|Year : 2021 | Volume
| Issue : 3 | Page : 139-146
Sunscreen use among albinos in Enugu, South-Eastern Nigeria
Uche Rowland Ojinmah1, Chinwe Laura Onyekonwu1, Ikechukwu Emmanuel Obi2, Jane Baridakara Uche-Ejekwu1, Nkiru Pauline Onodugo1, Chinechelum Nneoma Anyanechi1, Chika Mary Emeka1
1 Department of Medicine (Sub-Department of Dermatology), University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
2 Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
|Date of Submission||02-Jan-2020|
|Date of Decision||21-May-2020|
|Date of Acceptance||31-Jan-2021|
|Date of Web Publication||20-Apr-2021|
Uche Rowland Ojinmah
Skin Clinic, Sub-Department of Dermatology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State.
Source of Support: None, Conflict of Interest: None
Background: Albinism is a congenital skin condition which is caused by lack or deficiency of tyrosinase enzyme leading to partial or complete absence of melanin from skin with attendant solar skin damage which could lead to premature skin aging, skin cancer, and visual problems. Good knowledge and proper use of sunscreens could prolong the life of people living with albinism. Materials and Methods: This cross-sectional study involved 40 people living with albinism who were recruited consecutively after giving informed consent. The subjects then responded to a pretested questionnaire and had their skin also examined. Analysis of data was done with SPSS version 20. Results: About 92.5% (n = 37) know about sunscreen but only 22.5% (n = 9%) have known about it for more than 10 years. Based on the ages of the study participants, many had lived for more than 10 years before getting to know about sunscreen and hence have been unprotected from damaging effects of sunlight for long. The most important sources of information about sunscreen are doctors 32.5% and fellow albinos 22.5%. Most subjects (90%) had poor knowledge of what makes a good sunscreen and most (82.5%) used it inappropriately. Conclusion: While many knew about sunscreen, only a small fraction got the information early which is vital for commencement of skin protection early, hence forestalling damage. Doctors were found to be important source of information about sunscreen, although many subjects used it inappropriately.
Keywords: Albinism, solar damage, sunscreen use
|How to cite this article:|
Ojinmah UR, Onyekonwu CL, Obi IE, Uche-Ejekwu JB, Onodugo NP, Anyanechi CN, Emeka CM. Sunscreen use among albinos in Enugu, South-Eastern Nigeria. Int J Med Health Dev 2021;26:139-46
|How to cite this URL:|
Ojinmah UR, Onyekonwu CL, Obi IE, Uche-Ejekwu JB, Onodugo NP, Anyanechi CN, Emeka CM. Sunscreen use among albinos in Enugu, South-Eastern Nigeria. Int J Med Health Dev [serial online] 2021 [cited 2022 May 19];26:139-46. Available from: https://www.ijmhdev.com/text.asp?2021/26/3/139/313947
| Introduction|| |
Albinism is a congenital, inheritable condition which has lack of pigmentation as its main feature. Due to lack of pigmentation, albinos are readily exposed to the damaging effects of sunlight, thus making deployment of sun protection vital in their daily lives. To derive full benefit from the sun protectors, it has to be started early in life and used appropriately. In this study, we looked at knowledge of sunscreens, appropriate topical sunscreen use, and the benefits.
