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Culture and Sun Exposure in ImmigrantEast Asian Women Living in AustraliaHaeyoung Jang PhD a , Fung Kuen Koo PhD b , Liang Ke CandidatePhD a , Lindy Clemson PhD a , Rosemary Cant PhD a , David R. FraserPhD c , Marcus J. Seibel PhD d , Marilyn Tseng PhD e , Elias Mpofu PhDf , Rebecca S. Mason PhD g & Kaye Brock PhD aa Faculty of Health Science , University of Sydney , Lidcombe ,Australiab Sydney Nursing School , University of Sydney , Sydney , Australiac Faculty of Veterinary Science , University of Sydney , Sydney ,Australiad Discipline of Medicine, ANZAC Research Institute , ConcordHospital, University of Sydney , Sydney , Australiae Department of Kinesiology , California Polytechnic State University,San Luis Obispo , California , USAf Discipline of Rehabilitation Counselling , University of Sydney ,Lidcombe , Australiag School of Medical Sciences , University of Sydney , Sydney ,AustraliaAccepted author version posted online: 29 May 2013.Publishedonline: 23 Jul 2013.

To cite this article: Haeyoung Jang PhD , Fung Kuen Koo PhD , Liang Ke Candidate PhD , LindyClemson PhD , Rosemary Cant PhD , David R. Fraser PhD , Marcus J. Seibel PhD , Marilyn TsengPhD , Elias Mpofu PhD , Rebecca S. Mason PhD & Kaye Brock PhD (2013) Culture and Sun Exposurein Immigrant East Asian Women Living in Australia, Women & Health, 53:5, 504-518, DOI:10.1080/03630242.2013.806386

To link to this article: http://dx.doi.org/10.1080/03630242.2013.806386

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Women & Health, 53:504–518, 2013Copyright © Taylor & Francis Group, LLCISSN: 0363-0242 print/1541-0331 onlineDOI: 10.1080/03630242.2013.806386

Culture and Sun Exposure in ImmigrantEast Asian Women Living in Australia

HAEYOUNG JANG, PhDFaculty of Health Science, University of Sydney, Lidcombe, Australia

FUNG KUEN KOO, PhDSydney Nursing School, University of Sydney, Sydney, Australia

LIANG KE, PhD Candidate, LINDY CLEMSON, PhD,and ROSEMARY CANT, PhD

Faculty of Health Science, University of Sydney, Lidcombe, Australia

DAVID R. FRASER, PhDFaculty of Veterinary Science, University of Sydney, Sydney, Australia

MARCUS J. SEIBEL, PhDDiscipline of Medicine, ANZAC Research Institute, Concord Hospital,

University of Sydney, Sydney, Australia

MARILYN TSENG, PhDDepartment of Kinesiology, California Polytechnic State University, San Luis Obispo,

California, USA

ELIAS MPOFU, PhDDiscipline of Rehabilitation Counselling, University of Sydney, Lidcombe, Australia

REBECCA S. MASON, PhDSchool of Medical Sciences, University of Sydney, Sydney, Australia

KAYE BROCK, PhDFaculty of Health Science, University of Sydney, Lidcombe, Australia

In this qualitative study, researchers examined cultural and atti-tudinal factors that might be related to sun-exposure behaviorsamong East Asian women living in Australia. Researchers asked

Received June 1, 2012; revised May 4, 2013; accepted May 12, 2013.This study was funded by a University of Sydney Institute of Social Sciences Research

Grant.Address correspondence to Kaye Brock, PhD, Faculty of Health Science, C42-

Cumberland Campus, University of Sydney, Lidcombe, NSW 2141, Australia. E-mail: kaye.brock@sydney.edu.au

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Culture and Sun Exposure 505

