Development and validation of an instrument to assess the knowledge of general practitioners and pediatricians about photoprotection and solar radiation

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Anais

Brasileiros

de

Dermatologia

www.anaisdedermatologia.org.br

INVESTIGATION

Development

and

validation

of

an

instrument

to

assess

the

knowledge

of

general

practitioners

and

pediatricians

about

photoprotection

and

solar

radiation

夽,夽夽

Fernanda

Mendes

Araújo

a,b,∗

_,

_Julliana

_Andrade

_do

_Carmo

c

_,

Letícia

Diniz

Cunha

c

_,

_Igor

_Monteiro

_Lima

_Martins

b

_,

_Airton

_dos

_Santos

_Gon

d

_,

Antônio

Prates

Caldeira

b,e

a_Department_of_Clinical_Medicine,_Dermatology,_Universidade_Estadual_de_Montes_Claros,_Montes_Claros,_MG,_Brazil

b_Postgraduate_Program_in_Health_Sciences,_Universidade_Estadual_de_Montes_Claros,_Montes_Claros,_MG,_Brazil

c_School_of_Medicine,_Faculdades_Integradas_Pitágoras_de_Montes_Claros,_Montes_Claros,_MG,_Brazil

d_Department_of_Clinical_Medicine,_Dermatology,_Universidade_Estadual_de_Londrina,_Londrina,_PR,_Brazil

e_Department_of_Pediatrics,_Universidade_Estadual_de_Montes_Claros,_Montes_Claros,_MG,_Brazil

Received17September2017;accepted8October2018

Availableonline30September2019

KEYWORDS Healtheducation; Skinneoplasms; Solarradiation; Sunscreeningagents; Ultravioletrays; Validationstudies Abstract

Background: Theknowledgeofgeneralpractitionersaboutphotoprotectionisunknown.

Objectives: Todevelopandvalidateaninstrumenttoevaluatetheknowledgeofgeneral

practi-tionersandpediatriciansaboutphotoprotection,gaugingtheknowledgeoftheseprofessionals.

Methods: The study followed the steps: (1) Literature identiﬁcation and item elaboration

related tothetheme;(2) Contentvalidation; (3)Apparent validation;(4)Construct

valida-tion:internalconsistencyanalysisanddiscriminatoryanalysis;(5)Reliabilityanalysis.InStep

4,theinstrumentwasappliedto217generalpractitionersandpediatricianswhoworkedinthe

hostcityofthestudy;thescoreswerecomparedwithdermatologistsscores.

Results: The ﬁnal instrument had 41 items and showed satisfactory internal consistency

(Cronbach’salpha=0.780),satisfactoryreproducibilityandgoodtest---retestreliability (good-to-excellentkappastatisticinmorethan60%ofitems).Thediscriminatoryanalysisregistered

ameanscoreof54.1pointsfor dermatologistsand31.1pointsforgeneralists and

pediatri-cians, from a total of 82 possible points, representing a statistically signiﬁcant difference

夽 _Please_cite_this_article:_Araujo_FM,_Carmo_JA,_Cunha_LD,_Martins_IML,_Gon_AS,_Caldeira_AP._Development_and_validation_of_an_instrument toassesstheknowledgeofgeneralpractitionersandpediatriciansaboutphotoprotectionandsolarradiationAnBrasDermatol.2019;94: 532---41.

夽夽_Study_conducted_at_the_Postgraduate_Program_in_Health_Sciences,_Universidade_Estadual_de_Montes_Claros_(Unimontes),_Montes_Claros, MinasGerais,Brazil.

∗_{Corresponding}_author.

E-mail:fernandamendes@me.com(F.M.Araújo). https://doi.org/10.1016/j.abd.2019.09.011

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(p<0.001).Generalistsandpediatriciansdemonstratedanunderstandingoftherelationship betweenexcessivesunexposureandskincancer,buttheyrevealedlackoftechnicalinformation necessaryfortheirprofessionalpractice.

Studylimitations: Theinstrumentevaluatesonlyknowledge,withoutevaluatingtheconduct

oftheparticipants.

Conclusion: Theresultsshowthattheinstrumenthasgoodinternalconsistencyandgood

repro-ducibility. Itcould be usefulin theidentiﬁcation ofgeneralpractitionersand pediatricians

knowledgegapsonthesubject,forthesubsequentdevelopmentoftrainingandeducational

strategies.

ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/

by/4.0/).

