Knowledge, Attitude, and Practice (KAP) Survey toward Skin Cancer among Ecuadorian Population

Background Skin cancer is one of the most common cancers, and melanoma is a highly preventable cancer. In Ecuador, few studies have evaluated the awareness levels of the population about the disease. For this reason, the objective of this study was to measure the level of knowledge, attitudes, and practices regarding skin cancer and its determining factors. Methods A cross-sectional analysis using an online self-assessment questionnaire containing 40 questions was delivered. A total of 537 participants were included in this study. Knowledge, attitude, and practice scores were assigned to each participant based on the number of correct or appropriate responses. Logistic regression analysis was used to calculate crude and adjusted odds ratios. Results In total, 75% of participants referenced knowledge of the harmful effects related to noncontrolled solar exposure. Concerning sunscreen, 76.7% knew the reason for using it. The female group was 1.68 times more likely to get a higher score than the male group, and the groups between 61–70 and 71–80 years were 0.30 and 0.17 times less likely to get a higher score compared with the less than 20-years-old group, respectively. Conclusions The findings of this study indicate the requirement to increase the population's knowledge about skin cancer and possible protection measures. For this reason, the prevention and health promotion programs at a national level from primary healthcare centers are recommended. Due to the limitation of the representativeness of the sample, the use of more studies among Ecuadorian residents of the low socioeconomic level and replication in different provinces of Ecuador is justified.


Introduction
Cancer is the second leading cause of death worldwide, with skin cancer as one of the most common. Melanoma is the most clinically relevant skin cancer, either in frequency or mortality [1,2], whose trend has increased over the years [3,4].
Diagnosis increases after 60 years of age. It is 1.5 times more frequent in men than in women, and this may be due to the fact that they are more exposed to UV radiation due to economic and work activities. Similarly, the incidence is higher in people with fair skin [5]. e risk of developing skin cancer depends on constitutional factors such as skin phototypes I and II, solar lentigines, dysplastic nevi, immunosuppression, a family history of melanoma [6,7], and environmental factors such as altitude, latitude, and season of the year.
Excessive exposure to ultraviolet (UV) radiation can be considered the main cause, especially in recent years due to the reduction in the ozone layer. It has shown significant differences between UVA and UVB radiation, such as ionizing radiation and the ability to penetrate the skin, with UVB being the main cause of cutaneous neoplasms, even though it only represents 5% of solar radiation.
is is because UVB radiation causes the appearance of point mutations in target genes [8][9][10].
According to the "Sociedad de Lucha contra el Cáncer" (SOLCA) data, cutaneous neoplasms are the third most frequent cancer in the country, and Quito presents the highest number of cases [11]. is could be due to the fact that the capital is 2850 meters above sea level; in the equatorial zone, the solar rays fall in a direct way so that in the middle latitudes and the UV radiation are consequently more intense in this area. In addition, as Quito is located in a high mountainous area, it facilitates the path of solar rays; so that at higher altitudes, there is greater UV radiation [12]. e increased incidence of skin cancer is due to diagnostic deficiencies in both primary and secondary care, as well as unnecessary exposure to environmental factors by the population, in many cases due to lack of knowledge on the subject [8,13,14].
In Ecuador, few studies have systematically evaluated the level of awareness of the population about the disease. For this reason, the objective of the present study was to measure the level of knowledge and the attitudes and practices regarding skin cancer and its determining factors.

Study Setting.
e population of Ecuador is estimated at 17.3 million [15]. is study was conducted in three different zones of Quito-North, Center, and South-with a total population of 3.1 million (18% of the entire country).

Study Design.
A cross-sectional study of the primary sources was carried out during the dissemination of the campaign of prevention and health promotion for the "Melanoma Day" organized by the Ecuadorian Society of Dermatology in Quito, Ecuador, in May 2019.

Study Size and Participants.
Participants were between 15 and 80 years old. e aim of the study was explained to potential participants, who then agreed to participate in this study and signed the informed consent form. Participation was strictly voluntary, and no incentives were provided. e sample size was calculated with a 95% confidence level, obtaining a minimum of 385 subjects. e real sample size was 537 respondents.
In addition, all participants who rejected informed consent and provided incomplete questionnaires (n � 56) were excluded from the study.

Study Instrument and Data Collection.
A survey previously reviewed and validated by experts was applied after a pilot study with ten people from different age groups. Five difficult-to-understand questions were identified and reformulated. In addition, the interviewers were instructed on the application of the survey in general and the specifications to be given to the participants in those questions. e questionnaire was composed of a few sections: sociodemographic characteristics (sex, age, marital status, education, occupation, income, number in household), knowledge, attitudes, and practices about the sunscreen use to prevent skin cancer.

