Rural–Urban Differences in Sun Exposure and Protection Behaviors in the United States

Background: Evidence regarding whether rural residence is a risk factor for skin cancer is mixed. We compared sun exposure and protection behaviors between rural and urban residents by ethno-racial group in the United States. Methods: We analyzed data from three (2013–2018) National Health and Nutrition Examination Survey cycles. We compared self-reported sun exposure and protection measures (sunburn, time spent outside, sunscreen use, wearing long sleeves, staying in shade) by rural–urban residential status using survey-weighted logistic regression models stratified by ethno-racial group, adjusting for age, sex, income, education, body mass index, and smoking. Results: Hispanic rural versus urban residents more often reported sunburns in the past year [41.6% vs. 31.2%, adjusted OR (aOR): 1.46 (1.15–1.86)]. White rural versus urban residents more often spent 2þ hours outside on workdays [42.9% vs. 29.1%, aOR: 1.60 (1.27–2.01)] and non-workdays [72.2% vs. 64.8%, aOR: 1.45 (1.12–1.88)] and less often used sunscreen [26.0% vs. 35.1%, aOR: 0.74 (0.59–0.93)] and stayed in the shade [21.7% vs. 26.7%, aOR: 0.72 (0.57–0.89)]. Black rural versus urban residents stayed in the shade less often [31.6% vs. 43.9%, aOR: 0.60 (0.39–0.91)] but less often spent 2þ hours outside on non-workdays [47.6% vs. 56.8%, aOR: 0.67 (0.51–0.90)]. Conclusions: Across all ethno-racial groups included, rural residents reported greater sun risk behaviors than urban residents, with some nuances by ethno-racial identity, suggesting rural residence is a potential risk factor for skin cancer. Impact: Sun protection promotion programs should consider rural–urban settings while also accounting for ethno-racial identities.