristics are for their daily skin care products. Data Analysis Data were analyzed using SAS 9.4 (Cary, NC). Chi-Square statistics with P< 0.05 were used to analyze bivariate, categorical variables. Logistic regression was used to analyze outcomes of interest while controlling for independent variables.

Our final sample included 705 people who identified as male. Table 1 presents the demographic characteristics of the study sample. Our sample was 78% white, 78% straight or heterosexual, and 16% Hispanic. Participants varied in age, and 69% possessed a bachelor's degree or higher. Men Skincare Product Use Most (n=612; 83%) men reported not using sunscreen daily, and only one-third (n=280; 38%) reported using sunscreen weekly. The most commonly used general skincare products that men reported using daily were liquid soap/body wash (n=460; 65%), followed by bar soap (n=332; 47%), and moisturizer (n=229; 32%). Men reported using moisturizer and aftershave at least weekly 54% (n=381) and 38% (n=267), respectively. Demographic Predictors of Sunscreen Use In bivariate comparisons, income was significantly associated with use of sunscreen daily or weekly, such that men at higher income levels were more likely to use sunscreen at least weekly (P=0.001). Race and ethnicity were also related to use of sunscreen at least weekly, where participants who identified as white or other were more likely than participants who identified as black or African American to use sunscreen at least weekly (P=0.047), and men who identified as Hispanic or Latino were less likely to use sunscreen at least weekly compared to men who did not (P=0.015). Age group, sexual orientation, and region where men lived were not related to use of sunscreen in bivariate comparisons. In a logistic regression to assess demographic predictors of using sunscreen weekly or more

often (Table 2), men with household incomes of between $40,000 - $50,000 were significantly less likely to use sunscreen weekly or more compared to men with household incomes of $100,000 per year or more (OR 0.54, 95% CI: 0.33–0.88). Other covariates, including age, sexual orientation, and region were not related to using sunscreen daily or weekly. Motivation for Sunscreen Use, Including Characteristics of Daily Sunscreen Facial Lotions That Could Facilitate or Hinder Use Reasons that men reported that they wear or would consider wearing sunscreen regularly are reported in Table 3. The main motivators for men wearing or considering using sunscreen on a regular basis included reducing skin cancer risk (n=575; 82%) and to look younger (n=299; 42%). When thinking about a daily sunscreen facial lotion, the most important product characteristics were moisturizing (n=222; 31%) and non-irritating (n=188, 27%). The characteristic that was most deterring to using a daily sunscreen lotion was if it was too oily (n=302; 43%). In bivariate analyses, age, income, region, and use of sunscreen at least weekly were not related to the factor that would be most deterring from using a daily sunscreen facial lotion. Sexual orientation was strongly related to responses to the most deterring factor (P<0.0001), where men who identify as gay or bisexual were more likely to be deterred if the lotion was too thick, or had a strong scent, and less likely to say that an irritating lotion would deter them and men who identified as straight were more likely to be deterred if the lotion was irritating. Race was also related to responses to the most deterring factor from using a daily sunscreen lotion (P<0.0001). Black or African American men were less likely to report ‘too oily’ as a deterrent, and more likely to be deterred by a strong scent. Ethnicity was also related to factors that would deter men from using daily sunscreen lotion (P<0.0001), such that men who identify as Hispanic or Latino were more likely to be deterred by lotion that is too thick, or that has a strong scent, and less likely to be deterred by a lotion that is irritating.

Overexposure to the sun and ultraviolet light dramatically increases the risk of skin cancer.¹⁹ While men are more than twice as likely as women by age 65 to develop skin cancer throughout their lifetimes,⁵ our study indicates that most men are not using sunscreen on a daily basis. The results suggest that men are most likely to use a sunscreen when the messaging focuses on the risks of skin cancer and when the product characteristics are catered to their skin types. This research has implications for physicians, especially family physicians and dermatologists who see individuals at risk of skin cancer regularly, communications’ specialists, and patients. Perceived credibility may be a key influencing factor to help people change their behaviors.^20-22 Patients in the United States have significant trust in their physicians, and physicians help

