Ultraviolet Radiation Knowledge and Exposure Practices Among Serbian High School Students: Results of a Nationwide Survey

Abstract

The incidence of skin carcinoma has significantly increased among the Serbian population, with mortality rates among the highest in the world. Basic interventions can reduce the effects of ultraviolet radiation (UVR) exposure, especially in youth, and decrease incidence and morbidity. This study is the first cross-sectional nationwide research on knowledge, attitudes, and sun exposure practices among Serbian high school students. The results revealed that fewer than 5% of students can correctly interpret the sunburn effect of a given UV index, while sun protection strategies are infrequently adopted. Most students (55.97%) expressed favorable attitudes regarding tanning, while more than half (64.48%) reported moderately high and high exposure. Females are more likely than males to expose themselves to UVR, especially intentionally. Females use protection more than males, while even 62.65% of males use protection insufficiently. The most commonly used sun protective measures were sunscreen and shade. The results indicate the necessity for innovative and age-suitable education methods and age- and gender-directed awareness campaigns for skin cancer prevention and the promotion of sun safety. Specifically, campaigns aimed at females should focus on motivating reduced intentional exposure, while those targeting males should emphasize the consistent use of sun protection measures.

1. Introduction

Ultraviolet radiation (UVR) is identified as the primary and most preventable contributor to the incidence of melanoma (MSC) and nonmelanoma (NMSC) skin cancers, which impact millions of individuals worldwide each year [1]. Around 65% of MSC cases and nearly 90% of NMSC, including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are linked to this environmental factor [2]. Occasional exposure to high levels of UVR is associated with a significant risk of developing MSC [3,4]. Additionally, malignant MSCs are positively associated with a history of sunburn, particularly when it happens at a young age [5]. NMSCs are most commonly found on body parts that are frequently exposed to solar radiation, including the ears, face, neck, and forearms. This indicates that prolonged and repeated exposure to UVR plays a crucial role in their development [6].

In recent decades, the rates of both NMSC and MSC have increased significantly, and growth is expected to continue in the future [7,8]. Like various forms of cancer, skin cancer exhibits a prolonged latency period, and excessive exposure to UVR during childhood and adolescence increases the likelihood of developing skin cancer in later years [9,10]. It is estimated that 50% of total UV exposure before the age of 60 occurs prior to the age of 20 [10]. Although exposure to UVR up to the age of 20 infrequently results in MSC and much less commonly in NMSC, exposure during this stage of life can substantially increase the risk of skin cancer later in life, contributing to 33% of the overall MSC risk by the time one reaches 60 years of age [10]. Therefore, adolescents are identified as a particularly important demographic for initiatives aimed at sun protection.

Many studies have been conducted on the level of awareness regarding the impacts of UVR and protective practices [11,12,13,14,15,16,17,18,19,20], some of which focus particularly on the young population [21,22,23,24,25,26,27,28,29,30,31,32]. Research findings indicate that awareness of UVI was generally low to moderate, while understanding of UVI is lacking. The influence of UVI on sun protection measures is minimal, while views regarding tanning and sun exposure are generally favorable [33,34]. Regarding the young population, studies have indicated that awareness of risks does not lead to safer sun-related behaviors, as their practices are influenced by perceptions of body image that favor tanning [14,21,30].

According to available studies, the incidence trend of MSC and NMSCs has also increased significantly in the Serbian population [35,36,37,38,39]. Although the incidence of skin cancer in Serbia is not high, the mortality rates for both MSC and NMSCs remain among the highest in the world [38,40]. Age-specific incidence rates are most pronounced in the elderly demographic, which can be attributed to the aging population in Serbia, as well as to a lack of knowledge regarding the harmful consequences of prolonged UVR exposure that they experienced during their youth [37,38]. Despite the low incidence rate observed in younger populations, early age is the appropriate time to launch preventive efforts. The adoption of basic interventions at a young age could reduce the effects of UVR exposure, resulting in a decrease in both the incidence and morbidity of skin cancer. Since adolescents have the potential to adopt and foster beneficial sun protection practices and prevent the entrenchment of harmful behaviors [41,42,43], it is important to establish an appropriate educational framework. This involves determining their level of knowledge and understanding of the UVR and sun exposure practices, as well as recognizing the wide range of factors that influence their decisions about sun protection, which is the aim of this research. The significance of this information lies in its implications for public health, as behavioral patterns are, to some extent, shaped by knowledge. Individuals lacking knowledge may exhibit a reduced motivation to utilize protection [44]. Two studies on UVR behavioral protection patterns among the younger population in Serbia were conducted, but they included only a student sample from the capital city [45,46]. Therefore, this study aimed to assess knowledge about UVR and motivation, attitudes, and behaviors toward sun exposure among high school students across Serbia to support future skin cancer prevention campaigns. The specific objectives are as follows: (i) Assess the knowledge level regarding the risks of UVR exposure and protection. (ii) Investigate students’ attitudes and motivation toward tanning and sunbathing to identify potential barriers to implementing protection measures. (iii) Assess exposure behaviors and the use of protective practices related to sun exposure. (iv) Evaluate the association between knowledge, motivation, exposure, and practices. (v) Identify a wide range of factors (gender, personal and sociodemographic characteristics, skin health status, regional factors) that influence students decisions about exposure and sun protection.