Albinism manifests as oculo-cutaneous (OCA) or just ocular type, with variable levels of melanin deficiency which could be focal or generalized.,, Prevalent varieties of albinism in sub-Saharan Africa are OCA2 and 3 with some rare types.,,
Albinism is the most important risk factor for the development of skin cancer in sub-Saharan Africa with a worldwide affectation of 1 in 20,000 people. Oculo-cutaneous albinism is more common than the ocular type with a worldwide prevalence of 1:17,000 and a reported prevalence range of 1:5,000 to 1:15,000 in sub-Saharan Africa., Okoro reported a prevalence of 1:15,000 in the East-Central state of Nigeria.,
Repeated exposure to the ultraviolet (UV) component of solar radiation can cause damage to the dermis, and this manifests as expedited skin aging relative to the chronological age., Acute effects of repeated UV radiation exposure include erythema, hyperpigmentation, delayed tanning, epidermal hyperplasia, vitamin D synthesis, and the formation of free radicals, whereas the chronic effects include photoaging, immunosuppression, photocarcinogenesis, worsening of photodermatosis, freckling, wrinkling, actinic keratosis, solar lentigines, squamous cell cancer, and basal cell cancer.,,,
Sun protection measures are lifelong and must start early in life, though ideally it should start at birth to be maximally beneficial.,, These measures include wearing sunglasses and protective clothing, staying in shades, wearing a wide-brim hat, tree-planting, constructing shades, using sunscreen lotions and sprays, and avoiding the outdoors between the hours of 10 am and 4 pm especially.,,,
According to the National Health and Nutrition Examination Survey on sun-protective behaviors, sunscreen application behavior was defined as the average number of days per week that participants applied sunscreen during the preceding 30 days.
Factors that could affect a person’s exposure to the sun and sun protection behavior include gender, age, skin type, a person’s ethnicity, a personal or family history of skin cancer, the educational status, the type of work being done (outdoor vs indoor), and whether a person has been educated on the use of sun protection.
Regular use of sunscreen in temperate regions with an effective sun protection factor (SPF) of 7.5 within the first 18 years of life has been shown to reduce the lifetime incidence of non-melanoma skin cancers by 78%.
The eyes of many albinos are sensitive to visible light because reduction or absence of melanin in the iris makes them translucent, thus allowing passage of light through the pupil and iris unhindered. This causes photophobia and glare but darkly tinted UV filtering sunglasses are beneficial in reducing these and consequent retina damage.,
This study aims in general to determine the knowledge and pattern of use of sun screen among albinos in Enugu State Nigeria and to objectively determine their knowledge of sunscreen and the benefits of appropriate use, pattern of use of sunscreen, and the association between appropriate use of sunscreen and absence of sun damage.
This work will be an addition to the body of knowledge available in the field of albinism and also provide materials that care providers and people living with albinism can rely on to improve skin care, thereby preventing sun damage and its complications.
| Subjects and Methods|| |
This study was carried out at the Skin Clinics of University of Nigeria Teaching hospital (UNTH), south-east Nigeria and through The Albino Foundation (TAF) Enugu state chapter. UNTH is a tertiary health institution in Enugu that provides healthcare services to residents of Enugu state and also receives referrals from and beyond all the five south-eastern states of Nigeria. The south-east of Nigeria is primarily inhabited by people of Igbo ethnic group who speak Igbo language and is one of the three major ethnic groups in Nigeria.
TAF is principally an independent non-governmental organization establishment run by people living with albinism (PWA). It came into being in 2006. They are a special focus organization advocating for the recognition and respect of the rights and socio-economic inclusion of PWA. The organization works to create awareness of the social challenges PWA face in Nigeria and the world, by working with governments and development institutions in program areas that improve the health and social wellbeing of PWA in Nigeria. It also assists and empowers PWA to find their rightful place in society and has a national spread with 30 functional state chapters across the country. According to the 2006 National Population Census of Nigeria, Enugu state and South-East have a population of 3.2 million and 16.3 million, respectively, with the South-East population making up 11.70% of the national population.
There were 148 registered members of TAF on record in Enugu state chapter as at the time of this study.
This was made up of patients 10 years and above, with cutaneous and oculo-cutaneous albinism that attended the skin clinic of UNTH or TAF focus group meetings in the state.
This was a cross-sectional descriptive study carried out between March and October 2016.
Sample size was determined using the formula: N = Z2PQ ÷ D2, where N is the minimum sample size; Z the estimated standard deviation of 1.96; P the prevalence of 0.02% (1 in 5,000),; Q = 1‒P; D the degree of accuracy desired of 5% (0.05). The minimum sample size N calculated was approximately 31 but was increased to 40 subjects to improve statistical accuracy.