Introduction

SkincanceristhemostprevalentneoplasminBrazilandthe world;approximatelytwomillionnewcaseswereregistered intheUnitedStatesalone,representingasigniﬁcantburden forthatcountryhealthsystem.1---3_Skin_exposure_to

ultravio-let(UV)radiation,resultingfromprolongedandunprotected sunexposure,isthemainenvironmentalriskfactor associ-atedwiththeonsetofskincancer.4---6_The_way_sun_exposure

occursis a determinantin the affected cell line: chronic and cumulative exposure is associated with the onset of squamouscellcarcinoma,whereasacuteandintermittent exposureismoreassociatedwithbasalcellcarcinomaand melanoma.7

To date, exposure to UV radiation is the only estab-lished modiﬁable cause of melanoma; thus, primary prevention strategies for skin neoplasms focus on lim-iting UV exposure through sun-protective behaviors.8,9

Effective sun protection includes the adoption of several measures, including environmental, mechanical, topical, and systemicphotoprotection,as well asphotoprotection education.10,11

Ofallpreventivemeasures,photoprotectioneducationis perhapstheslowestinreducingtheincidenceofskincancer, butitiscertainlythelargestandmosteffectiveinvestment inpopulationhealth,especiallythepediatricpopulation.12

Whencomparedwiththehighcostoftreatmentofskin neo-plasms,effective implementation of preventive measures canleadtoasigniﬁcantreductionintheresourcesusedby healthsystems.6

Statistics from the Brazilian Society of Dermatology (Sociedade Brasileira de Dermatologia [SBD]) show that, among the Brazilian population, sun protection is far fromadequate.13 _Educational_campaigns_in _Australia_have

increased the adoption of protective measures at leisure times from 12% to 48% over a ten-year period.14,15

How-ever,althoughthepopulationofthatcountryismoreaware oftheimportanceofphotoprotectioninthepreventionof skincancer,adherencetophotoprotectionpracticesremains suboptimal; less than half the population adopt sun pro-tectionmeasuresduringoutdooractivities.14,15_Olsen_et_al.

observedthattheeducationallevelwasstronglyassociated with the use of photoprotectors and, to a lesser extent, theuseofhats;furthermore,theseauthorsindicated that adherence to the use of photoprotectors was higher in womenthaninmen.14

Themostsuccessfulprogramsinphotoprotection educa-tionarethosethatcontemplatediverseandcomplementary approaches; the objective is that the knowledge leads toa signiﬁcant change of attitudes and behaviors in the population.12_{Photoprotection}_guidelines_are_part_of_the

rou-tineofthedermatologist.11 _However,_general_{practitioners}

andpediatricianshaveaparamountroleintheprevention ofskin cancer, since theyrepresent physicianswithgreat educativepower.

InBrazil,theincreasingexpansionofprimarycareteams observed in recent years reinforces the role of general practitioners and family/community doctorsin promoting educational activities, including the promotion of effec-tivephotoprotection.TheWorldHealthOrganization(WHO) advocates that photoprotection programs are urgently neededtopromotegreaterawarenessofUVradiation dam-ageandtofosterchangesinlifestylehabitsassociatedwith increasedexposureandriskforskin cancers.16 _The

Ameri-cantaskforceforthereductionofskincancerhasstrongly recommendedthatchildren,adolescents,andyoungadults beadvised onthe appropriate photoprotectionmeasures, giventheimportanceofearlyexposuretoUVradiation.17

Despite the context presented, little is known about the protection guidelines provided by general practition-ersand pediatricians.Moreover,little is knownabout the knowledgeofhealthcareprofessionals about photoprotec-tion measures.18 _Knowing _the _theoretical _background _of

theseprofessionalswithregardtophotoprotectionisofvital importanceinthestrategic planningof educational activ-ities on the subject. No Brazilian studies evaluating the knowledgeofgeneralpractitionersandpediatriciansonthe subjectusingvalidatedinstrumentswereretrievedfromthe literature. The present study aimed to develop and vali-datean instrument toassess theknowledge of physicians onphotoprotection.

Methods

Studydesignandethicalaspects

This was a cross-sectional study in which an instrument to assess the knowledge of general practitioners and pediatricians about photoprotection and solar radiation was elaborated and validated. The project of this study was approved by the Ethics Committee of the present

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Stage 1 - Literature search and listing of the items related to the instrument

Dimensions: (1) Solar radiation and its effects on the skin and (2) Photoprotection

Preliminary instrument I (98 items)

Stage 2 – Content validation

28 items excluded

Preliminary instrument II (70 items)

Stage 3 – Apparent validation

1 item excluded

Preliminary instrument III (69 items)

Stage 4: Construct validation: internal consistency analysis and discriminatory analysis

Instrument was applied to 217 generalists and pediatricians

Item-total correlation analysis

26 items excluded (too easy)

2 items excluded

Preliminary instrument IV (41 items)

Internal consistency analysis and discriminatory analysis

Stage 5: reliability assessment (test-retest)

Kappa statistics

Final instrument: knowledge of general practitioners and pediatricians about photoprotection Instrument was reapplied to 15%

of the respondents Instrument was applied to Medical School professors Instrument was applied to a pannel

of experts Literature review

Item identification/development

Figure1 Summaryofthestepsforthedevelopmentoftheinstrument‘‘Theknowledgeofgeneralpractitionersandpediatricians

aboutphotoprotectionandsolarradiation’’.

institution(opinionNo.1,792,189).Theresearchobjectives wereexplainedtoallparticipants,whosubsequentlysigned aninformedconsentform.