2. Materials and Methods

This research was conducted using a self-reported online survey based on relevant literature. Data were collected in December 2024 by sending the online questionnaire to representatives of all high schools in Serbia. A total of 1273 students agreed to participate and returned the questionnaire. After checking for irregularities, 1222 respondents were finally included, which exceeds the required sample size according to the standard formula [47], given that the total population of high school students in Serbia is around 230,000 [48]. We excluded 51 questionnaires from further analysis for several reasons, such as providing too few valid answers, incomplete data, identical answers across all items, or reporting ages above 21 years. The high school students included were aged 14 to 19, with an average age of 16.09. The gender distribution of respondents favored females (67.35%) and does not fully reflect the general population of high school students, where female students represent 49.70%. The distribution of secondary school students by grade and age was similar to that of the general population, with the highest representation among first-grade students aged 14 and 15 (36.33%) and the lowest among fourth-grade students aged 18 and 19 (14.98%). The sample included high school students from all parts of Serbia, reflecting their regional distribution well. The largest number of respondents came from northern Serbia (Belgrade region and Vojvodina), accounting for 56.38%, and the smallest number came from Kosovo and Metohija (2.45%), which reflects the spatial distribution of the general high school population in the country. Respondents from gymnasiums were represented at a higher percentage in the sample than in the general population. At the same time, those from vocational secondary schools were less represented (49.92% versus 26.70% for gymnasiums and 47.49% versus 65.27% for secondary vocational schools).

The survey consisted predominantly of multiple choice questions subdivided into six subsections: (i) sociodemographic data, (ii) personal characteristics and skin health status, (iii) general knowledge about UVR, sun exposure, and sunscreens, (iv) attitude, subjective norms, and motivation for sunbathing, (v) habitual sun exposure, and (vi) adoption of safety measures. Questions related to sociodemographics included age, gender, geographical region, type of settlement, type of high school, and family economic status. Skin characteristics and health status were assessed through self-reporting skin sensitivity (physical characteristics–hair and eye color, and tendency to tan) and questions about a personal and familial history of skin cancers. Regarding the general knowledge about UVR and sunscreens, we first asked whether participants knew what the UVI is and where they obtained information about UVR. Then, through 11 statements, we assessed knowledge about UVI, UVR characteristics, UVR health effects, and sunscreen and sunbathing knowledge. Seven statements were used to measure attitude towards sun protection and motivation for sunbathing. Concerning exposure, we first focused on the amount of time students spent outdoors during three specific periods (weekdays, weekends, and summer vacations) and the number of weeks during the year they visited sunny summer destinations. We then investigated how many days during the summer they sunbathed with the intention of tanning. There were nine questions regarding students’ sun protection practices. Six statements (with possible answers ranging from never to always) revealed how much time students spent outside in sunny weather between 11 a.m. and 3 p.m. using specific methods of sun protection (clothing, hat, sunglasses, sunscreen with high sun protection factor (SPF), and sun avoidance). Three multiple-choice questions were used to investigate behavior related to sunscreen use (SPF, time of application, and frequency of reapplication). The analysis of the internal reliability of questions [49,50] was acceptable (Cronbach’s α = 0.726). The entire questionnaire can be found in the Supplementary Materials.

Following the previously mentioned, four key research topics were identified. They are as follows: 1. knowledge about UVR, 2. attitude and motivation for sunbathing, 3. exposure to UVR, and 4. protection against UVR. These topics are addressed by defining indicators based on response scores: knowledge, motivation, exposure, and protection.