The sampling method was recruitment of consecutive patients who met the inclusion criteria until the sample size was attained.
A pretested semi-structured interviewer-administered questionnaire was utilized to collect the information from the respondents.
The questionnaire to be used was pretested via five members of the research team giving out five questionnaires to five different albino subjects who met inclusion criteria to fill. The aim was to ensure that: (a) what we had in mind in framing individual questions was what the respondent understood from the question, (b) unnecessary medical terminologies were eliminated, (c) necessary questions toward capturing appropriate data were included, and (d) to, if necessary, titrate downward time spent on each section and entire questionnaire, thus making it less cumbersome for the respondent. At the end, individual researchers received the questionnaires from the respondents. The filled questionnaires were analyzed individually and collectively by the research team and necessary corrections made in line with the above aims.
All individuals with cutaneous or oculo-cutaneous albinism who were 10 years or older, not moribund, gave informed consent and were able to respond to the research questionnaire.
The first 40 albino patients and participants who visited the clinics and participated in the Albino foundation focus group discussions and fulfilled the inclusion criteria were recruited into this study. All those recruited had the pretested research questionnaire administered on them by the researchers, being careful to respect their privacy. After completing the questionnaire, the albinos had their skin examined and were subsequently properly educated on the appropriate use of sunscreens.
Analysis of data was done with the Statistical Software Package for Social Sciences SPSS version 20 (Chicago, IL, USA).
The data were collated and summarized showing the frequency and percentage of the variables observed, and then the χ2 test/Fischer’s exact test was applied to test for association between variables. Results were presented in tables.
Approval for the study was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital. Written informed consent was also obtained from the participants or their next-of-kin where necessary before the study instruments were administered.
| Results|| |
The highest age frequency of 15 (37.5%) came from the range of 20–29, whereas 40–49 had the lowest frequency of 6 (15%). There were more females at 55% (n = 22) than males. About 50% of the study population (n = 20) had post-secondary education, whereas 17.5% had no formal education. Most of the population studied were single at 80% (n = 32), and 45% (n = 18) were students by occupation. Details are as shown in [Table 1].
[Table 2] shows a lot of albinos in the study population, 92.5% (n = 37) know about sunscreen but only 22.5% (n = 9) have known about it for more than 10 years.
|Table 2: Knowledge of sunscreen, types of sunscreen, sunscreen use, and its application|
Click here to view
About 32.5% (n = 13) of the study participants obtained information about sunscreen from doctors, whereas 22.5% (n = 9) received the information from contact with fellow albinos.
The basis for being classified as having good knowledge was knowledge of more than four sun blocks, and the basis for good use is as follows: the use of a combination of two or more sun blocks and use of sunscreen cream/lotion/spray with SPF of 15 or more, whereas sunscreen cream/lotion/spray every day in the previous 30 days and application of sunscreen cream/lotion/spray every 2 h during the day is advised in the tropics. Thus poor knowledge of appropriate use of sunscreen was evident in 36 (90%) of the respondents, and the pattern of use of sunscreen among the respondents was also found to be inappropriate among 33 (82.5%) of them.
[Table 3] shows the association between appropriate/inappropriate use of sunscreen and sun-induced skin damage. In the sample population, there was no observed association between appropriate/inappropriate use of sunscreen and presence or absence of skin damage determined by examination. Erythema alone was rated as skin damage and was present in most of the population studied. The knowledge of sunscreen and appropriate use of sunscreen were found to be poor throughout the age ranges, though relatively worse in the 20–29 (100%) and 30–39 (80%) age ranges. The outcomes were also poor based on gender, educational qualification, marital status, and occupation, though the observed associations were not statistically significant.
|Table 3: Factors influencing knowledge and appropriate use of sunscreens|
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[Table 4] shows the lesions found on examination of the respondents and their description and diagnosis in relation to knowledge of its existence. On diagnosis, eight (29.6%) of the 27 respondents with solar elastosis/rhomboidalis were unaware of this, 11 (28.9%) of the 38 with erythema were unaware of this as a sign of sun damage, 6 (35.5%) of those with ephelides were unaware, and 5 (35.7%) of the respondents with pachyderma were unaware of this.