Thestudyfollowedthefollowingsteps:(1)Identiﬁcation ofthe relevant literature andlistingof the items related totheinstrument;(2)Contentvalidation;(3)Apparent val-idation;(4)Constructvalidation,withinternalconsistency analysisanddiscriminatoryanalysis(orhypothesistest);(5) Reliabilityanalysis,asshowninFig.1.

Step1:Identiﬁcationoftherelevantliteratureand listingoftheitemsrelatedtotheinstrument

Fortheidentiﬁcation ofthebasicliteratureforthelisting oftheitems,asearchwasconductedintheMedical Liter-ature AnalysisandRetrievalSystem Online(MEDLINE),the US National Library of Medicine (PubMed),and the Scien-tiﬁcElectronicLibraryOnline(SciELO)databases,usingthe termssolarradiation,sunburn,photoagingoftheskin, pho-toprotection,andsunprotectionfactor,andtheirrespective

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equivalent terms in Portuguese. In addition to scientiﬁc articles, the research also sought to identify protocols, guidelines,andinstructional materialsdirectedto health-careprofessionals.ThesearchwasconductedbetweenApril and May 2015. Texts not entirely in Portuguese, English, Spanish,orFrenchwereexcluded.Aftertheretrieved mate-rial was assessed, the references for the listing of the itemsweredeﬁned.8,11,13,16,17,19---24_The_synthesis_of_the_main

contents resulted in 98 items, which were transformed intoshortandobjectivestatementsinordertocreatethe instrument to be validated, encompassing two different dimensions: (1) Solar radiation and itsadverse effects on theskin;and(2)Photoprotection.

Step2:Contentvalidation

The instrumentwas submitted to analysis of the content andthe semanticstructure by fourspecialistsin theﬁeld (dermatologistsfromdifferentregionsofthecountry),who evaluated the relevance of each item (irrelevant, some-whatrelevant, relevant,or veryrelevant)and clarityand appropriateness of the assertion (clear and adequate or inadequate).Aftertheanalysisbytheexperts,the instru-mentwasreformulated;itemsconsideredclear,adequate, and relevant or very relevant by at least three of the evaluatorsweremaintained.Someitemshadtheirwriting adapted,assuggested bytheevaluators,andthen 70%of the itemswere maintainedastrue statements, similarto thereferencetext,and30%wererandomlytransformedinto falseassertions.

Step3:Apparentvalidation

Aftertheevaluationofthespecialists,thenewinstrument wasthenappliedtosixprofessorsofundergraduatemedical coursesthat teachdisciplinesrelatedtoclinical medicine andpediatrics,whoansweredthequestionnaireand evalu-atedtheclarityandcomprehensionofeachitem.

Step4:Constructvalidation:internalconsistency analysisanddiscriminatoryanalysis

Toidentifythephysicians,theauthorsrequestedlistswith a nominal relation of generalists and pediatricians who workedin healthandeducationalinstitutionsinthestudy hostcity,includingthepublicandprivatesystems, outpa-tient clinics, and hospital services. There wasno sample calculation. All 298 physicians identified were personally approached at their workplace and asked to answer the questionnaire. Three attempts were made to approach each physician, with a weekly interval between each approach; 221 physicians agreed toparticipate.Data col-lectionoccurredduringafour-monthperiodfromDecember 2015toMarch2016.Duringdataprocessing,four question-naires were excluded because they had been applied to physicians of other specialities other than the two con-sidered in this study. Thus, 217 physicians answered the instrumentatthisstage,whichalsoincludeditemsto char-acterize therespondent. Each statementwasfollowedby fiveLikertscaleresponseoptions(‘‘Ifullyagree,’’‘‘I par-tially agree,’’ ‘‘Ido not agree or disagree,’’ ‘‘I partially disagree,’’ and‘‘Istronglydisagree’’). Professionals were asked to indicate their level of agreement or disagree-ment regarding the affirmative, according tothe level of

knowledgeonthesubject,andcouldalsoindicatethatthey hadnolevelofagreementordisagreement(‘‘Idonotagree or disagree’’), assuming ignorance about the item.Then, thelevel of correlation between the items of the instru-mentwasassessed, aswell astheinternal consistency of theinstrumentthroughCronbach’salpha.

