Despite prevention campaigns highlighting the short- and long-term harmful effects of UV radiation, the French population continues to use insufficient sun protection, and social inequalities regarding sun protection have been observed. In the summer, tourists along the Mediterranean coast are particularly at risk due to high UV radiation levels and behaviors that involve overexposure driven by the desire to tan. The Occitanie region, with its Mediterranean coastline stretching over 200 km, is a popular summer destination and particularly affected by this exposure.

To better guide the prevention strategy regarding sun-related risks in these coastal areas, and thereby reduce the health impacts of summer sun exposure, the Prisme project was launched by the Occitanie Regional Unit in 2017. It consists of two components:

• 1st component: a study of tourists along the Occitanie coast to analyze their protection and exposure behaviors and assess the effectiveness of prevention interventions;

• Component 2: a study of the short-term impact of summer sun exposure on the use of burn/sunburn treatments at coastal pharmacies.

Prevention Component

The first component of the Prisme project had two objectives:

• To identify the determinants, particularly social ones, of sun protection and sun exposure during the summer among French tourists on the Mediterranean coast of Occitanie.

• To evaluate and compare the effectiveness of two types of interventions on tourists’ sun protection behaviors: one based on physical appearance and the other on health risks.

Study Design

During the summer of 2019, a cluster-randomized crossover trial was conducted among French tourists aged 12 to 55 staying at eight campsites along the Occitanie coast. Participants were divided into three groups: a control group, a health risks intervention group (information on health effects, phototype calculation), and a physical appearance intervention group (information on photoaging, UV photography). These interventions drew on mechanisms from behavior change theories (the Theory of Planned Behavior and the Transtheoretical Model). The intervention allocation varied each week at each campground. Data were collected face-to-face via questionnaires, along with skin color measurements before (T0) and 4 days after the interventions (T1). A long-term follow-up was also conducted in October 2020 (T2) using an online questionnaire (Durand 2020).

Results

• 1,355 campers were included at the start of the study, of whom 95% participated in the follow-up at T1 and 44% at T2.

• Tourists who intentionally exposed themselves to the sun for tanning purposes were more often 15–24-year-olds, women, those with a less sensitive skin type, and those with a favorable attitude toward tanning and sun exposure.

• The tourists who used the least protection were also those aged 15–24, with a less sensitive skin type, lower educational attainment (parents’ educational level for minors), lower theoretical knowledge of sun protection, a favorable attitude toward tanning, a social circle that encouraged them less to protect themselves (social norm), and who found it difficult to protect themselves during their stay (perceived control).

• The lower level of sun protection among tourists with lower educational attainment was partly explained by their lower level of theoretical knowledge (regarding peak sun hours, protective measures, and the effects of sun exposure), and to a lesser extent, by the existence of misconceptions (regarding risks and protective measures) and a positive attitude toward tanning (Durand 2022).

Regarding the effectiveness of the interventions, both interventions improved protective behaviors in the short term, but only the intervention based on physical appearance led to long-term improvements as well as a reduction in intentional exposure in both the short and long term. More educated individuals appeared to be more responsive to the health-risk-based intervention, while those with a high school diploma were more responsive to the physical appearance-based intervention (Durand 2023).

Conclusion

The results of this study highlight at-risk subpopulations among coastal tourists and provide original evidence of the effect of individual interventions aimed at modifying sun protection behaviors in this population. They underscore the relevance of messages based on physical appearance to complement health messages in this context, particularly among certain subpopulations with low to intermediate levels of education. They also demonstrate the need to improve knowledge to reduce social inequalities in sun protection.

More broadly, proposals have been formulated regarding prospects for intervention research for researchers in this field, as well as prospects for local actions for stakeholders in tourism, health, and local governments (Durand-Gontéro 2022).

The results of this study have been summarized in a brochure intended for the general public, tourism professionals, local authorities, and decision-makers.

• Access the summarized results

References

Durand C, Catelinois O, Bord A, Richard JB, Bidondo ML, Ménard C, Cousson-Gélie F, Mahé E, Mouly D, Delpierre C. Effect of an Appearance-Based vs. a Health-Based Sun-Protective Intervention on French Summer Tourists' Behaviors in a Cluster Randomized Crossover Trial: The PRISME Protocol. Front Public Health. 2020 Nov 5;8:569857. PMID: 33251173; PMCID: PMC7676153.

Durand C, Lamy A, Richard JB, Saboni L, Cousson-Gélie F, Catelinois O, Bord A, Lepage B, Mouly D, Delpierre C. Influence of Social and Psychosocial Factors on Summer Vacationers' Sun Protection Behaviors, the PRISME Study, France. Int J Public Health. 2022 Aug 10;67:1604716. PMID: 36032272; PMCID: PMC9399345.

Durand C, Magloire L, Cousson-Gélie F, Bord A, Saboni L, Zeghnoun A, Lepage B, Richard JB, Catelinois O, Mouly D, Delpierre C. Efficacy of an appearance-based and a health-based sun protection intervention on summer vacationers' behaviors, PRISME cluster randomized crossover trial, France. British Journal of Health Psychology. 2023;00:1–13.

Durand-Gontero C. Summer exposure to natural UV radiation among tourists on the Mediterranean coast of Occitanie: a study of the determinants of sun protection and sun exposure and an evaluation of sun protection interventions. Thesis in epidemiology defended on 12/02/2022. Paul Sabatier University - Toulouse III, 2022. French. NNT: 2022TOU30257ff. HAL Id: tel-04148054.

Impact section

To estimate the short-term health impact of overexposure to the sun on the Mediterranean coast, a study based on healthcare utilization data from the coastal region of Occitanie is currently underway.

Given the potential care pathways for individuals seeking medical care following overexposure to UV radiation, pharmacy medication sales data represent a valuable data source for the study. In this context, sales of prescription drugs in retail pharmacies were the subject of a preliminary study in the summer of 2019 to develop an algorithm based on the list of Product Identification Codes (CIP) to be tracked (Riondel 2023).

In 2023, Santé publique France obtained sales data covering approximately 67% of pharmacies in the study area. To construct a proxy for exposure prior to healthcare utilization, Santé publique France collaborated with Météo-France. The objective is to compare trends in medication sales with a representative indicator of sunshine exposure.

Other data sources, such as those from the SOS Médecins association and hospital emergency departments, will also be used to measure the impact of overexposure to solar UV radiation.

References

Riondel A, Simac L, Catelinois O, Morlan-Salesse C, Bounoure F, Galan B, Mouly D. Syndromic Surveillance of Health Effects Due to Summer Sun Overexposure: Construction of an Indicator Based on Drug Sales in Pharmacies—Preliminary Study within the PRISME Project. Int J Environ Res Public Health. 2023 Jul 3;20(13):6287. doi: 10.3390/ijerph20136287.