Regarding the knowledge, each student’s correct answers to the survey were given two points, and incorrect answers were given one point. A total knowledge score was calculated by adding points representing each participant’s knowledge level (ranging from 11 to 22). Similarly, total motivation and exposure scores were calculated by summing the points of the 5-point Likert scale, with higher scores representing higher motivation for sunbathing and higher exposure to sunlight (in the ranges 7–35 and 5–25, respectively). The total protection score was calculated by adding the points for the first six questions of the 5-point Likert scale (one point corresponding to “never” and five to “always”), then for the following two questions, adding from two to five points, and for the final question, from two to four points (total range: 12–44). The scoring was designed so that a higher score reflects better protective measures. Based on the frequency distribution of scores, common categories were derived for the variables of interest: low (L), moderate-low (M-L), moderate-high (M-H), and high (H) levels of knowledge, motivation, exposure, and protection. The Chi-squared test of dependency and Fisher’s exact test [51] were conducted to gain a deeper understanding of the determinants of specific awareness and protection practices defined through target indicators among high school students in Serbia. Considering that the size of the contingency table exceeds 2 × 2, the Cramer’s V test was employed to evaluate the strength of the association between the observed variables [52]. Various studies utilize different thresholds for this test statistic to describe associations. In this study, a Cramer’s V value greater than 0.15 is deemed to indicate a strong association [53,54,55]. The list of independent variables for each research topic is shown in Table 1.

The authors compiled a questionnaire based on literature reviews and expert input to cover all relevant topics. A group of UVR professionals and dermatologists then reviewed the questionnaire for content validity. Subsequently, the questionnaire was tested with ten random students to confirm that the survey questions were clear and comprehensible to the respondents. Finally, the questionnaire was refined by removing redundant or invalid items.

3. Results

3.1. Knowledge

The data indicate that the highest percentage of students (33.80%) demonstrated moderate-high knowledge about UVR, scoring between 17 and 18 points on an 11–22 scale. However, less than half of the respondents are aware that cloudy weather does not protect them from UVR. The internet is the predominant source of information about UVR for 78.56% of students, while only 12.11% cite textbooks and 22.67% cite doctors as sources.

Analysis from Table 2 reveals that female students have significantly higher knowledge levels compared to males (χ² = 50.003, p < 0.0001, Cramer’s V = 0.202). Students attending three- and four-year vocational secondary schools exhibit significantly lower knowledge than those attending gymnasiums (χ² = 60.250, p < 0.0001, Cramer’s V = 0.128), as do students from rural areas compared to urban counterparts (χ² = 31.369, p < 0.0001, Cramer’s V = 0.160). Family skin cancer history does not appear to influence UVR knowledge. Furthermore, students from the least economically developed regions (Eastern and Southern Serbia, Kosovo and Metohija) have the lowest proportion of high UVR knowledge. Considering the obtained Cramer’s V statistics, it can be concluded that gender, followed by settlement type, has the strongest association with knowledge.

Regarding knowledge about UVI, although 85.76% of respondents report awareness of the UV index, as many as 35.54% of them stated that they do not know its meaning. Six of the eleven knowledge questions assessed understanding and interpretation of the UVI. Despite approximately 60% of high school students having moderate-high or high overall knowledge about UVI, fewer than 5% correctly interpret the sunburn risk associated with specific UVI values. Females demonstrate a significantly higher UVI knowledge than males (χ² = 17.967, p < 0.0004, Cramer’s V = 0.032), as do students from urban areas compared to rural ones (χ² = 13.251, p < 0.0041, Cramer’s V = 0.104). Additionally, students attending gymnasium and art school show greater UVI knowledge than vocational secondary school students (χ² = 40.586, p < 0.0001, Cramer’s V = 0.105). Cramer’s V values indicate that these associations do not fall within the domain of the strong.

3.2. Motivation

More than half of the students exhibit moderate-high and high motivation to sunbathe to get a tan (35.27% and 20.70%, respectively). Although 42.96% of students believe they look better when tanned, and 33.87% feel better when tanned (predominantly females), only 9.98% consider tanning to be healthy for the skin.