For discriminatory analysis or hypothesis testing, the instrument was applied to 20 dermatologists working in thehost city of thestudy.The answers of thegeneralists and pediatricians, and those of the dermatologists, were transformed into scores by adding the values assigned in the Likert scale for the items that comprised the instru-ment, as follows: (0), when the professional registered thattheyneitheragreednordisagreedwiththeassertion; (+2)for correctanswers(equivalentto‘‘Ifullyagree’’or ‘‘stronglydisagree’’fortrueandfalsestatements, respec-tively);and(+1),for partiallycorrectanswers(equivalent to‘‘partially agree’’or ‘‘partially disagree’’ for trueand false,respectively).Thevalues−2and−1wereattributed totheincorrectorpartiallyincorrectanswers,inthe oppo-site direction of the evaluations of correct answers. The discriminatory analysis or hypothesis test aimed to verify whetherthe instrumentwasabletodiscriminatebetween dermatologists(whoshouldobtainhigherscores)or general-istsandpediatricians(whoshouldobtainlowerscores).The meanscores of therespondents werealso calculatedand compared,seekingassociationwithgroupvariables (profes-sionaltraining,gender, age,andpersonalorfamilyhistory ofskincancer).Answerswereconsideredcorrectwhenthey showedpartialorfull agreementfor thetruestatements, aswell aspartialorfull disagreementforthe false state-ments.Forthe comparisonofthe scoresbetween groups, the Mann---Whitney U-test with 5% signiﬁcance level was used.

Step5:Temporalstabilityanalysis(test---retest)

Thetemporalstabilitywasassessedusingthekappa statis-tic, after the instrument was re-applied to 15% of the respondentsfollowingaperiodoftwotofourweeksafter theﬁrstresponsetotheinstrument.Forthisanalysis,the dichotomousresultsoftheanswers(correctandincorrect) wereconsidered. The following parameters were used to interpret kappa statistics: low agreement: <0.40; regular agreement: 0.41---0.60; good agreement: 0.61---0.80, and excellentagreement: >0.80.25 _A _{Bland---Altman} _graph _was

plotted for validation of the test---retest, considering the total score of the instrument. The intraclass correlation coefﬁcientswerealsocalculatedforperfectagreementfor eachoftheinstrumentdimensions,consideringthe respec-tivebefore(test)andafter(retest)scores.

Allstatisticalanalyseswereperformed usingthe statis-ticalpackageIBM-SPSS,v.22.0forWindows.

Results

After assessment by the panel of experts in the content validationstage,theinstrument,whichinitiallyincluded98 items,thenhad70items.Intheapparentvalidationstage, a consensus was reached among the group of professors toexclude a single item.During the constructvalidation stage,26itemscorrectlyansweredbymorethan90%ofthe

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Table1 Characterizationofthegeneralpractitionersand pediatricianswhoparticipatedinthestudy;2016.

Variables (n) (%) Sex Male 64 29.5 Female 153 70.5 Age(years) <30 74 34.1 30---39 68 31.3 40---49 44 20.3 >50 31 14.3 Specialty Pediatrics 38 17.5 ClinicalMedicine 103 47.5

FamilyandCommunityMedicine 76 35.0

Mainprofessionalactivity

Directpatientcare 196 90.3

Academiccareer 18 8.3

Administrativefunction 3 1.4

Previousorfamilyhistoryofskincancer

Yes 39 18.0

No 178 82.0

professionals (considered to be tooeasy) were excluded. Theexclusionofitemscorrectlyansweredbylessthan10% of respondents (considered to be too difﬁcult) had been proposed,butnoitemreachedsuchclassiﬁcation.

Themaincharacteristicsofthegroupofphysicianswho participatedinthestudyarepresentedinTable1.

Assessing the correlation of each item with the mean scoreof the complete questionnaire, twoitems (Q60and Q68)thatpresentedvalueslowerthan0.2forthecorrelation coefficientwereexcluded.Theinternalconsistency analy-sisindicatedaCronbach’s˛of0.780forthefinalinstrument with41items,whichreflectsagoodlevelofinternal con-sistency.Forthedimension‘‘Solarradiationanditsadverse effectsontheskin,’’Cronbach’s˛was0.720;forthe dimen-sionPhotoprotection,thisvaluewas0.816.

Table2 presentsthe kappastatisticsin the instrument reproducibilitytest.Over60%oftheitemspresentedgood toexcellentagreement.

For the ‘‘Solar radiation’’ dimension, the intraclass correlation coefﬁcient for the maximum agreement was 0.769(95%CI:0.554---0.887)andforthe‘‘Photoprotection’’ dimension,0.763(95%CI:0.578---1.874). DIFF_T1_T2 MEAN_T1_T2 10.00 5.00 .00 -5.00 -10.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00

Figure2 Bland---Altmanplotforevaluationoftheagreement ofthetest---retestscores.

Table3 Comparisonbetweenthemeanscoresof

knowl-edgeonphotoprotectionamongphysicians;2016.

Variable Mean SD p-Valuea

Professionaltraining1 <0.001 Generalists/pediatricians 30.8 12.9 Dermatologists 54.1 8.8 Professionaltraining2 0.175 Clinicalmedicine 29.2 12.9 Familymedicine 31.7 13.2 Pediatrics 33.4 12.3 Sex 0.072 Male 28.6 11.9 Female 31.8 13.3 Age 0.617 <40years 31.4 12.6 ≥40years 30.2 13.3

Familyhistoryofskincancer 0.296

Yes 33.1 12.9

No 30.3 12.9

a _{Mann---Whitney}_U-test.