influence the behavior of most Americans annually.²³ While physicians may find the low rates at which men are using a daily sunscreen alarming, they can alter these rates by strong messages emphasizing the simplicity of adding a sunscreen to a daily routine. Brief recommendations from a physician have been shown to influence patient behaviors across a broad spectrum of health.^20,23,24 Physicians could also consider how their patient population could benefit from more catered product recommendations. For instance, doctors serving patients of lower socio-economic status or those of differing skin tones may find more success when recommending one sunscreen over another if it meets that population’s requirements for smell, price and marketing. Professionals who are tasked with developing new products as well as marketing existing sunscreens clearly recognize the potential of tailored messaging.^25,26 Since the great majority (80%) of men said they could be motivated to wear a facial moisturizer with sunscreen on a regular basis to decrease their skin cancer risk, campaigns may simultaneously want to emphasize multiple product attributes, such as SPF to reduce skin cancer risk, anti-aging appeal and skin tone. Informational campaigns (including both community-oriented in person campaigns and online campaigns), rather than companyspecific efforts, may also present the opportunity to target all at-risk patients, given their emphasis on spreading knowledge over selling products.^27-29 Finally, this research has implications for male and female patients. While men did not use sunscreen daily, a significant majority stated certain factors would convince them to use it daily, with skin cancer risk and anti-aging being the highest. Such messages, particularly if targeted in a family narrative, likely resonate with both men and their partners.^19,30,31 In addition, this research has implications for men of certain subpopulations that may need more intensive sun protective counseling as well as tailored sunscreen products. Although skin cancer is less prevalent in people of color, it is still important for these individuals to wear sunscreen as they are still at risk of skin cancer.³² Research has also found that gay and bisexual men, and gender-non-confirming individuals, have increased self-reported lifetime prevalence of skin cancer.^33,34 African Americans, gay and bisexual individuals in our study reported unique wants in a sunscreen, being more deterred by lotions that were thick and had a strong scent. Creation of products that meet sub-population needs should hopefully result in increased adherence to sunscreen recommendations. Men may also be interested in moisturizers that already contain sunscreen.³⁵ Several areas for new research exist. While recent studies suggest men and women differ in which audiences they trust most,³⁶ further research should explore which influential sources, avenues, and locations could have greatest impact, such as information attained from informal social gatherings (eg, salons, sporting events, clubs), new information mediums (eg, podcasts, social media) and in which language format (eg, narrative, informational, or promotional) to better qualify the impact of informational campaigns.³² Limitations exist to this research. This research was a onetime cross-sectional survey, and thus causation between any measured or unmeasured variables cannot be determined. While participants were a convenience sample, MTurk is increasingly being used for social science and health research to cost-effectively recruit large and diverse samples with valid results.^37-41 We also do not know if men who report using moisturizer or aftershave, but do not report using a daily SPF, may not realize that their daily products already contain sunscreen. Although the men in our study did not consider cost to be an important consideration for their sunscreen facial lotion for themselves, cost may still be a prohibitive measure for low-income earners who were not included in this survey. The relationship between sunscreen usage, cost, and income should be explored in depth in future studies as long-term daily sunscreen use.

The lack of improvement in the rates of skin cancer among men over the last two decades is a call for increased methods to educate men about skin cancer prevention. Better knowledge of the daily routines of men may result in products that men can and are willing to integrate into their daily lives to prevent skin cancer. New sunscreen products must be carefully formulated so that they are not excessively oily but still provide adequate moisturization in order to increase skin cancer prevention adherence among men and subsequently marketed accordingly to increase usage.

Co-authors Dr. Adam Goldstein, Dr. Karina Paci, Kristen Jarman, and Courtney Roberts have no potential conflicts of interest to disclose, including specific financial interests and relationships and affiliations relevant to the subject of the manuscript. Dr. Beth Goldstein and Ms. Elianna Goldstein are developing a new sunscreen product and are co-owners of Proven, LLC, the study funder. The study was funded by Proven, LLC. to serve as market research in their mission to prevent skin cancer by creating a daily sunscreen that men are more likely to use.

Courtney Roberts and Kristen Jarman had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr. Beth Goldstein, Dr. Adam Goldstein and Ms. Elianna Goldstein participated in the design and conduct of the study; interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.   

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Adam Goldstein MD adam_goldstein@med.unc.edu