Table 3 shows that females have a significantly higher motivation for sunbathing than males (χ² = 49.617, p < 0.0001, Cramer’s V = 0.202). At the same time, the strongest connection was established for gender. Students from urban areas are more motivated to sunbathe than those from rural areas (χ² = 22.734, p < 0.0001, Cramer’s V = 0.136). Interestingly, the level and quality of education, as indicated by the type of school attended, positively influence motivation for sunbathing (χ² = 45.748, p < 0.0001, Cramer’s V = 0.112). However, the level of knowledge about UVR does not have a significant effect on motivation to sunbathe. Regarding skin type, only students with skin type IV show a statistically significantly higher percentage of high motivation for sunbathing compared to those with other skin types. Furthermore, a considerably lower percentage of students with a family history of skin cancer are highly motivated to sunbathe compared to those without such a history.

3.3. Exposure

More than half of the responders (64.48%) reported moderate-high and high exposure to UVR. Table 4 shows that the variables significantly associated with UVR exposure include motivation, settlement type, gender, family income, region, and school type. The highest exposure is most strongly linked to higher motivation (χ² = 97.967, p < 0.0001, Cramer’s V = 0.164), settlement type (χ² = 23.251, p < 0.0001, Cramer’s V = 0.138), and gender (χ² = 20.794, p < 0.0001, Cramer’s V = 0.130). Interestingly, no statistically significant differences in levels of UV exposure were observed across skin phototypes (χ² = 14.549, p = 0.104, Cramer’s V = 0.063).

Regarding time spent outdoors, 43.94% of students reported spending between half and two hours outdoors during a typical weekday, while 42.39% extended this time to 2–5 h per day during weekends. During summer vacation, most students (54.83%) spend more than five hours outdoors daily. Additionally, most students (53.27%) usually spend 1–2 weeks in sunny destinations annually. A strong association was found between gender and time spent sunbathing; females spend significantly more time sunbathing with the intention of getting a tan than males (χ² = 49.443, p < 0.0001, Cramer’s V = 0.350), with 19.08% of females sunbathing more than 15 days per year compared to 6.52% of males.

3.4. Protection

Table 5 shows that variables significantly associated with sun protection include gender, type of school, knowledge, settlement type, skin type, region, and motivation.

There is a statistically significant difference between males and females in the degree of protection (χ² = 40.070, p < 0.0001, Cramer’s V = 0.181). Notably, 62.65% of males report low or moderate-low levels of sun protection

Regarding protection methods, both females and males most commonly use sunscreen and seek shade, while protective clothing is the least used for both groups (Figure 1). The strongest association was found for the use of sunscreen. Females use sunscreen (χ² = 86.193, p < 0.0001, Cramer’s V = 0.266), as well as wear protective glasses (χ² = 24.447, p < 0.0001, Cramer’s V = 0.141) significantly more than males. More than half of females (56.14%) often and always use sunscreen, compared to 32.58% of males, while 25.31% of males do not use sunscreen.

There is no statistically significant association between family income level and sunscreen usage (χ² = 3.241, p = 0.518, Cramer’s V = 0.036). Therefore, high prices do not appear to be a barrier to sunscreen use among Serbian high school students. Furthermore, there is a statistically significant difference and strong association in the correct use of sunscreen between females and males, with females using sunscreen more correctly (χ² = 73.075, p < 0.0001, Cramer’s V = 0.265). The percentage of students who often or always wear protective glasses is significantly lower than that of those who use sunscreen, with 35.65% of females and 23.05% of males reporting frequent use.

3.5. The Association Between Research Topics

Figure 2 illustrates the overall findings regarding the statistically significant mutual influence among the four research topics, as well as the theoretical framework.

It is evident that knowledge significantly influences the use of protective measures but does not affect tanning motivation or exposure behavior. Additionally, motivation plays an important role in both exposure behavior and the adoption of protection measures.

4. Discussion

The UVI is a valuable tool for assessing the health risks of UVR exposure, as it combines simple numerical assessments with behavioral recommendations for protection and is applied uniformly worldwide [56]. In recent decades, the Serbian high school student population has mainly received information about UVI values and sun protection recommendations through the media. Similar to other countries, the basic messages have emphasized avoiding sun exposure around noon and using protective measures. However, since the Montreal Protocol began to show results and the ozone layer began to recover, attention to UVR risks and sun protection has diminished over time, although UVR levels remain high. Media attention has shifted focus to other health topics, and sun protection promotion has become scarce, covering only basic information. In Serbia, comprehensive campaigns focused on sun protection have been very rare. Serbia participated in the Euromelanoma initiative, a pan-European program aimed at preventing MSC and NMSC [57,58].

