Knowledge, Attitudes, and Practices (KAP) Regarding Photoprotection Among Medical Students at a Nicaraguan University: A Cross-Sectional Study

This cross-sectional study of 133 medical students in Nicaragua reveals a significant gap between their high theoretical knowledge and low practical adherence to photoprotection, highlighting the need for enhanced, behavior-oriented education in medical curricula to improve future skin cancer prevention counseling.

The Gist

Imagine the human body as a house, and the sun as a relentless, invisible storm that can slowly damage the roof and walls over time. Photoprotection (using sunscreen, wearing hats, seeking shade) is like putting up a strong umbrella and reinforcing the roof to keep that storm from causing leaks (skin cancer) or cracks (premature aging).

This study is like a "health check-up" for a specific group of people who are about to become the home inspectors of society: medical students in Nicaragua. Since these students will soon be the doctors telling patients how to protect themselves, the researchers wanted to see: Do these future doctors know how to use their own umbrellas? Do they actually use them?

Here is the story of what they found, broken down simply:

1. The Setup: A Room Full of Future Doctors

The researchers asked 133 medical students at a university in Managua, Nicaragua, to fill out a survey. Think of this as a "knowledge and habit quiz." They wanted to measure three things:

• Knowledge: Do they know the facts? (The "Textbook" part)
• Attitudes: Do they care about the risks? (The "Heart" part)
• Practices: Do they actually do it? (The "Action" part)

2. The Big Surprise: The "Know-Do" Gap

The results showed a funny disconnect, like a chef who knows the recipe for a perfect cake but never actually bakes one.

• The Good News (The Textbook): Almost everyone (97%) knew what sunscreen was. Most could pick a "good" bottle off the shelf. They were smart about the theory.
• The Bad News (The Action): Despite knowing the theory, only about 4 out of 10 students used sunscreen regularly. In fact, nearly 1 in 4 students said they never used it at all.

It's like knowing that smoking causes cancer but still lighting up a cigarette. The students knew the sun was dangerous, but they weren't protecting themselves consistently.

3. The "Who" and the "Why"

The study looked at different groups to see who was doing better:

• Gender Gap: The female students were the "sun-safe champions." They scored higher on knowing the facts, caring about the risks, and actually using sunscreen. The male students were lagging behind, much like how some people might ignore a "low fuel" warning light while others immediately stop for gas.
• The School Years: You might think that as students learn more medicine, they would get better at protecting themselves. But the study found no improvement as they moved from 1st year to 6th year. The medical school curriculum wasn't teaching them how to practice what they learned. It was like teaching someone the rules of swimming but never letting them get in the water.
• Age: Interestingly, the older the student, the less likely they were to use sunscreen. It seems that as they got busier with studies, the habit of protecting their skin faded away.

4. The Real Culprits: Forgetfulness and Confusion

When the researchers asked, "Why don't you use sunscreen?" the answers were relatable:

• Forgetfulness (The #1 Reason): Nearly 50% of students just forgot to put it on. It wasn't that they didn't care; they just got distracted.
• Confusion: Many didn't know how often to re-apply it.
• The Fix: The students suggested simple solutions, like setting phone reminders (digital alarms) or making sunscreen cheaper and easier to find.

5. The Takeaway: Why This Matters

This study is the first time anyone has asked these questions to medical students in Central America and the Caribbean.

The Main Lesson:
Knowing the facts isn't enough. You can have a PhD in "Sun Safety," but if you don't put on the sunscreen, you aren't safe.

The Future Plan:
The authors suggest that medical schools need to change their approach. Instead of just lecturing students on what sunscreen is, they need to teach them how to make it a habit—like a daily routine as automatic as brushing teeth. If future doctors don't practice what they preach, they can't effectively teach their patients.

In a nutshell: These future doctors are smart enough to pass the test, but they need a little more help to remember to actually use their "umbrella" in the real world.

Technical Summary

1. Problem Statement

• Context: Solar ultraviolet radiation (UVR) is a primary modifiable risk factor for skin cancer and premature aging. Medical students are a critical demographic as future healthcare providers who must model protective behaviors and counsel patients.
• Knowledge Gap: While international studies (e.g., in Peru, Vietnam, Europe) have documented a disconnect between theoretical knowledge and actual photoprotective behaviors among medical students, no prior research has characterized KAP regarding photoprotection among medical students in Central America or the Caribbean.
• Regional Specificity: Nicaragua, located in an intertropical zone with high year-round solar irradiance and significant ethnic diversity, presents a unique context where socioeconomic factors and skin phototypes influence sun protection behaviors. There was a lack of baseline data to inform medical curricula or public health interventions in this region.