Chinese (n = 20) and Korean (n = 16) immigrant women whoparticipated in a larger cross-sectional quantitative study of vita-min D blood levels to volunteer to participate in an in-depthinterview in 2010. These women reported a number of culturalfactors related to their attitudes and behaviors with regard to sunexposure. They expressed preference for fair skin, a tradition ofcovering skin when outdoors, and no sunbathing culture. Theybelieved that fair skin was more beautiful than tanned skin. Theyreported that beauty was the reason for active avoidance of sun-light exposure. Although they reported knowledge of the need forsun avoidance due to skin cancer risk, few reported knowledgeabout the benefits of sun exposure for adequate vitamin D levels.These findings may provide some reasons for vitamin D deficiencypreviously reported in these populations. Thus, researchers recom-mend that these attitudes of excessive sun protection and limitingsun exposure be further investigated as they may have implica-tions for planning and delivery of health promotion programs tothis growing population of immigrants in Australia.

KEYWORDS sun avoidance, fair skin preference, vitamin D, EastAsian women

INTRODUCTION

Vitamin D is critical to the development and the maintenance of healthybone and muscle (Fraser, 1995). As well as causing rickets in children andmuscle weakness and frailty in adults, vitamin D deficiency is associatedwith increased risk of falls, fractures, colon cancer, and other cardiovascularconditions such as diabetes (Holick, 2007). In most populations the onlysignificant natural source of vitamin D is sunlight, in the form of ultravioletB (UVB) radiation acting on the skin. Thus, the maintenance of adequatevitamin D levels is a challenge, especially for immigrant and ethnic minorities(Fraser, 1995; Ford et al., 2006; Smith, 2010; Von Hurst, Stonehouse, & Coad,2010).

Vitamin D deficiency/insufficiency has been reported in women of allage groups in both China and South Korea (Mithal et al., 2009). South Koreanwomen were reported to have the lowest vitamin D level of all countries ina recent international study of 1,285 osteoporosis patients from 18 countries(Lips et al., 2006). A recent survey of women of child-bearing age in Chinareported more than 90% of the study participants were vitamin D deficient(serum 25(OH)D ≤50nmol/L) (Woo et al., 2008). In Australia, migrant pop-ulations from East Asian countries had a higher risk of vitamin D deficiencythan their Australian peers, a finding that has been hypothesized to be due to

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insufficient sun exposure (Brock et al., 2004, 2007). A survey in Hong Kongsuggested that East Asian women often deliberately avoided sunlight as theytraditionally preferred “fair skin” (Kung & Lee, 2006).

The idealization of fair skin, especially for women, has a long historyin many East Asian countries, where Buddhism and Confucianism are thepredominant philosophies. In the past, a fair complexion was an indica-tion of beauty, privilege, social status, and femininity. Those from poor,working class families, who had to work in the sun, had rough, tannedskin; fair skin was seen as “noble” and “aristocratic” and became a sign ofhigher status (Li et al., 2008). In modern times, this idealization has beenmore related to standards of beauty; fair skin is the desired beauty goal,and women with fair skin are often looked at with envy (Kung & Lee,2006).

The question current researchers wished to investigate was, “What arethe cultural beliefs and attitudes that are related to sun-avoidance behaviorin East Asian immigrant women living in Australia?” Based on this ques-tion, the researchers aimed to provide qualitative insights into knowledgeabout cultural factors including fair skin preference that may be related tosun-exposure attitudes and behaviors among East Asian women living inAustralia.

METHODS

Study Participants and Setting

In 2010, researchers conducted a quantitative study to determine factorsrelated to serum 25(OH)D levels (vitamin D) in a cross-sectional sampleof 152 East Asian women (Brock et al., 2013) who were recruited pur-posively through Asian (Chinese and Korean) community and universityorganizations. Women were eligible if they were aged 18–80 years andof the defined ethnic origin. Researchers asked a stratified random sam-ple of women if they were willing to volunteer for the qualitative study.This sample (n = 48) was randomly selected from four strata based on(1) age and ethnicity and (2) the distribution of the total sample. Thirty-sixof these 48 women (20 Chinese and 16 Korean) volunteered to be inter-viewed about attitudes and behaviors toward sunlight; thus, the responserate was 75%. Researchers defined the women’s ethnic origins accord-ing to their or their parents’ country of origin, in accordance with theAustralian Standard Classification of Countries for Social Statistics (ASCCSS),issued by Australian Bureau of Statistics (ABS, 1994). Researchers classi-fied a participant as “Chinese” if either she or her parent(s) were bornin Chinese-speaking countries, including China, Hong Kong, Macau, andTaiwan. Similarly, they classified a participant as Korean who herself or bothparents were Korean-born.