TheBland---Altmangraphindicatedasatisfactory agree-ment between thetest andretest evaluations, withlittle dispersionofresults(Fig.2).

Thediscriminatoryanalysisrecordedameanscoreof54.1 (SD±8.8) points for dermatologists and 31.1 (DP±12.9) pointsforgeneralistsandpediatricians,fromatotalof82 Table2 Kappastatisticsforthereproducibilityoftheinstrument;2016.

Kappa Agreementrating Items

<0.40 Low Q43,Q45

0.41---0.60 Moderate Q6,Q8,Q13,Q16,Q23,Q30,Q36,Q42,Q50,Q54,Q56,Q66,Q74,Q91

0.61---0.80 Good Q12,Q18,Q20,Q24,Q28,Q33,Q35Q53,Q55,Q57,Q58,Q65,Q73,Q78,Q82,Q85,

Q92,Q94,Q95,Q96

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possiblepoints,representingastatisticallysigniﬁcant differ-ence(p<0.001).Nodifferenceswereobservedamongother characteristicsevaluatedforthegroup(Table3).

The items with lower scores in the dimension ‘‘Solar radiationanditsadverse effectsontheskin’’refertothe periodandtimeofsunexposurethatleadstogreater dam-age(Q8),effectsofUVAandUVBradiation(Q12andQ18), and the classiﬁcation of people into phototypes accord-ing to skin color and skin response to sunlight (Q9). In the‘‘Photoprotection’’dimension,itemswithlowerscores addressed the combination of sunscreens with repellents (Q53),sunprotectionfactor(Q55andQ56),fabrictypesthat havethegreatestphotoprotectiveeffect(Q65),anduseof sunscreens asthemain recommendation for photoprotec-tion(Q78).Table 4presents theﬁnal instrumentwiththe percentageofcorrectanswers.

Discussion

Inthepresentstudy,aninstrumenttoassesstheknowledge ofgeneralpractitioners andpediatriciansabout photopro-tection andsolar radiation waselaboratedand validated. Thefinalinstrumentshowedasatisfactorylevelofinternal consistency,asassessedbyCronbach’salpha.The reliabil-ityof thetool canalsobe considered satisfactory,witha good-to-excellentagreementlevelformostoftheevaluated items,asmeasuredbythekappastatistic,showingadequate reproducibility.Discriminatoryanalysiswasalsoableto ade-quatelyidentifyprofessionalswithgreaterknowledge;other characteristicsoftheparticipatingphysicians(gender,age, specialty,andfamilyhistoryofskincancer)hadnoinfluence onthemeansofthefinalscore.

Although a factorial analysis of the instrument items wasnotconducted,internalconsistencyanddiscriminatory analysisaresatisfactorymeasuresforconstructvalidation, accordingtoPasquali.26_For_that_author,_factor_analysis_is_a

techniqueforanalyzingthebehavioralrepresentationofthe construct,whichcanalsobemeasuredbytheinternal con-sistencyanalysis.Thediscriminatoryanalysisdemonstrated thehigherscoresinthegroupofdermatologists:the derma-tologistsobtainedameanscoreof64%onthequestionnaire, in contrast to the mean of generalists and pediatricians (37%),whichrepresentsastatisticallysignificantdifference. The analysisof the scores of the doctorsparticipating in the study led to the identification of knowledge gaps intheareaofphotoprotection.Thereisgrowingscientific evidenceratifyingthedeleteriouseffectsofprolongedsun exposureontheskin,togetherwiththerecognitionofthe urgentneedforbetterawarenessofthegeneralpopulation regarding healthiersun exposure habits.2,4,8,15,16 _However,

healthcareprofessionalsdonotappeartobecommittedto this goal. Photoprotection education is still a dermatolo-giststask, although it shouldbe partof the primarycare strategies,consideringthatskincanceristhemostprevalent neoplasminBrazilandworldwide,andthatthediseasehas beenincreasinglyunderstoodasapublichealthissue.1,2,4,14

TheAmericanAcademyofPediatrics,inconjunctionwith theUSCentersforDiseaseControl,hasdevelopedaguide for primaryandsecondary skin cancerprevention.12

How-ever, shortcomings in theunderstanding of sun-protective behaviorsandeducationinskincanceringeneralhavebeen

observed.12 _Weinstein _et _al. _assessed _the _knowledge _and

attitudesofover200parentsinpediatricanddermatological clinicsregarding photoprotection,and observedthattheir sourcesofinformationonthesubjectcamemainlyfromthe media(television,magazines,radio),butthattheywanted toget informationfromtheirprimarycarephysicians.12,27

Thatis:therecommendationsexistandphysiciansare con-sideredasafesourceofinformationbythepopulation,and shouldbeincluded instrategic photoprotectioneducation planning.17 _While_there_are_{questionnaires}_to_evaluate_sun

exposureanditsassociationwithskincancer,untilnowthere wasnovalidatedquestionnairetomeasuretheknowledge ofphysiciansaboutphotoprotection.Knowledgeisan impor-tantparameterandrepresentstheﬁrststepinanyprogram thataimsforlong-termresults.