2. Methodology

• Study Design: Quantitative, cross-sectional, exploratory study.
• Setting & Population: Conducted at the Universidad Iberoamericana de Ciencias y Tecnología (UNICIT) in Managua, Nicaragua. The target population was all medical students ($N=210$); the final sample consisted of 133 students (94.26% confidence level, 5.17% margin of error).
• Instrument: An ad hoc, self-administered questionnaire developed based on a literature review and validated by a board-certified dermatologist and a resident.
  • Note: The instrument was not formally psychometrically validated (no construct validity or reliability testing performed), limiting direct comparability with standardized KAP tools.
  • Structure: 19 items covering Sociodemographics, Knowledge (6 items), Attitudes (6 items), and Practices (7 items).
  • Scoring: Domain scores (0–6 for Knowledge/Attitudes, 0–7 for Practices) and a Global KAP score (0–19).
• Data Collection: In-person distribution during academic activities with informed consent. Data were anonymous and self-reported.
• Statistical Analysis:
  • Descriptive statistics (frequencies, medians/IQR, means/SD).
  • Normality assessed via Kolmogorov–Smirnov test; homogeneity of variances via Levene's test.
  • Bivariate Analysis: Mann–Whitney U, Kruskal–Wallis, Student's t-test, One-way ANOVA, and Brown–Forsythe ANOVA (for variance violations). Spearman's rank correlation for age associations.
  • Limitation: No multivariable regression was performed; analysis remained descriptive and bivariate.

3. Key Results

• Demographics:
  • Predominantly female (73.7%), median age 20 years.
  • Skin phototypes were diverse: Type III (36.4%), Type II (25.0%), and Type IV (22.0%).
• Knowledge vs. Practice Gap:
  • High Awareness: 97.0% knew what sunscreen is; 88.0% could identify adequate sunscreen characteristics.
  • Critical Deficiencies: Only 33.1% knew the minimum recommended SPF for daily use; only 21.8% understood endogenous photoprotective mechanisms (e.g., melanin).
  • Behavioral Discrepancy: Despite high theoretical awareness, only 39.1% reported regular sunscreen use, while 24.8% reported never using it.
• Sociodemographic Associations:
  • Sex: Women scored significantly higher than men across all domains (Knowledge, Attitudes, Practices, and Global KAP). Effect sizes were moderate for Practice ($d=0.56$) and Global KAP ($d=0.60$).
  • Academic Year: No significant improvement in KAP scores was observed as students advanced through medical school ($p > 0.05$), suggesting current curricula do not effectively reinforce these behaviors.
  • Age: Weak but significant negative correlations were found between age and Practice ($\rho = -0.237$) and Global KAP ($\rho = -0.204$).
  • Phototype: No significant association was found between skin phototype and protective practices.
• Barriers and Facilitators:
  • Primary Barrier: Forgetfulness (49.6%), followed by lack of knowledge regarding reapplication frequency (27.8%).
  • Primary Facilitators: Use of reminders (33.8%) and improved affordability (21.8%).

4. Key Contributions

• Regional Baseline: This is the first study to evaluate photoprotection KAP among medical students in Nicaragua and the broader Central American/Caribbean region, filling a significant geographic evidence gap.
• Curriculum Insight: The study provides empirical evidence that standard medical training in this setting is insufficient to translate theoretical knowledge into sustained preventive behavior, highlighting a need for behavior-oriented educational interventions.
• Identification of Modifiable Barriers: By pinpointing "forgetfulness" and "reapplication uncertainty" as primary barriers, the study suggests specific, actionable targets for future interventions (e.g., reminder systems, practical training).
• Gender Dynamics: It reinforces the global trend of gendered disparities in sun protection, with female students demonstrating significantly better adherence, likely influenced by sociocultural factors and skincare marketing.

5. Significance and Implications

• Public Health Impact: As future physicians, these students will be the primary counselors for skin cancer prevention. Their current lack of consistent personal practice may hinder their ability to effectively counsel patients, particularly in a high-UV environment like Nicaragua.
• Educational Reform: The findings argue for integrating practical, behavior-oriented photoprotection training into medical curricula, moving beyond theoretical lectures to address behavioral barriers (e.g., habit formation, product selection).
• Future Research: The study establishes a baseline for longitudinal studies and highlights the need for psychometrically validated instruments in future regional research to allow for international comparisons.
• Policy: Supports the development of targeted national campaigns focusing on the specific barriers identified (forgetfulness, reapplication knowledge) rather than just general awareness.

Limitations Noted by Authors

• Cross-sectional design: Precludes causal inference.
• Single-center sample: Limits generalizability to all Nicaraguan medical students.
• Instrument Validity: The ad hoc questionnaire lacked formal psychometric validation.
• Self-reporting bias: Susceptible to social desirability and recall bias.
• Sample size: Slightly below the target calculation, reducing power for subgroup analyses.