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Procedure

The current study protocol was approved by the Human Ethics Committee ofthe University of Sydney. All potential participants were fully informed of theaim of the study and procedures, and each participant provided individualwritten consent prior to participating in the study.

Researchers conducted qualitative, in-depth interviews with individualparticipants between May and December 2010. They used an interviewguide to probe for the participants’ attitudes and behaviors in relation to sunexposure and protection, skin tone preference, knowledge of vitamin D andof health campaigns related to sun exposure, and perceived changes aftermigration to Australia (see Appendix). The interviews took from 40 minutesto one hour, usually occurred in the interviewees’ homes, and were con-ducted by the researchers who were native speakers of either Cantonese orKorean. Researchers used the same-language interview to minimize misun-derstandings resulting from inadequate translation procedures and to createa more trustful interview environment (Squires, 2009). They audio-recordedinterviews with participants’ permission and then transcribed these verbatimfor analysis.

Ten mls of blood were taken by venipuncture at the time of the quan-titative interview, kept on ice, and transported to the hospital laboratorywithin five hours of collection, where they were then centrifuged. Serumsamples were stored at −70◦C and subsequently analyzed in a batch by aradioimmunoassay measuring both vitamin D2 and vitamin D3 metabolites(Diasorin USA). The intra-coefficient of variation (CV) in these analyses was5% with a range of 0%–17%. Serum 25(OH)D levels >50nmol/L were usedto indicate vitamin D adequacy. A minimum acceptable target concentrationof 25(OH)D is at least 50nmol/L (Nowson et al., 2012; Rosen et al., 2012).

Data Analysis

Researchers analyzed qualitative interview scripts using a grounded the-ory approach (Charmaz, 2006) with the assistance of NVIVO 8 software,which facilitated the development of the interlinking themes, capturedredundancies and synergies within and between interviews, and added tocredibility and trustworthiness of data interpretation. The Cantonese andKorean researchers transcribed and translated the interviews directly fromCantonese or Korean into English. During this process, they read and re-read the interview transcripts adding a reflective approach as the interpretivedocument emerged (Denzin, 1994). To minimize bias and enhance trust-worthiness, they employed a third party to translate and back-translatea randomly selected proportion of the interviews to Chinese or Koreanfrom English. With the purpose of protecting the interviewees’ identities,pseudonyms were used in all verbal and written reporting.

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One investigator conducted the coding and tentative identification ofthemes through initial line-by-line coding. In the second phase, researchersemployed focused coding to give meaning to segments of the data andto identify emergent themes, supported by the reflective process in read-ing and re-reading the stories completely. In parallel, regular discussionswith the team members (who included a sociologist, a psychologist, a med-ical pathologist, an occupational therapist, an epidemiologist, and vitaminD medical researchers) reviewed the coding, considered the way transcriptswere coded, and helped make sense of the meanings and themes arising.Interviews for each person were continued until it was considered that nonew information was being collected (data saturation) (Glaser & Strauss,1967).

RESULTS

As with the larger study, the age range for the qualitative study sample waswide, from 18 to 83 years, with a mean age of 49 years; Koreans were older(mean = 54 years) than Chinese (mean = 46 years). Over 75% of participantsreported that they had completed secondary education (compared to 66% inthe larger study). Nearly half of the women (49%) had lived in Australia for≥10 years. These women were very similar to those in the larger study withrespect to demographics and the proportion with vitamin D deficiency. Fifty-five percent of the present sub-sample was vitamin D deficient compared to53% in the larger study.