In the present study, the exclusion of items from the instrumentbecausetheywerecorrectlyansweredbymore than90%ofprofessionals(consideredtobetooeasy) indi-catesthat participantsdemonstrated an understanding of therelationship between excessivesun exposureand skin cancerandtheimportanceofprimarypreventioninefforts tocombatmelanoma,showingthatthegrouprecognizesthe relevanceofthetopic.Theparticipantsalsodemonstrated knowledgeoftheconceptofphotoprotection,theavailable photoprotectionmeasures, theneed toapproachthe sub-jectasasetofinterventions, theneed toreapply topical photoprotectors,and the importanceof offering a differ-entiatedapproachtothepediatric population (itemsthat wereexcludedfromtheﬁnalinstrument).Therefore,some generalandsuperﬁcialconceptsapparentlyareinthepublic domain,contrastingwiththelack oftechnicalinformation demonstratedintheotheritems,whichrepresentnecessary informationinthepracticeofprimarycareprofessionals.

On the other hand, less than 30% of the participants demonstratedknowledgeaboutthehigherrelevanceofUVB over UVA in sunburn and skin carcinogenesis, exposing a clearconceptualﬂawinatopicofabsoluterelevance. Con-versely,over80% oftherespondentsagreethat childhood andadolescencearecriticalperiodsinrelationtosun expo-sure,corroboratingthe need for instructionof healthcare professionals,reinforcing theimperative recommendation thatguidelinesonsafesunexposureareimplementedearly enoughtoallowchangesinattitudesandbehaviors through-outlife.12

Approximately85%oftheparticipantsconsideredtheuse ofsunscreensasthemain photoprotectivestrategy,which goesagainsttherecommendationofthemainguidelineson thesubject.Althoughtheyareconsideredexcellent meth-odsofphotoprotection,sunscreensshouldbepartofarange ofmeasuresthatincludechangesinlifestyle,activepursuit ofshade,anduseofprotectiveclothing,widebrimhats,and sunglasses.28_For_the_American_Academy_of_Dermatology,_the

useoftopicalphotoprotectorsisconsideredthethirdlinein photoprotectivestrategy,afterclothingandshade.6,8

Lessthan 20%ofthe respondentsdemonstrated knowl-edge about the deﬁnition and interpretation of the solar protectionfactor(SPF),whichalsoindicates animportant knowledgegap,sinceSPFisconsidered themain informa-tionabouttheeffectivenessofasunscreen.8,22 _The_results

suggestthatthesubjectisprobablylittlediscussedin medi-calschools,beingrestrictedtospecialists.Anotherquestion iswhetherthelackofknowledgeaboutsunscreenscouldbe

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Table4 Instrumentfortheevaluationoftheknowledgeofgeneralpractitionersandpediatriciansaboutphotoprotection,and

percentageofcorrectanswers;2016.

Item(original) Item(new) Statement T/F Correct

answers(%)

Dimension1:Solarradiationanditsadverseeffectsontheskin

Q6 1 Theultravioletindex(UVI)scaleisintendedtosimplifythe

disclosureofultravioletradiationlevelstothelaypublicaccording toatableofvaluesthatrangesfrom0to11+.

T 57.1

Q8 2 Exceptinthewinter,apersonexposedtothesunwithoutprotection

between8amand5pmcanreceiveadoseofultravioletradiation

superiortotherecommendedone.

F 36.9

Q9 3 Peopleareclassiﬁedintophototypesaccordingtoskincolorand

responsetosunlight;thehigherthephototype,thegreaterthe

incidenceofskincancer.

F 54.4

Q12 4 SunburnismainlycausedbyultravioletA(UVA)radiation. F 29.5

Q13 5 Heatstrokeisanexaggeratedincreaseinbodytemperatureafter

excessiveexposuretosunlight.

T 87.1

Q16 6 Ultraviolet(UV)radiationcausesimmunosuppression,decreasingthe

immuneresponseoftheskintoallergenicandinfectiousantigens,

butitalsofacilitatesskincarcinogenesis.

T 81.1

Q18 7 UltravioletB(UVB)radiationismorerelatedtocarcinogenesisthan

ultravioletA(UVA)radiation.

T 45.6

Q20 8 Skincancersareassociatedonlywithchronicexposuretoultraviolet

(UV)radiation.

F 65.0

Q23 9 Intenseexposuretoultraviolet(UV)radiationinchildhoodand

adolescence,resultinginsevereburns,haslittleeffectontheriskof

developingmelanomathroughoutlife.