Data
Analysis. Characteristics of the study population were analyzed using descriptive statistics (frequency and percentage). Knowledge, attitude, and practice scores were assigned to each participant based on the number of correct or appropriate responses. An appropriate answer was assigned one point. e knowledge and attitude scales were 0-12 points, and the practice scale was 0-20 points. Indeed, the scores were dichotomized into low (poor) or high (good) taking into account the mean of each category as follows: knowledge (low � 0-5 points; high � 6-12 points); attitude (poor � 0-5 points; good � 6-12 points); and practice (poor � 0-11 points, good � 12-20 points). Logistic regression analysis was used to calculate crude and adjusted odds ratios as well as corresponding 95% confidence intervals (CI). Each variable was first entered separately into bivariate logistic regression models to evaluate the crude association with sociodemographic characteristics. All predictors were then entered in multivariable logistic regression to get adjusted odds ratios (ORa). Data were analyzed with SPSS version 21 software.

Sociodemographic Characteristics.
ere were a total of 537 participants in this study. Of these, 60.5% (n � 325) were female. e median age of the study participants was 41.5 years (IQR: 19-58). e most common age subgroup was between 51 and 60 years. Concerning race, 92.9% (n � 499) of the participants identified themselves as mestizo followed by 4.1% (n � 22) as indigenous. Regarding marital status, 54.4% (n � 292) were married and 26.8% (n � 144) were single (Table 1). Relating to nationality, only 1.9% (n � 10) were non-Ecuadorian. According to the demographic factors of the participants, 95.7% were residents of the Quito city. e most relevant social factor was that family income for 43.2% (n � 232) corresponded to the interval between 1 and 2 unified minimum wages followed by 30.2% (n � 162) who earned less than 1 minimum wage. According to the number of inhabitants per house, 60% (n � 322) answered that they shared with between 2 and 4 people. Within the educational level, it was observed that 43.4% (n � 233), 29.2% (n � 157), and 19.6% (n � 105) had completed the secondary, primary, and third level of education, respectively. e majority of the participants reported that they wrought as housewives 25.7% (n � 138) followed by professionals 17.5% (n � 94), students 15.6% (n � 84), among others. In addition to working conditions, 60.7% (n � 326) reported working in urban areas, while suburban and rural levels counted for only 6.9% (n � 37), and the rest were not working at the time of the survey. On the other hand, the residential conditions of the registered participants demonstrate that 91.8% of the participants live in urban areas (n � 493), while the rest live in suburban or rural areas. According to the basic services, it is evident that 1.1% (n � 6), 1.3% (n � 7), and 0.2% (n � 1) had no drinking water, sewage, and electricity services, respectively (Table 1).
Of the respondents, only 1.7% (n � 9) had a personal history of skin malignancy, and 6.1% reported having a family history of it. On the other hand, almost half of the participants (n � 225; 41.9%) reported having type IV skin according to the Fitzpatrick classification (Table 1).

3.2.
Knowledge. Approximately 75% of participants (n � 400) referenced knowledge of the harmful effects related to noncontrolled solar exposure. Of those participants, 49.3% knew several effects; 22% linked it to skin tumors followed by 9.9% to solar burns, 6.5% to skin spots, and others ( Table 2). Concerning causality, 72.3% (n � 388) of participants agreed that there is a direct relationship between noncontrolled solar exposure and skin cancer. Concerning sunscreen, most people, 74.5% (n � 400), answered that they knew of the concept and types, and 76.7% knew the reason for using it. Finally, 62.2% of the participants reported knowing other protection measures in addition to the use of sunscreen.
Concerning the regression results, in the bivariate analysis, it was demonstrated that people with a monthly income higher than $1000 were 2.36 times more likely to score higher on the knowledge scale compared with those with an income lower than a minimum living wage. Related to education, people who have finished the secondary, technician, tertiary, and fourth level were 9.92, 20, 23.87, and 12.5 times more likely to score higher compared with people with no education, respectively. In addition, relating to employment, the categories of housewife, trade, students, and unemployment were 0.44, 0.57, 0.5, and 0.23 less likely to score higher compared with professionals, respectively. However, after appropriate adjustments were made, all study levels remained unaffected, while for other categories only students were still less likely 0.24 (0.07-0.91) to have higher scores compared with professionals.