Nevertheless, the importance of public health in this initiative appears to be overlooked within the country, and there is an absence of a national strategy dedicated to the prevention and management of these types of cancer [18,37]. Prevention and screening programs are lacking, especially for children and adolescents. In schools, this topic is covered only at a basic level, in terms of UV wavelengths, the function and damage of the ozone layer, and scant information about the impact on the skin. Detailed information on accurately interpreting UVI values, adequate protection methods, and skin health monitoring is lacking in textbooks and rarely addressed in the media. The growing importance of this issue is underscored by the increase in students reporting a family history of skin cancer, from 0.88% in 2012 to 3.85% in this study, a more than fourfold rise [45]. Although high school students spend much of their day indoors in the classroom, they still spend more time outside than most adults. It is, therefore, essential to limit exposure during the early stages of life due to the cumulative effect of UVR. Therefore, educational initiatives targeting adolescents to enhance primary prevention are very important. Unfortunately, this study suggests that insufficient education and scarce information in Serbia likely contributed to inadequate sun protection behavior among students.

The majority of participants in this study demonstrated moderate knowledge of UVR, but their understanding was not comprehensive. Notably, over 85.76% of participants reported being aware of UVI, a figure considerably higher than the average awareness in Europe (50.20%) and comparable to levels reported in Australia (over 90%) [59]. However, many of those who claimed awareness of the UVI admitted they did not understand its meaning. This discrepancy highlights the subjective nature of self-assessment and suggests caution when comparing awareness levels across populations. Further analysis showed that most of the participants do not adequately understand UVI and do not know how to interpret its values and skin effects correctly, nor do they fully understand the importance of protection. Although our findings are in accordance with other studies, with less than 5% of those who know the correct interpretation of the UVI value, Serbian students are well below the average in different European countries. For example, in the UK, 40% were able to correctly identify a “high” UVI value, while in Germany, 18% correctly identified the meaning of UVI [12,18]. Other studies have also highlighted the disparity between awareness of UVI and actual understanding, as well as the deficiency of proper knowledge despite self-reported claims of understanding. As an illustration, Harrison et al. [60] explored the knowledge regarding UVI and sun protection among directors and educators in early childhood services in Queensland and found that despite a high level of awareness regarding UVI (92.8%), only 20% of them could interpret it accurately. Gefeller et al. [61], who investigated the awareness and knowledge concerning UVI among kindergarten directors in southern Germany, also reported that the proportion of respondents who considered themselves to have a detailed understanding of UVI was five times higher than the actual knowledge evaluated through a structured interview.

The survey revealed significant gender differences in UVR knowledge, with females exhibiting significantly higher knowledge than males. This finding aligns with previous research [5,21,62,63], although some studies, such as [12], report contrasting results. The study also showed that there is no direct connection between knowledge and motivation or knowledge and exposure. Still, it was shown that the desire to sunbathe and exposure were positively correlated with the level and quality of education, which is represented by the type of school. This suggests that even those students attending schools of a higher level of education still have a high motivation to sunbathe. Moreover, our study demonstrated a clear link between knowledge about UVR and protective behaviors, indicating that higher awareness of UV risks correlates with better protection practices, which is in accordance with other studies [5,64]. However, as noted in the literature [30,44,65], possessing good knowledge about the harmful effects of UVR does not always translate into consistent use of protective measures.

Similar to other studies, findings in this study indicate that most students hold favorable attitudes toward tanning and sun exposure [19,24,31], which is closely linked to behaviors associated with sun exposure [13,23,29]. The attitudes reported reveal a significant discrepancy, as over 90% of students expressed disagreement that tanning is beneficial for skin health. This may indicate that, even with students’ awareness of the harmful effects of UVR exposure, they tend to prioritize the immediate benefits associated with tanning. This issue is of great importance because, during adolescence, young individuals are especially susceptible to the beauty ideals promoted by the media, which can significantly impact their attitudes. Considering that it is quite challenging to change their attitudes towards tanning, sunbathing, and sun protection and to retain these changes for an extended timeframe [66], for this age group, changing what the media promotes as attractive could be a significant preventive action.