|Table 4: Presence of skin problems, description, and diagnosis in relation to knowledge of its existence|
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| Discussion|| |
This study has thrown more light on the use of sunscreen and associated factors. Most of the albinos in the study population (92.5%) knew about sunscreen but only 22.5% have known about it for more than 10 years. This was not satisfactory in that 77.5% of the study population was over 20 years of age. For instance, Lund and Taylor stated that use of sunscreen ideally should start at birth and continue through life in order to be maximally beneficial. This therefore suggests that a reasonable proportion of the population studied lived for more than 10 years of life without knowing about and not using any form of sunscreen and this is in tandem with the findings of Hall et al. in USA among white children aged 12 years or younger. It is therefore right to say that in agreement with the findings of Wright et al., they may have to live with skin and psychological effects of sun damage probably for the rest of their lives having lived without protection for most part of their childhood when the skin is most susceptible to sun damage, as noted by Cestari and Buster in USA and also Lund and Taylor in South Africa. The majority of our study population had poor knowledge of appropriate use of sunscreen and also used it inappropriately. This was found to be relatively worse in the 20–29 (100%) and 30–39 (80%) age ranges, which are active years with attendant sun exposure and hence not a good indicator. Knowledge about sunscreen was majorly through information received from doctors (32.5%) and contact with fellow albinos (22.5%), making medical practitioners important players in albinism management, which must be carried along by all stakeholders while encouraging the establishment of conditions to engender albino-to-albino interactions such as focus groups and albino care organizations. This is essentially in agreement though in reverse order with the findings of Godeliver et al. in Tanzania, with Tanzania Albino Society being the major source of information (71.95%), followed by hospital/pharmacy at 15.8%.
The clinical implications of this study are that albinos in this study population lack adequate knowledge and hence have poor practice of sun protection with attendant sun damage; therefore, more attention should be focussed on availing albinos of formal education and more vigorous attempt at enlightenment about sun protection using pictorials/short videos made in English, vernacular, and “pidgin English” for ease of acceptance and assimilation. Thus the appropriate use of topical sunscreen as defined by studies in the temperate region may not be fully effective in the study population.
There was no observed association between appropriate/inappropriate use of sunscreen and presence or absence of skin damage. This we suspect may be due to the fact that in this study, skin erythema was labeled solar skin damage in agreement with Sambuco et al., and all participants had erythema but it was the sole finding in those who use sun blocks appropriately as defined in this study while those who use it inappropriately had a combination of features of sun damage in addition to erythema. The presence of erythema in those using sunscreen appropriately may also be an indication that we need to establish a more stringent topical sunscreen application regime in our environment different from what is obtainable in the temperate region to achieve optimal benefit or the need for sustained quality control inspection of topical sunscreens to exclude fake and counterfeits. Lazovich et al. in their study in Minnesota found that optimal use of routine sunscreen or other sun protection methods were most strongly associated with decreased solar damage and melanoma risk, which is in tandem with our findings mentioned earlier.
Despite reporting absence of skin lesions while completing the questionnaire, most of the participants were found to have erythema and other features of prolonged sun damage such as pachyderma, ephelides, and solar elastosis during examination. This emphasize the obvious lack of knowledge about skin manifestations of sun damage, especially in the early phase. Thus, these patients may present to a doctor only when they noticed advanced solar damage which may lead to poor treatment outcomes.
Presence of sun damage in certain anatomic areas like low back and medial aspects of upper extremities may indicate improper covering of the skin and habitual bad posturing such as sitting or standing with arms over the head.