F 73.3

Q24 10 Thereisamarkedrelationshipbetweenintermittentsunburnand

thedevelopmentofmelanoma.

T 74.2

Q26 11 Skincanceristhemostprevalentneoplasminseveralcountriesin

theworld.

T 88.5

Q28 12 Mostskincancershavelowcurerateswithpropertreatment. F 89.9

Q30 13 Asigniﬁcantportionofthesunexposurethatapersonreceives

throughoutlifeoccursinchildhoodandadolescence.

T 83.9

Q33 14 Thepossibilityofultravioletradiation(UV)-inducederythemais

independentofskincolorandskinsensitivitytothesun.

F 78.8

Q35 15 Theminimumerythematosusdose(MED)referstothesmallest

amountofultraviolet(UV)radiationthatiscapableofcausingskin erythemaorslightreddeningoftheskin.

T 68.7

Q36 16 Childhoodandadolescenceareconsideredcriticalperiodsof

vulnerabilitytotheeffectsofsunexposure.

T 87.6

Dimension2:Photoprotection

Q42 17 Educationalcampaignsincreaseawarenessofskincancer,butdonot

alwaysleadtobehavioralchanges.

T 88.9

Q43 18 Mostpeopleuseonlyatopicalphotoprotectorasaphotoprotective

measure.

T 87.1

Q45 19 Ultravioletﬁlterscanbeorganic(chemical)orinorganic(physical)

compounds.

T 74.2

Q50 20 InBrazil,topicalphotoprotectorsarecategorizedbytheBrazilian

HealthSurveillanceAgency(ANVISA)ascosmetics.

T 59.4

Q53 21 Thecombinationofsunscreenandinsectrepellentsisrecommended,

asoneproductdoesnotinterferewiththeother.

F 27.6

Q54 22 Thesunprotectionfactor(SPF)quantiﬁestheprotectionagainst

erythema/sunburn.

T 73.7

Q55 23 Thesunprotectionfactor(SPF)evaluatestheprotectionagainst

ultravioletA(UVA)andB(UVB)radiation.

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Table4(Continued)

Item(original) Item(new) Statement T/F Correct

answers(%)

Q56 24 Thesunprotectionfactor(SPF)isapreventivemeasureagainst

sunburnandskincancer.

F 12.4

Q57 25 Thesunprotectionfactor(SPF)ofasunscreengenerallyrepresents

lessthantheexpectedprotection,sincelessthanhalfofthe

recommendedamountofsunscreenisapplied.

T 65.0

Q58 26 Theuseofsunscreenswithsunprotectionfactor(SPF)30is

consideredadequateforthevastmajorityofindividuals,bothinthe pediatricandadultpopulations.

T 64.5

Q65 27 Syntheticfabric(polyester,nylon)garmentsprotectlessthanthose

madeofnaturalﬁber(cotton,silk,wool).

F 24.9

Q66 28 Denselywovenfabrics(thick,closed,compact)anddarkcolorsoffer

greaterphotoprotection.

T 52.5

Q71 29 Itisrecommendedtoconsidershadeastheonlyprotectionstrategy. F 83.9

Q73 30 Theamountofsunscreenusuallyappliedgenerallymatchesthat

recommended.

F 82.5

Q74 31 Applicationininsufﬁcientquantitiesisthemaincauseforreduced

effectivenessofsunscreens.

T 78.8

Q75 32 Onestrategytoreachtheappropriateamountofprotectionisto

applythephotoprotectorintwolayers(doubleapplication).

T 48.4

Q78 33 Themainrecommendationforphotoprotectionistheuseof

sunscreens.

F 15.7

Q82 34 Theuseofatopicalphotoprotectoraloneissufﬁcientforpreventing

skincancer.

F 74.2

Q85 35 Early-lifesunexposurehasacrucialimpactontheonsetofskin

cancer.

T 81.6

Q91 36 Asigniﬁcantportionoftheultraviolet(UV)radiationthataperson

receivesthroughoutlifeoccursinchildhoodandadolescence.

T 88.9

Q92 37 Topicalphotoprotectorscanbeusedsincebirth. F 54.4

Q94 38 Upto2yearsofage,preferenceshouldbegiventotheuseof

organic(chemical)protectors.

F 56.2

Q95 39 Mechanicalphotoprotectionmeasures,suchasclothing,hats,

glasses,andshade,shouldbestimulatedinchildhoodand

adolescence,andshouldprevailovertheuseofsunscreens.

T 61.8

Q96 40 Parentsshouldbeinstructedabouttheshadowrule:thegreaterthe

shadowofthechildprojectedontheﬂoorinrelationtotheirheight, thelowertherisk.

T 44.7

Q97 41 Inpreschoolandprimaryschoolagechildren,photoprotection

dependsontheparentsawarenesslevel.