Consistent with the literature, females in this study are more likely than males to expose themselves to elevated levels of UVR, especially intentionally [28,67]. This tendency could be attributed to the fact that studies have demonstrated women generally possess more positive perceptions regarding attaining a tan. Research conducted in both Austria and the United States indicated that female participants were more likely to believe that having a tan could improve their attractiveness [16,68]. However, females also report more frequent and regular use of UVR protective measures, especially sunscreen. This finding could imply that motivations for sun exposure differ by gender, possibly indicating a reduced interest in activities such as sunbathing or tanning among males. Outdoor exposure patterns of high school students indicate increased activity during weekends and holidays when they use the outdoor environment not only for physical activity but also for socializing. This exposure could be classified as recreational exposure, which significantly impacts the overall solar UV burden. Consequently, this suggests that skin cancer prevention efforts would benefit from concentrating on high-dose recreational exposure rather than the lower-dose exposure that occurs during weekdays.

The findings of this research indicate that, even with basic knowledge about UVR being moderate to high, the adoption of sun protection strategies is not as frequent as it should be to reduce skin cancer incidence rates. Similar gaps have been documented in other populations as well [21,26]. Less than half of respondents reported that they often or always use at least one of the sun protective methods, which is much lower than reported among German adolescents (91.70% use at least one protective measure [28]). Similar to other countries in Europe, Australia, and North America, it is found that using sunscreen is the most common method of protection, but also that female students use sunscreen more correctly than males [11,15,20,69]. Consistent with findings from other research [17,28,62], this could suggest that females exhibit a greater awareness of the risks associated with unprotected sun exposure, which results in their more frequent application of suggested sun protection measures. However, it may also be a result of the attitudes of men who may consider some sun protection practices, e.g., the use of sunscreen, as insufficiently masculine. Therefore, prevention campaigns targeting males should be focused on encouraging them to use sun protection measures. Comparing current findings with those reported by Miljković and Jovanović Lešković [45], it is noticeable that sunscreen use among Serbian high school students has increased by approximately 5% between 2012 and 2024 (from 51.06% to 56.14% for females and from 28.55% to 32.58% for males). However, compared to data from Skiljevic and Sreckovic [46], the proportion of students who often or always use sunscreen has decreased over the last five years (from 57.56% to 48.45%). A gender-specific analysis reveals that the percentage of females who often or always use sunscreen has decreased (from 69.46% in 2019 to 56.14% in 2024), while the rate of males increased (from 23.78% to 32.58%). Additionally, the percentage of students who often or always wear sunglasses has also decreased from 57.56% to 42.44%, whereas those who often or always wear hats increased from 11.48% to 21.11%. Seeking shade is the second most common protective method. Consistent with the results observed among Lebanese students [21], Swedish adolescents [70], and Australian adults [25], wearing protective clothes is less commonly reported among Serbian students. This contrasts with German and United States studies, which found that protective clothing is the most frequently adopted protective measure [14,28].

This analysis, based on a large and geographically diverse sample of Serbian high school students (n = 1222), provides credible insight into the actual relevance of their UVR knowledge, motivation, and exposure and protection practices. The number of participants can be considered representative according to the total population of high school students in Serbia, and it is comparable to similar European studies such as [16] (n = 1502). Other respective skin health studies included even fewer participants, such as [21] and [27] (n = 385 each) or [22] (n = 315). The sample’s regional and age distribution is satisfactory, ensuring proportional representation across the country. However, the sample is less representative in terms of gender, as females are naturally more willing to fill out surveys than males, which can be considered one of the limitations of the study.

Additionally, students from gymnasiums are overrepresented, and vocational secondary schools are underrepresented compared to the actual high school student population in Serbia. This imbalance could also lead to bias in the findings. The limitations include the cross-sectional nature of the research, which limits the ability to establish causal relationships among the identified associations, as well as reliance on self-reported data, which has the potential for recall bias and social desirability bias. Furthermore, comparison with previous studies in Serbia is constrained by differences in the territorial coverage of the focus group (the 2012 and 2019 studies were conducted on a sample that included only secondary schools in the capital, while our research covered the entire territory of Serbia). Methodological differences, such as differences in outcome definitions, measurement scales, and the specific focus groups included, also influence the comparability of the results with both national and international studies.

5. Conclusions

This study represents a pioneering effort to assess UVR knowledge, motivation, exposure, and protection among Serbian high school students nationally. Most of the students demonstrated moderate to high knowledge of UVR, but their understanding was not comprehensive. Despite awareness of the harmful effects of UVR exposure, their perception of body image frequently influences their behaviors and practices, especially among females. Our findings revealed a significant prevalence of self-reported UVR exposure, while the implementation of sun protection measures remains insufficient to reduce skin cancer incidence rates effectively. Outdoor exposure dynamics indicate greater engagement during weekends and holidays, considerably contributing to the cumulative solar UV burden.