Factors that influenced good knowledge of sunscreen use include female gender (probably because females are more interested in their physical appearance than males and the fact that they are more in number in this study), formal education (secondary level and above), being single as it pertains to marital status (probably because they are still “searching” and need to be in optimum skin condition for display), and being a civil servant as it pertains to occupation (being able to read and understand English language makes enlightenment easy because most enlightenment materials are in English language and civil service usually presents a career away from sun exposure). Lund and Taylor in South Africa in a study among albino children recorded the fact that females initiate sun avoidance behavior more than males while in the USA, Tuong and Amstrong found health-based and appearance-based enlightenment videos beneficial in improving knowledge of sunscreen use among students of a high school.
It was observed also that factors that influence sun protection are younger age (this is a good finding as it could be a pointer to better skin condition as they age) and female gender (this is in line with the fact that in our society, most males view paying close attention to maintaining skin beauty as time-wasting activities better left for females). Others were formal education (majority at post-secondary level), being single as it pertains to marital status, and student as an occupation which in our clime all favor better skin care to look more presentable, and occupations with less direct exposure to sun damage and ability to easily understand and assimilate enlightenment materials which are mostly in English language. Nahar et al. in their study attributed it to female gender just like we found in this study, older age which is at variance with our finding, white race, a personal history of skin cancer, spending long time in outdoor work, and sun safety training.
The strengths and limitations of this study: Dearth of data in the field of albinism from Nigeria makes this study important, and findings shall be of benefit to healthcare givers and albinos themselves. The limitations include the hospital-based nature of the study and the small sample size, which limit generalization of the study.
| Conclusion|| |
A high proportion of albinos in this study knew about sunscreen, although most only got to know about it late in life. Doctors and contacts with other albinos were important sources of getting to know about sunscreen, although use of sunscreen was generally poor. Being young in age, female gender, having a formal education, being single, being a student, and being civil servants are factors that impacted positively on knowledge and use of sun protection among albinos in our study population. We therefore recommend that special attention be paid to enlightenment and deepening of the knowledge of parents, especially during antenatal/postnatal care about sunscreen use and attendant benefits. This hopefully will encourage them to introduce their children early to sunscreen use, and the knowledge will be transferred to the offspring. Emphasis should be laid on the fact that erythema is a feature of sun damage especially when persistent. More attention should be placed on teaching albinos about different types and stages of sun damage in our clinics and focus groups, especially with pictorials and video clips. Enlightenment and focus group discussion should specifically target proper skin covering and posturing. Enlightenment materials/jingles should also be produced in vernacular and “pidgin English.” Short video format is also suggested. Governmental and non-governmental organizations should make formal education of albinos a target as it improves their ability to receive and understand enlightenment and also provides opportunities for careers with minimal or no sun exposure. Future research direction should be targeted toward establishing appropriate topical sunscreen application protocol suitable for obtaining optimum benefit (erythema free skin) among albinos in the study population. A community-based study with wider representation is also needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wright CY, Norval M, Hertle RW Oculocutaneous albinism in sub-Saharan Africa: Adverse sun-associated health effects and photoprotection. Photochem Photobiol 2015;91:27-32.
Opara KO, Jiburum BC Skin cancers in albinos in a teaching hospital in Eastern Nigeria—Presentation and challenges of care. World J Surg Oncol 2010;8:73.
Thuku M Myths, discrimination, and the call for special rights for persons with albinism in Sub-Saharan Africa. 2011 (Cited February 12, 2016):1-24 (about 7pm). Available from https://undocs.org/pdf?symbol=en/A/71/255 [Last accessed on 2021 Mar 13].
Lund PM, Gaigher R A health intervention program for children with albinism at a special school in South Africa. Health Edu Res Theory Pract 2002;17:365-72.
Lund PM, Taylor JS Lack of adequate sun protection for children with oculo-cutaneous albinism in South Africa. BMC Pub Health 2008:8:225 (about 12pm). Available from https://doi.org/10.1186/1471-2458-8-225
Kamaraj B, Purohit R Mutational analysis of oculocutaneous albinism: A compact review. Biomed Res Int 2014;2014:905472.
Grønskov K, Ek J, Brondum-Nielsen K Oculocutaneous albinism. Orphanet J Rare Dis 2007;2:43.