Attitude.
Approximately half of the participants (n � 269; 50.1%) reported having presented more than three burns caused by solar radiation during their lifetime. Regarding the amount of exposure to solar radiation during childhood and adolescence, the majority of participants, 71.3% (n � 383), reported having been exposed without protection for more than 6 days in each week during their development.
About sun protection factor (SPF) present in sunscreens, the most commonly used were more than 50% described by 24.6% (n � 172) followed by the range of 30 to 50% described by 16.6% (n � 89). A third of respondents, 37.4% (n � 201), reported that the approximate value of a sunscreen is in the range of 11 to 20 US dollars. In addition, 61.9% of the participants (n � 332) reported that this cost is affordable. Finally, half of these products are purchased in pharmacies, 48.8% (n � 262), while the rest of the products were purchased in stores, catalogs, among others (Table 3).
In bivariate analysis, the female group was 1.63 times more likely to score higher on attitude score than the male group. According to marital status, it was observed that people who live with a partner (married/consensual union) were 0.62 times less likely to score higher compared with those with no partner (single/divorced/widowed). Another important finding was that the age groups 61-70 and 71-80 both presented less likely to score higher compared with those <20 years. Moreover, for monthly income, it was evidenced that both groups ($650-$1000 and more than $1000) had 1.95 and 3.72, respectively, more likely to obtain higher scores compared with the less-income group. Concerning education, only secondary, tertiary, and fourth level were 9.92, 16.92, and 20 times more likely to get higher scores compared with the noneducated group, respectively. Finally, compared with professionals, trades and retired were 0.43 and 0.31 times less likely to score higher, respectively. In contrast, when multivariate analysis was performed. Adjusted results that remains significant were live with a partner (ORa � 0.57), income over $1000 (ORa � 2.73) and secondary, tertiary and fourth level of education with (ORa � 9.9), (ORa � 16.47), and (ORa � 18.95), respectively (Table 4).

Practice.
Close to half of the participants reported daily sun exposure of less than two hours in 42.1% (n � 226) and three to five hours in 39.5% (n � 212). Regarding protection practices, 70.4% (n � 378) of participants had some type of sunscreen at home. Furthermore, 63.1% (n � 339) use it regularly. Of this group, approximately 50.4% (n � 270) use it every day, while the other half only use it occasionally or on weekends. Furthermore, 71.5% (n � 384) reported that Dermatology Research and Practice      Table 5). e results of bivariate analysis demonstrated that the female group is 1.68 times more likely to get a higher score than the male group. In addition, related to age, it was observed that the groups between 61-70 and 71-80 years were 0.30 and 0.17 times less likely to get a higher score in the practice section compared with the <20-years-old group. Concerning the level of education, the primary, secondary, technician, tertiary, and fourth level groups were 9.38, 18.77, 15, 23.87, and 80 times more likely to get higher values on practice scores compared with no education group, respectively. Moreover, it was found that trade and retired groups were 0.37 and 0.27 less likely to get a higher score compared with professionals, respectively. Lastly, it was shown that the group that lives outside the city was 0.48 times less likely to get a higher score compared with urban residents. However, after appropriate adjusted comparison, there still remained differences per sex (ORa � 1.71); per age in the group 61-70 (ORa � 0.16) and group 71-80 (ORa � 0.15); per family income over $1000 (ORa � 3.97); per education in secondary, technician, tertiary, and fourth levels (ORa � 16.51, 11.51, 17.57, and 62.18, respectively); and per residential location (ORa � 0.41) ( Table 4). Suddenly concerning the household, it was shown that the group from 2 to 4 people in the house which increases 2.17 times more likely to obtain a higher score compared with less than 2 persons. Finally, another important fact is that only the student group was 0.24 times less likely to get higher practice scores compared with professionals.