Researchers observed how a number of cultural factors played animportant role in forming negative attitudes toward sun exposure among par-ticipants, including fair skin preference, cover-up tradition, the non-existenceof sunbathing culture, and indoor lifestyle, as explored below.

Cultural Factors Identified

FAIR SKIN PREFERENCE

Researchers found from the interview analysis that the prevailing desire forfair skin in both Chinese and Korean study participants was most evident.When asked why they avoided sunlight and used sunscreen, the most fre-quently reported reason was to keep their skin fair. Women wished to retainfair complexion continuously. In the summer months, they believed, sun-light was most dangerous in causing skin damage, such as age spots anddark patches.

Fair skin was closely linked to “beauty.” The vast majority of the partic-ipants perceived that fair skin was more beautiful than tanned or dark skin.Fair facial complexion rather than fair skin on the body was emphasized

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Culture and Sun Exposure 509

through the interviews. Participants talked about a longing for clean, beauti-ful, fair skin, an ideal deep-rooted in their minds. One participant explainedthis

Certainly fair skin is more beautiful. The old saying says: “One fair coversup three flaws.” If a person has a fair skin the fairness would surely coverhis or her ugliness. If you are ugly and also have a dark skin, the uglinessbecomes more apparent. What a pity. [Chinese 6, 72 years, vitamin D =49nmol/L]

The fair complexion desired by these women was closer to naturallylight-toned skin rather than European white skin. This strong preferencefor fair skin was apparent even among younger, more Westernized partici-pants. They explained that it was deeply rooted in the culture and thereforeenduring, regardless of age or length of time living in Australia.

Some participants agreed that skin tone became less important sinceliving in Australia. One said

I think fair skin is more beautiful . . . but living in this multicultural societyof Australia, I have gotten used to different skin colors. I guess I havebecome less obsessed with skin fairness. In Korea, differences in skincolor are not common. People with a dark complexion like me easilystand out. But here in Australia, people are less conscious of differencesin skin color. [Korean 6, 45 years, vitamin D = 32nmol/L]

For many participants, fair skin was connected not only with beautybut also femininity, youth, nobleness, cleanness, softness, and natural-ness. They thought that fair skin would make them look more beautiful,clean, delicate, feminine, and younger. Dark skin was preferred by only asmall number of participants, while most associated it with physical labor,uncleanness, ugliness, rigidity, and being foreign. Those with darker skintones often envied fair skin, while those with fair skin rarely envied darkskin.

A person with fair skin gives a favourable impression that he or she is asoft, gentle and friendly person. As an Asian myself, I kind of feel thata person with a dark skin looks strict and strong. [Korean 13, 31 years,vitamin D = 23nmol/L]

More than a third of the participants admitted to having tried skinwhitening products to lighten up their skin tone or to eliminate skin pig-ments or dark spots. Younger participants were more likely than the olderwomen to try whitening cosmetics. Participants commented that its usagewas common in their home countries.

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“COVER-UP” TRADITION

Another cultural factor associated with sun exposure in the sample was a“cover-up” tradition. In traditional East Asian societies where Confucianismis prevalent, women were not allowed to expose their bodies to others, espe-cially men, but had to be covered up year-round in long sleeves and dresses(Rosenlee, 2006). The findings from these interviews suggest that clothingculturally acceptable for women in traditional Chinese and Korean societies,to some extent, has limited East Asian women’s exposure to sunlight. A fewparticipants said that they rarely left their arms, legs, and shoulders nakedin public, even in hot weather, because of tradition and perceived ethicalnorms. They explained that it was not appropriate for a woman’s skin to beexposed in public, that the cover-up tradition seemed to remain even today.One Chinese participant described this

I sometimes wear things with no sleeves, but only when I am inside thehouse. When I go outside, I wear long sleeves, right to the wrist, mostof the time. I sometimes wear medium sleeves but not short sleeves . . .And I wear socks, if it is not too hot. In summer I don’t want to wearthem. But I was taught ladies should wear stockings. [Chinese 1, 29 years,vitamin D = 31nmol/L]