T 84.8

T/F,TrueorFalse.

relatedtothefactthattheseproductsareclassiﬁedas cos-meticsinBrazilandinmostcountries,whichcouldgiverise tothemisinterpretationthattheiruseisoptional,shifting thefocusfromhealthcarepromotionandreducingits rele-vancein theprevention ofskin neoplasias. Alsoregarding topicalphotoprotection,lessthan30%demonstrated knowl-edgeabouttheinteractionbetweensunscreensandinsect repellents,whichisacauseforconcerninlightoftherecent epidemicsofdenguefever, Zika, chikungunya,andyellow fever,whichledtofrequentrepellentusebyaconsiderable percentageofthepopulation.

Regarding the use of clothing as a mechanical pho-toprotection strategy, less than 30% of the participants demonstrated knowledge about which fabrics have the

greatestprotectionpower,whichisworrying,sincethishas been selected as the main measure to be emphasized in the educationalefforts for the population regarding con-sciousexposuretoUVradiation.14 _The_use_of_clothing_is_an

easily available and effective approach toprotecting the bodyagainsttheharmfuleffectsofUVradiation.Stifferand thickerfabrics,moreﬁrmlyinterwovenanddarkerincolor, haveagreaterprotectivecapacity;polyesteristhematerial withthegreatestcapacityforabsorbingUVlightandcotton isthematerialwiththelowestcapacity.28,29

Less than half of the participants were familiar with the shadow rule, which determines that the greater the lengthofashadow,thelowertheriskofsunexposure,and

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childhood appears to be the ideal time to intervene in terms of protective behaviorsin the sun and the shadow ruleisasimpleandeffectivestrategy,recommendedinthe educationalapproachofchildren.8

The limitationsofthis studyinclude:smallsamplesize (despiteagooditem/respondentrelation),priority partic-ipation of female and young professionals, and regional application(inamedium-sizedcityinnorthernMinasGerais, Brazil).The application of previously acquired knowledge is another important aspect that was not addressed in this study --- a combination of knowledge assessment and measurementoftheprescribedpreventionmethodswould provideamorecomprehensivepictureofthesituation.Itis notpossibletoevaluatethebehaviorofhealthprofessionals fromanisolatedevaluationofknowledge,butknowledgeis fundamentalforprofessionalstoadoptappropriate behav-iorsintheirpractice,guidingtheirchoicesandattitudes.

Conclusion

This study successfully completed the elaboration of the instrument‘‘Knowledgeofgeneralpractitionersand pedia-triciansaboutphotoprotection,’’whichwasvalidatedwith goodinternalconsistencyandgoodreproducibility,as mea-suredbythetest-retest.Itwaspossibletoidentifyimportant knowledge gaps among professionals participating in the study.Theﬁnalinstrumentshouldbeconsideredasa valu-abletoolinidentifyingknowledgegapsofpediatriciansand general practitioners on photoprotection, and may serve asabasisforthedevelopmentoftrainingandeducational strategiesforthesephysiciansindifferentregions.

Financial

support

Nonedeclared.

Author’s

contribution

Fernanda Mendes Araújo: Statistical analysis; approval of theﬁnal version of the manuscript; conception and plan-ningofthestudy;elaborationandwritingofthemanuscript; obtaining, analyzing and interpreting the data; effective participation in research orientation; intellectual partici-pationin propaedeuticand/or therapeuticconduct ofthe cases studied; critical review of the literature; critical reviewofthemanuscript.

Julliana Andrade do Carmo: Approval of the ﬁnal ver-sion of the manuscript; conception and planning of the study;obtaining,analyzingandinterpretingthedata; criti-calreviewofthemanuscript.

LetíciaDinizCunha:Approvaloftheﬁnalversionofthe manuscript;conception andplanningofthestudy; obtain-ing,analyzingandinterpretingthedata;criticalreviewof themanuscript.

IgorMonteiroLimaMartins:Approvaloftheﬁnalversion ofthemanuscript;obtaining,analyzingandinterpretingthe data;criticalreviewofthemanuscript.

Airton dos Santos Gon: Approval of the ﬁnal version of themanuscript; conception and planningof the study; elaboration and writing of the manuscript; effective

par-ticipationinresearchorientation;intellectualparticipation in propaedeutic and/or therapeutic conduct of the cases studied;criticalreviewoftheliterature.

Antônio Prates Caldeira: Statistical analysis; approval of the ﬁnal version of the manuscript; conception and planning of the study; elaboration and writing of the manuscript;obtaining,analyzingandinterpretingthedata; effectiveparticipationinresearchorientation;intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied; critical review of the literature; criticalreviewofthemanuscript.

Conﬂicts

of

interest

Nonedeclared.

Acknowledgements

The authors would like to thank Fernanda Quadros Mendonc¸a, resident physician of Clinical Medicine at the University HospitalClementedeFaria oftheUniversidade EstadualdeMontesClaros(Unimontes),forhercollaboration intheapplicationofquestionnaires.

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