Discussion
Skin cancer is currently among the most common cancers, showing increasing incidence and mortality rates [16,17]. In Ecuador, skin cancer is found in the three most frequent SOLCA malignancies. is study was carried out to evaluate the level of knowledge and the attitudes and practices regarding skin cancer and sunscreen in the adult population of the city of Quito. e data obtained concerning the level of knowledge showed a direct association between socioeconomic level and its indicators, such as monthly income greater than $ 1000, as well as those with a higher academic degree, results that are consistent with those presented in the studies of Rhazi et al. [18]. is was also found associated with the workplace and residence, with the urban population achieving the highest levels of knowledge, compared with the rural population, a relationship that has also been evidenced in a study by Rhazi et al. in Moroccan population [18].
Sun exposure during childhood has been recognized as a risk factor for the development of skin cancer in adult life [19]. In this context, 49.2% of the respondents have presented at least three sunburns during their childhood. e phototype is a risk factor for the development of skin cancer. Studies carried out in populations located in eastern regions show a lower prevalence of skin cancer than in Western countries [20]. However, probably due to the geographical location of Ecuador, the most frequent phototypes in our study, according to the Fitzpatrick scale, were type IV in 42% of the participants and type III in 30%, Mufti et al. [21] showed that low skin cancer rates in dark phototypes in the Arab population, and the research by Yan et al. [20] carried out in Chinese population showed that most of them present a type IV skin phototype with a low prevalence of skin cancer. Correspondingly, only 1.7% of our respondents have a personal history of skin malignancies and only 6.1% had a family history.
Compared with studies carried out in defined populations, we found that knowledge about the general risk of exposure to sunlight was present in 75% of participants, among them 72% reported knowing the existence of a relationship between sun exposure and the development of skin cancer. However, in a study of 387 Greek students, skin cancer (97.7%) was identified as the main consequence followed by skin aging in 72.9%; similar results have been shown in Arab and United States students [22][23][24].
Concerning sex, men have shown less interest in skin care compared with women due to cultural gender roles [25].
is is supported by the data of Almuqati et al. [23], where women present more knowledge about the consequences of sun exposure including burns, hyperpigmentation, aging, and skin cancer. Despite not finding differences on the level of knowledge regarding sex in our study, it was evidenced that female participants were more likely to develop attitudes (OR: 1.63; CI: 1.15-2.31) and practices (ORa: 1.71; CI: 1.04-2.80) for skin care and protection against sun rays and skin cancer.
About the sources of information dissemination, the perception of the participants of our study showed 69% as the main source of information as a favorite of the media, television, radio, and shops, a behavior seen in a similar way in the study of Wan [19] carried out in China's adult population that chose television ads as the main source of information (52%) on sun protection. However, only 8% of our participants took data from professional sources such as doctors, dermatologists, and health campaigns.
A variety of protective measures have been described to reduce the incidence of skin cancer, at the moment the best measures are to limit exposure to sunlight, especially during peak hours and the use of sunscreen [26,27]. Unlike the data provided by Almuqati et al. [23], which showed that only 23.6% of Arab students use sunscreen regularly, while 63% of the population in our study does, this difference was possibly influenced by the fact that different age groups of adults make up the population and not only students [23]. In addition, 45% erroneously maintain that the use of sunscreen is not necessary on cloudy days with or without sun, a belief also accepted by Mexican inhabitants 47.1% [28].
Regarding the use of other sun protection measures, 70% of participants reported opting for alternatives to sunscreen, among these, the use of caps and hats were the most frequent in 53%. ese measures are also carried out in Western populations from different regions, such as Mexico, where the use of sunglasses and caps as physical protection measures are present in 73% and 66.9%, respectively, of people who practice sports on the beach [28].
Due to the limitation in the representativeness of the sample, more studies are warranted to investigate the KAP toward skin cancer among Ecuadorians residents of low socioeconomic status and for subsequent studies it can be assessed in different provinces of Ecuador.

Conclusions
Skin cancer is one of the most frequent cancers in the country for both men and women; indeed it is a type of cancer that is highly preventable. e findings of this study indicate the need to increase the population's knowledge about skin cancer and the risk factors for its development, as well as possible protection measures. For this reason, the formulation of prevention and health promotion programs at a national level for primary healthcare centers is recommended.
Data Availability e data collected in this study do not have the ability to identify the participants; however, they are subject to a confidentiality agreement with the researchers. Anonymized information concerning the database can be shared upon reasonable request to the corresponding author by e-mail address: ksimbanarivera@gmail.com.

Ethical Approval
is cross-sectional analysis was performed under the local regulations for observational studies. As no identifiable data were collected, the study did not require an internal review board approval.
e Universidad de las Americas IRB guidelines exempt this type of work from ethical committee approval.

Consent
According to the local standards, every patient signed an informed consent for their voluntary participation, and since identifiable information was not collected, local IRB approval was not needed and the research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.
S. Izquierdo-Condoy were responsible for collecting the data, statistical analysis, and elaboration of the first and final draft of the manuscript. Esteban Ortiz-Prado was responsible for the conceptualization of the project, he wrote the first and final draft of the manuscript, and Charlie Merry was involved in the critical review of the manuscript and her comments were very useful to improve the quality of the work for a broader audience.