The results suggest that greater effort is necessary to raise the level of understanding of UVI levels and motivation to decrease exposure and use protective measures. The insufficient understanding of the UVI among many high school students indicates an opportunity to implement innovative and age-suitable education approaches in schools that move beyond basic metric explanations. Future campaigns should focus on increasing motivation to reduce exposure and enhance protection by modifying the standards of attractiveness that are propagated by the media. Specifically, for females, the focal point of campaigns should be motivation to lower intentional exposure, while for males, to use sun protection measures and properly use sunscreen. Campaigns targeting adolescents should also be directed towards high-dose recreational exposure during weekends and holidays rather than the lower-dose exposure typically experienced during weekdays. Given that seeking shade is a commonly protective method, attention should also focus on increasing shaded areas within recreational facilities.

Author Contributions

Conceptualization, S.M.-M. and G.S.; methodology, S.M.-M. and G.S.; software, G.S. and D.D.; validation, S.M.-M. and G.S.; formal analysis, S.M.-M. and G.S.; investigation, S.M.-M., G.S., D.D. and E.M.; resources, S.M.-M., G.S. and E.M.; data curation, S.M.-M., E.M. and D.D.; writing—original draft preparation, S.M.-M.; writing—review and editing, S.M.-M., G.S., E.M. and D.D.; visualization, S.M.-M. and G.S.; supervision S.M.-M.; project administration, S.M.-M.; funding acquisition, S.M.-M. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors on request.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:

BCC	basal cell carcinoma
MSC	melanoma skin cancer
NMSC	nonmelanoma skin cancer
SCC	squamous cell carcinoma
SPF	sun protection factor
UVI	ultraviolet index
UVR	ultraviolet radiation

Footnotes

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Figures and Tables

Figure 1 Percentage of high school students using different protection measures by gender.

Figure 2 Interdependence of indicators and formative elements.

Table 1

Considered variables for each research topic.

	Research Topics
	Knowledge	Motivation	Exposure	Protection
Explanatory variables	GenderSkin typeFamily skin cancer historyRegionSettlementSchoolFamily income	GenderSkin typeFamily skin cancer historyRegionSettlementSchoolFamily income Knowledge	GenderSkin typeFamily skin cancer historyRegionSettlementSchoolFamily income KnowledgeMotivation	GenderSkin typeFamily skin cancer historyRegionSettlementSchoolFamily income KnowledgeMotivation

Table 2

The Chi-square and Fisher’s exact test statistics for knowledge and sociodemographic data, personal characteristics, and skin health status data. Blue (red) values indicate significantly (p < 0.05) lower (higher) observed frequencies compared to the theoretical value. χ², p, and Cramer’s V in italics indicate statistical significance (p < 0.05).

Variables	Categories	Count (%)	Knowledge (%)				χ2, p, Cramer’s V
			L	M-L	M-H	H
Gender	Male	32.65	27.82	21.55	31.83	18.80	50.003, <0.0001, 0.202
	Female	67.35	14.22	17.50	34.75	33.54
Skin type	I	11.95	15.07	21.92	28.08	34.93	15.227, 0.080, 0.064
	II	44.84	18.43	16.79	35.58	29.20
	III	38.22	19.49	20.34	35.12	25.05
	IV	4.99	22.95	18.03	21.31	37.70
Family skin cancer history	No	96.15	18.55	18.98	34.13	28.34	3.128, 0.372, 0.051
	Yes	3.85	21.28	14.89	25.53	38.30
Region	City of Belgrade	15.22	17.20	16.67	32.26	33.87	20.372, 0.060, 0.075
	Eastern and Southern Serbia	26.35	21.74	18.94	36.65	22.67
	Western Serbia and Šumadija	14.81	18.78	17.13	29.83	34.25
	Vojvodina	41.16	16.30	20.28	33.80	29.62
	Kosovo and Metohija	2.45	33.33	16.67	36.67	13.33
Settlement	Rural	33.06	26.24	20.30	32.18	21.29	31.369, <0.0001, 0.160
	Urban	66.94	14.91	18.09	34.60	32.40
School	Gymnasium	49.92	12.95	17.38	36.72	32.95	60.250, <0.0001, 0.128
	Four-year vocational secondary school	36.09	21.09	20.63	32.88	25.40
	Three-year vocational secondary school	11.70	37.06	19.58	25.87	17.48
	Art school	2.29	10.71	17.86	25.00	46.43
Family income	Below average	6.55	20.00	20.00	36.25	23.75	4.017, 0.674, 0.040
	Average	80.61	18.78	19.19	32.69	29.34
	Above average	12.85	17.20	15.92	39.49	27.39