NO SUNBATHING CULTURE AND INDOOR LIFESTYLE

Indoor lifestyle and no culture of sunbathing also appeared to preventthe participants from getting enough sunlight. A majority was opposed tosunbathing. It appeared to be rare in Asian communities:

There might be some young Korean people who like to have tanned skin.They may sunbathe under the sun or visit a tanning studio like westernpeople do. But they are just an unusual few. Not common. [Korean 2,67 years, vitamin D = 98nmol/L]

A few other participants said that they liked sun exposure and occa-sionally sunbathed. However, they mostly sunbathed in a very moderateway described as follows:

When exposing to the sun I like to do it on my legs. My husband andI roll up our trousers, but we wear a hat and sunglasses to protect theupper body, not to get a suntan except for our legs. [Chinese 9, 68 years,vitamin D = 45nmol/L]

Nearly all of the participants were unenthusiastic about going to thebeach. Reasons for not going to the beach included no interest, no time,

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Culture and Sun Exposure 511

little chance, and/or not wanting to get a tan. Even when they went to thebeach, they did not necessarily go into the water or sunbathe. Most saidthat they tended to sit back in the shade looking around at people andthe scenery and enjoying the ocean breezes. Only a minority said that theyenjoyed being in water, walking on the sand, or basking in the sun. Whetherthey enjoyed going to the beach or not, all participants reported that theyapplied sunscreen on the face and other exposed body parts, wore a hat andlong-sleeved tops, and/or even carried a parasol, often in an effort to keeptheir skin from tanning on the beach.

Likewise, most participants reported that they did not have holidays insunny places in recent times. Instead, they often spent their summer holidaysin their home countries in the Northern hemisphere, and this deprived themof an Australian summer and an opportunity to boost vitamin D levels natu-rally. In addition, participants explained their lack of exposure to sunlight asa result of spending more time indoors due to working long hours indoors,being confined to their home for child care and/or indoor housework duties,too hot or too cold weather, and/or old age. They explained

I work and stay in the office all day every day. No time to spend in thesun really. [Korean 12, 29 years, vitamin D = 18nmol/L]

At my age, I usually stay inside. I meet my friends at home. I go out onlyonce in a while for grocery shopping. Even when going to the seniorclub, I don’t get much sunlight because I’m usually in the car or train.[Korean 15, 79 years, vitamin D = 24nmol/L]

Culture and Attitudes and Behaviors

The current findings suggest that identified cultural factors played a role inshaping negative attitudes toward sun exposure, which resulted in excessivesun-avoidance and sun-protective behaviors among the two ethnic groups,as explored below.

NEGATIVE ATTITUDES TOWARD SUN EXPOSURE

Overall, women in the study had a negative attitude toward sun exposure.Most said that they did not like being directly exposed to the sun. Reasons fordisliking sun exposure were described as “it was too hot,” “the sun was toostrong in Australia,” or they had sun-related eye problems or skin problems.The most frequently reported reason, especially by younger participants, wasthat they feared sun damage causing a tan or sunburn and more importantlybrown spots on the face. They believed that exposure to sunlight was amajor threat for the skin as it causes damage and accelerates skin aging. Oneparticipant explained

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Lentigo, sunspot, melanin . . . , anyway, sun exposure is totally bad, Icannot stand that. Have to avoid the sun. [Interviewer: What is wrongwith the sunspots?] They are not beautiful. [Chinese 10, 38 years, vitaminD = 53nmol/L]

Researchers believe that negative attitudes toward sun exposure werepossibly fuelled by public health campaigns related to sun exposure inAustralia, as participants were generally well informed of and concernedabout the negative health consequences of sun exposure. More than half theparticipants were aware of skin cancer campaigns in Australia which weredevised to avoid all sun exposure to the skin, such as “Slip, Slop, Slap.”Concerns were expressed about the stronger sun (high UVB radiation) inAustralia, and researchers hypothesized that this may have been the reasonfor the reported high usage of sunscreen. Participants believed avoiding thesun was particularly important in Australia, where the sun was strong andplentiful, as skin damage could be prevented by reducing sun exposure. Onesaid

