SEPI Questionnaire
The results obtained indicated that three components in the first part of the SEPI questionnaire were significantly affected by skin tone and gender. Respondents with darker skin tones were generally less likely to use sunscreen and wear protective clothing when out in the sun than those with lighter skin tones. This has already been proven by multiple studies that found that individuals with a lower perceived UV sensitivity, as characterised by the Fitzpatrick skin types, were more likely to incorporate sunscreen usage when exposed to the sun [
24,
25]. This could be due to a false sense of security or a “sunscreen paradox” rooted in misconception about the amount of melanin in one’s skin and the subsequent protection it offers against UVA and UVB rays [
26,
27,
28,
29]. Furthermore, the Fitzpatrick classification for skin types has a poor correlation with UV sensitivity. From a preventive standpoint, the increased frequency of certain practices in the sun in populations with darker skin is not ideal as it places those with perceived low UV sensitivity in danger of overexposing themselves to UV radiation [
30,
31]. However, the mean scores for the use of protective clothing were lower across the board than sunscreen use, indicating that the group wore protective clothing more often than sunscreen when it came to sun protection, regardless of skin tone type. This could be due to the local demographic makeup of Malaysia, a majority Malay Muslim country. One of the major tenets of the religion is wearing conservative clothing that covers the whole body except the face and dorsum of the hand. Heavy influences from the culture and religion offer defence against the sun’s rays, fit into these characteristics, and thus, could explain the higher frequency of using this method as a form of sun protection. This aligns with findings from a Saudi Arabian study that revealed comparable outcomes, indicating that women tend to wear protective clothing more often, potentially influenced by cultural and religious factors [
32]. The above reason could also explain the inverse trend observed for the usage of hats and caps—the frequency of using this method increased as skin type became darker. While this is not in line with previous research, this could be explained by the fact that most Muslim women and some older men already wear religious headwear such as the head covering (hijab, “kopiah” or “songkok”), which would inevitably discourage them from adding on a cap or a hat when going into the sun. However, the effectiveness of these articles of religious headwear against UVA and UV rays has not been studied nor recommended as an alternative for protective headwear use.
Differences between tendencies to adopt safer sun practices were also noted between skin types within the three components, which are (i) staying in the shade, (ii) protective clothing use, and (iii) protective headwear use. Apart from those with skin type 1, those with darker skin types were less likely to adopt safer behaviours in the sun. This could be due to a false sense of security that darker skin helps to protect against UVA and UVB rays and, thus, could hamper individuals from changing their behaviour [
26,
27,
28,
29]. However, this trend was reversed when looking at protective headwear use, with the tendency to adopt this behaviour decreasing with darker skin types.
A difference in existing protective habits and an inclination to adopt such habits were also noted between genders. Male respondents had riskier sun habits in terms of low sunscreen usage and protective clothing compared to female respondents. This is similar to existing findings in the literature, which show that men generally endorse riskier sun practices and are more reluctant to implement protective behaviours [
33]. However, in this population, female respondents were seen to wear protective headwear less frequently than male participants in this group [
33]. This could be due to the pre-existing clothing practices in the community that see Malay Muslim women wear head coverings daily for religious purposes. This may discourage women from wearing sun hats or caps when out in the sun for several reasons, such as discomfort and their understanding that the hijab is adequate for sun protection. In general, men had riskier sun habits, which translated to an increased risk of UV exposure [
34].
In terms of inclination to adopt healthier habits, female respondents were less likely to want to stay in the shade or wear long-sleeved clothing when out in the sun. The latter could be explained by the fact that most Malay Muslim women in Malaysia, especially in more conservative rural localities, already wear long-sleeved clothing daily. However, the intention behind this clothing is not for sun protection; rather, it is for religious reasons. This demonstrated the influence of cultural and social norms in determining clothing patterns [
35]. From the cultural perspective, this could be because workforce participation in many sectors, particularly outdoor work, is very much influenced by socially constructed gender roles [
36]. In this scenario, more men in our group worked jobs that exposed them to regular sun exposure, which may make seeking shade during working hours more difficult than those working indoors. Regardless of this, however, the implementation of wearing long-sleeved clothing has been shown to effectively reduce the risk of sunburn [
37]. Conversely, male respondents were less likely to start using protective headwear than their female counterparts. Overall, men were less likely to adopt safer sun habits than women in this study. This concurs with the existing literature that generally groups women as more susceptible to adopting more beneficial habits to reduce over-exposure to the sun, plausibly due to the increased awareness of skin ageing and its after-effect, including cancer [
38]. Local studies have shown that while the Malaysian population does have adequate information about safe practices while in the sun, this does not necessarily translate into the incorporation of these behaviours in their daily life [
39,
40]. Addressing this gap is crucial to ensure that the Malaysian population can enjoy the advantages of sun exposure while also prioritizing safety.
The association between vitamin D levels and other factors such as demographics, exposure to sun, and vitamin D intake was also carried out. Only vitamin D intake yielded a statistically significant finding when compared to vitamin D levels. Regression analysis that was carried out demonstrated that vitamin D intake was significantly associated (R
2 = 0.764, F(1, 86) = 120.618,
p < 0.001) with vitamin D intake. This meant that about 57.9% of the variability in the levels of vitamin D could be attributed to dietary intake. This is important in the context of future intervention programmes specific to this demographic. Sun exposure has traditionally been the preferred way of increasing vitamin D levels in tropical countries [
41,
42,
43] due to the abundance of sunlight and the absence of additional cost needed compared to increasing vitamin D intake via supplements or whole foods. However, for a majority of working individuals in Malaysia, enjoying sunlight at the optimum hours of the day (early morning) remains a theoretical concept. Having indoor jobs and commuting early to work means many employed, working-class citizens are unable to reap the benefits of sun exposure as an effective way of increasing vitamin D levels. In this scenario, the above results show that increasing vitamin D intake externally can be a viable alternative to increasing vitamin D levels in a tropical society that is already struggling to reach optimum levels in the general population. The Malaysian population generally has easy access to foods rich in vitamin D in local supermarkets at an affordable price. Being a tropical country near the equator, the UV index is higher than other regions [
44]. Although dietary intake is seen as a small contributor to vitamin D synthesis in the body, its effects are not as negligible as the general population assumes [
45]. While there is a safe and beneficial limit to sun exposure, prolonged exposure to the sun may predispose the population to other issues, such as skin malignancies [
46] and cataracts [
47], leading to more health problems in the long run. Therefore, using sunlight as a primary tool to increase vitamin D levels in the general population could be akin to a double-edged sword.
However, these results must be interpreted in the context of the small sample size and niche population that was studied. Further studies could be carried out with a larger group and a more representative population so that these results can be generalised and used for further intervention purposes.