Hong ES, Zeeb H, Repacholi MH Albinism in Africa as a public health issue. BMC Public Health 2006;6:212.
Okoro AN Albinism in Nigeria. A clinical and social study. Br J Dermatol 1975;92:485-92.
Dixon KM, Deo SS, Norman AW, Bishop JE, Halliday GM, Reeve VE, et al
. In vivo
relevance for photoprotection by the vitamin D rapid response pathway. J Steroid Biochem Mol Biol 2007;103:451-6.
Seité S, Fourtanier AM The benefit of daily photoprotection. J Am Acad Dermatol 2008;58:S160-6.
Lim HW, Naylor M, Hönigsmann H, Gilchrest BA, Cooper K, Morison W, et al
. American Academy of Dermatology Consensus Conference on UVA protection of sunscreens: Summary and recommendations. Washington, DC, Feb 4, 2000. J Am Acad Dermatol 2001;44:505-8.
Kullavanijaya P, Lim HW Photoprotection. J Am Acad Dermatol 2005;52:937-58; quiz 959-962.
Stanton WR, Janda M, Baade PD, Anderson P Primary prevention of skin cancer: A review of sun protection in Australia and internationally. Health Promot Int 2004;19: 369-78.
Marrot L, Meunier JR Skin DNA photodamage and its biological consequences. J Am Acad Dermatol 2008;58:S139-48.
Nahar VK, Ford MA, Hallam JS, Bass MA, Vice MA Sociodemographic and psychological correlates of sun protection behaviors among outdoor workers: A review. J Skin Cancer 2013;2013:453174.
Tuong W, Armstrong AW Effect of appearance-based education compared with health-based education on sunscreen use and knowledge: A randomized controlled trial. J Am Acad Dermatol 2014;70:665-9.
Kirkwood BJ Albinism and its implications with vision. Insight 2009;34:13-6.
Lund PM Health and education of children with albinism in Zimbabwe. Health Educ Res 2001;16:1-7.
National policy on albinism in Nigeria: Federal Ministry of Education 2012 implementation guidelines. Federal ministry of health, Nigeria 2012. Available at <https://albinofoundation.org/wp content/uploads/2017/04/National-Policy-on-Albinism-Implementatio-Guideline.pdf>. Last accessed April 4, 2021.
National Population Commission (NPC) [Nigeria] and ICF Macro. 2009. Nigeria Demographic and Health Survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro. Available at https://www.scirp.org/(S(i43dyn45teexjx455qlt3d2q))/reference/ReferencesPapers.aspx?ReferenceID=1228243. Last accessed April 4, 2021.
Hall HI, Jorgensen CM, McDavid K, Kraft JM, Breslow R Protection from sun exposure in US white children ages 6 months to 11years. Pub Health Report 2001;116:353-61.
Cestari T, Buster K Photoprotection in specific populations: Children and people of color. J Am Acad Dermatol 2017:76(Suppl 1):S110-21 (about 8pm). Available from https://doi.org/10.1016/j.jaad.2016.09.039
Lund PM, Taylor J Lack of adequate sun protection for children with occulocutaneous albinism in South Africa. BMC Pub Health 2008;8:225 (about 2am). Available from http://doi.org/10.1186/1471-2458-8-225
Godeliver ABK, Maregesi SM, Mnyenye A Availability, Knowledge and use of sunscreen products by people with albinism in Dar es Salaam region-Tanzania. Int Res J Pharm App Sci 2013;3:70-4.
Sambuco CP, Forbes PD, Davies RE, Urbach F An animal model to determine sunscreen protectiveness against both vascular injury and epidermal cell damage. J Am Acad Dermatol 1984;10:737-43.
Lazovich D, Vogel RI, Berwick M, Weinstock MA, Warshaw EM, Anderson KE Melanoma risk in relation to use of sunscreen or other sun protection methods. Cancer Epidemiol Biomarkers Prev 2011;20:2583-93.
[Table 1], [Table 2], [Table 3], [Table 4]