In Australia, the sun is very strong, and I assume that it has contributedto skin damage such as early wrinkles that are common to Australianwomen. For this reason, I think it is important to avoid sunlight as muchas possible. [Korean 15, 79 years, vitamin D = 24nmol/L]

However, researchers observed that participants perceived that the riskof skin cancer was not as high for East Asians as it was for “white”Australians. One participant explained

The information reveals that a lot of Australians have skin cancer . . .I think it is related to the skin color. Black people have less skin can-cer. Asian people, well, still get it too but not as many as white people[Chinese 19, 79 years, vitamin D = 53nmol/L]

Also, many participants demonstrated considerable ignorance and con-fusion about the benefits of sunlight, especially in vitamin D production,and the importance of vitamin D. A majority had never had a vitamin D testbefore participating in the larger study (Brock et al., 2012), and most of themsaid that they had never heard about vitamin D, often being confused withvitamin C. One said

I just heard that it (vitamin D) is related to the sunlight but I’m not awarehow important it does to our body. [Korean 13, 31 years, vitamin D =23nmol/L]

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Culture and Sun Exposure 513

EXCESSIVE SUN-PROTECTION BEHAVIORS

The theme of negative attitudes toward sun exposure was expressed throughreported excessive sun-avoidance and sun-protective behaviors among thesetwo ethnic groups. Many participants reported deliberately avoiding sunlight.Some said they would not go outside while sunlight was strong, especiallybetween 10 a.m. and 3 p.m. or in summer. Those who consistently exercisedtended to do so in the morning when the sun was not strong.

Younger participants reported that they were more likely than their oldercounterparts (≥60 years) to take various measures to avoid sunlight. Theyfrequently used sunscreen on the face, foundation with Sun Protection Factor(SPF) on the face, hats, sunglasses, umbrellas, or a combination of these forsun protection. In addition, they used face moisturisers with SPF; carrieda long-sleeved top, a hat, and/or sunglasses. At an extreme, some opted touse books, handbags, or whatever available to cover their faces from sunlighteven for a few seconds. Some wore gloves while driving. To a lesser degree,older participants (≥60 years) also used various measures such as parasolsand gloves.

In this sample of women, extensive use of sunscreen was evident. Thesunscreen and/or makeup with SPF used by the participants were usually30+, which was the highest sun protection rating in Australia at that time.Over a third of participants said that they wore sunscreen all year round,whatever the weather. One explained

I first use sunscreen with a SPF 15. Then I use foundation with SPF 30.I use sunscreen if I am using the computer. I think the computer doesa lot of damage to our skin. I am quite careful with my skin . . . If mylegs are naked I use sunscreen, SPF 30. [Chinese 1, 30 years, vitamin D =31nmol/L]

However, a small number of participants said that they never usedsunscreen because they were hardly exposed to sunlight and/or becausethey did not like the “sticky” feel of it. Participants often commented that theAustralian sun was strong and made their skins darker and drier, which wasone of the reasons for them to start wearing sunscreen. One said

I didn’t use sunscreen when living in Korea. But because of strong sun-light, I can’t help but use it here in Australia . . . Because of the extrahot sun here in Australia, I tend to pay more attention to skin exposure.Sunscreen and sunglasses are a must in Australia. [Korean 7, 24 years,vitamin D = 33nmol/L]

Even participants who did not use sunscreen daily or frequently oftenagreed that it was essential for extended sun exposure, such as a day at

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the beach or in the park, to avoid suntan or sunburn. They often learnedabout the benefits of sunscreen from the media or family and friends andexpressed the belief that sunscreen would give skin protection and slow theaging process.

Blood Vitamin D Levels

The mean serum 25(OH)D in the sample was 47nmol/L (SD = 17) during thespring and summer. It was higher in older (≥60 years) (mean = 53nmol/L,SD = 20) than in younger (<60 years) participants (mean = 43nmol/L,SD = 14), p < 0.05, and also marginally but not significantly higher inChinese (mean = 48nmol/L, SD = 11) than Korean (mean = 46nmol/L,SD = 24) women. Each ethnic group had the same proportion of vita-min D deficiency. More than half (55%) of this population, both Koreansand Chinese, had inadequate serum 25(OH)D concentrations (<50nmol/L),which was a greater proportion than reported in other Australian populations(Van der Mei et al., 2007).

A further investigation of the women’s serum vitamin D levels suggesteda positive relationship between strong cultural values for sun avoidanceand low vitamin D levels. Vitamin D levels as measured by 25(OH)D weremuch lower amongst 14 participants who showed “extreme” sun protec-tion attitudes or behaviors by covering up for cultural reasons (e.g., toavoid skin exposure) or taking excessive measures for sun protection (e.g.,using sunscreen throughout the whole year). The mean serum 25(OH)D forthis extreme group was 43nmol/L (SD = 13), lower than that of both the“non-extreme” group (51nmol/L, SD = 20) and the whole group (48nmol/L,SD = 17, p < 0.05).

DISCUSSION AND CONCLUSION

In this small sample of immigrant women, researchers found that partic-ipants constructed their life routines actively to avoid the sun and sunexposure. Cultural factors, including fair skin preference, cover-up tradition,non-existence of sunbathing culture, and indoor lifestyle, all contributed tonegative attitudes toward sun exposure and excessive sun-protection behav-iors. The motivation of participants in the study for sun avoidance wasdeeply entrenched in the strong cultural value of skin fairness being associ-ated with beauty, gentleness, and femininity. Current exposure to their owncultural media messages and peer discourse appeared to strengthen theseparticipants’ value of skin fairness and resolve to avoid sun damage.

These avoidance actions are conducive to low risk of melanoma(Armstrong & Kricker, 2001). However, such avoidance means that thesewomen did not benefit from the positive health outcomes of a responsible

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Culture and Sun Exposure 515

exposure to the Australian sun (Nowson et al., 2012). Experts recommendthat at-risk people who have a low personal ultraviolet radiation exposureshould request that their general medical practitioner refer them for vitaminD testing, a practice which is not routine, and to follow up with vitaminD supplementation if they are found to be deficient (Nowson et al., 2012;Nehauser & Kreps, 2003). The alternative, promoting the health benefits ofsun exposure and vitamin D sufficiency for muscle strength and bone health,may well be of limited salience in a culture that prizes fair skin and cover-up(Kung & Lee, 2006).

The notion of tailoring approaches and messages about sun exposureand the importance of vitamin D for different ethnic groups has recently beenraised by others. Callister, Galtry, and Didham (2011) argued that skin colorand sun exposure should be key considerations and that the complexity ofrisk factors in particular target groups requires careful consideration. The cur-rent findings confirm that this must also include cultural values, beliefs, andbehaviors. While the participants of this study maintained fair complexion,the health promoters could suggest that they expose their upper or lowerlimbs to sun before 10 a.m. or after 4 p.m. (Nowson et al., 2012).

This study had several limitations. First, researchers obtained inter-view data from a small number of volunteers from a larger quantitativestudy of cross-sectional design, which prohibited assessment of the tem-poral sequence of attitudes and behaviors. Second, purposive sampling wasused, as is often the case with qualitative studies, which reduced the repre-sentativeness of the sample and thus the generalizability of the results. Anyconclusions drawn may not be applicable to all East Asian immigrant womenin Australia. Third, researchers did not use independent coding of transcriptsby more than one coder to enhance quality control of coding. Fourth, whileresearchers undertook statistical analyses in their larger study and controlledfor confounding variables, the sample size for the current qualitative studywas inadequate to undertake rigorous statistical analyses in which they couldcontrol for confounding, so that they have only reported qualitative resultshere, and any differences reported may have resulted from lack of control ofconfounding factors. The study also had the potential for social acceptabilityand selection and participation biases, which could affect the accuracy andgeneralizability of results. Additionally, the coefficients of variation for theserum vitamin D measures were rather large, which could have resulted inmisclassification of vitamin D status, so future studies should either ensurebetter reliability of the measure or perform repeat measures that are aver-aged. Further, researchers also did not include an appropriate control group,so it is not possible to determine if the attitudes and behaviors reportedhere differed from those of women with other cultural or religious back-grounds. Future studies should include an appropriate comparison group(e.g., Australian-born women of similar age), which would aid in betterunderstanding of the role that cultural background and beliefs may play

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in attitudes and behaviors regarding sun exposure. In addition, any furtherstudy should include a larger and more representative sample to give a widerrange of age, gender, and length of time in Australia to further explore therole of acculturation.

With almost a quarter of Australia’s resident population born overseas,the Chinese- and Korean-born populations in Australia have increased sub-stantially by more than sevenfold for Chinese and nearly twelvefold forKoreans between 1981 and 2006, with the majority concentrated in NewSouth Wales (ABS, 2001, 2007). Although Australia is becoming more diverse,little attention has been paid to aspects of culture that may influence healthbehavior and health outcomes among individuals from culturally and linguis-tically diverse backgrounds (Australian Institute of Health and Welfare, Sing& Looper, 2002).

Significantly, the contribution of cultural factors in shaping sun expo-sure attitudes and behaviors has rarely been investigated or documented(Manderson, Kasnitz, & Vasey, 2006). The Australian Osteoporosis Societyhas recently tried to counter this by targeting such ethnic groups on theirwebsite (“Osteoporosis,” 2012).

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Australian Bureau of Statistics. 1994. Australian Standard Classification of Countriesfor Social Statistics (ASCCSS), 1990. Retrieved July 21, 2011, from http://www.abs.gov.au.

Australian Bureau of Statistics. 2001. 4102.0—Australian social trends, 2001. RetrievedFebruary 11, 2011, from http://www.abs.gov.au.

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Australian Institute of Health and Welfare. Sing, M., and M. De Looper. 2002.Australian Health Inequalities: 1 Birthplace. Bulletin 2. AIHW Cat. No. AUS27.Canberra: AIHW.

Brock, K., R. Cant, L. Clemson, R. S. Mason, and D. R. Fraser. 2007. Effects of dietand exercise on plasma vitamin D (25(OH)D) levels in Vietnamese immigrantelderly in Sydney Australia. J Steroid Biochem Mol Biol 103:786–92.

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Brock, K. E., M. Wilkinson, R. Cook, S. Lee, and M. A. Bermingham. 2004.Associations with vitamin D deficiency in “at risk” groups living in Australia.J Steroid Biochem Mol Biol 89–90:581–8.

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Fraser, D. R. 1995. Vitamin D. Lancet 345:104–7.Glaser, B., and A. Strauss. 1967. The discovery of grounded theory: Strategies of

qualitative research. New York: Aldine Publishing Company.Holick, M. F. 2007. Vitamin D deficiency. N Engl J Med 357:266–81.Kung, A. W., and K. K. Lee. 2006. Knowledge of vitamin D and perceptions and

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APPENDIX. EXCERPT OF PROBE QUESTIONS FORQUALITATIVE INTERVIEWS

● Are you aware of the health benefits of vitamin D?● Do you like being directly exposed to the sun?● Do you ever sunbathe?● Are you aware of skin cancer campaigns in Australia such as the “Slip,

Slop, Slap” program?● Are you ever concerned about skin cancer?● Do you think if it is important to protect yourself from sun as it can cause

serious skin damage including skin cancer?● What do you use to protect yourself from sunlight?● Do you think a tanned skin or white skin is more beautiful?● Have you ever used skin-whitening creams?● Do you think your behavior and/or attitudes towards sun exposure and

skin fairness have changed since you moved to Australia?● What is your age?● How long have you lived in Australia?● What language do you use at home?● What was the highest level of education you finished?

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