Table 3

The Chi-square and Fisher’s exact test statistics for motivation and sociodemographic data, personal characteristics, and skin health status data. Blue (red) values indicate significantly (p < 0.05) lower (higher) observed frequencies compared to the theoretical value. χ², p, and Cramer’s V in italics indicate statistical significance (p < 0.05).

Variables	Categories	Count (%)	Motivation (%)				χ2, p, Cramer’s V
			L	M-L	M-H	H
Gender	Male	32.65	23.06	30.08	37.59	9.27	49.617, <0.0001, 0.202
	Female	67.35	17.86	21.75	34.14	26.25
Skin type	I	11.95	23.29	23.97	37.67	15.07	17.242, 0.045, 0.069
	II	44.84	18.98	25.18	35.58	20.26
	III	38.22	17.99	24.84	35.97	21.20
	IV	4.99	27.87	16.39	21.31	34.43
Family skin cancer history	No	96.15	19.32	24.26	35.23	21.19	4.978, 0.173, 0.064
	Yes	3.85	25.53	29.79	36.17	8.51
Region	City of Belgrade	15.22	22.58	25.27	31.72	20.43	20.661, 0.056, 0.075
	Eastern and Southern Serbia	26.35	19.57	22.98	35.40	22.05
	Western Serbia and Šumadija	14.81	27.07	26.52	29.28	17.13
	Vojvodina	41.16	15.11	24.25	39.17	21.47
	Kosovo and Metohija	2.45	30.00	26.67	26.67	16.67
Settlement	Rural	33.06	22.28	28.22	36.39	13.12	22.734, <0.0001, 0.136
	Urban	66.94	18.22	22.62	34.72	24.45
School	Gymnasium	49.92	16.23	20.82	35.74	27.21	45.748, <0.0001, 0.112
	Four-year vocational secondary school	36.09	22.68	27.44	34.47	15.42
	Three-year vocational secondary school	11.70	20.28	30.07	37.06	12.59
	Art school	2.29	39.29	28.57	28.57	3.57
Family income	Below average	6.55	23.75	27.50	35.00	13.75	6.624, 0.357, 0.052
	Average	80.61	19.49	24.67	35.53	20.30
	Above average	12.85	17.83	21.66	33.76	26.75
Knowledge	L	18.66	16.67	28.51	42.98	11.84	8.741, 0.462, 0.085
	M-L	18.82	21.30	24.78	35.65	18.26
	M-H	33.80	19.85	22.03	34.14	23.97
	H	28.72	19.94	24.50	31.34	24.22

Table 4

The Chi-square and Fisher’s exact test statistics for exposure and sociodemographic data, personal characteristics, and skin health status data. Blue (red) values indicate significantly (p < 0.05) lower (higher) observed frequencies compared to the theoretical value. χ², p, and Cramer’s V in italics indicate statistical significance (p < 0.05).

Variables	Categories	Count (%)	Exposure (%)				χ2, p, Cramer’s V
			L	M-L	M-H	H
Gender	Male	32.65	10.78	30.58	42.61	16.04	20.794, <0.0001, 0.130
	Female	67.35	9.96	22.72	40.34	26.97
Skin type	I	11.95	17.12	28.77	34.93	19.18	14.549, 0.104,0.063
	II	44.84	10.22	24.64	42.70	22.45
	III	38.22	7.92	25.27	40.90	25.91
	IV	4.99	11.48	22.95	42.62	22.95
Family skin cancer history	No	96.15	10.38	25.45	41.02	23.15	1.894, 0.595, 0.039
	Yes	3.85	6.38	21.28	42.55	29.79
Region	City of Belgrade	15.22	9.14	19.35	40.86	30.65	34.072, <0.0007, 0.096
	Eastern and Southern Serbia	26.35	9.32	24.84	42.24	23.60
	Western Serbia and Šumadija	14.81	13.81	25.41	38.67	22.10
	Vojvodina	41.16	8.55	27.44	42.74	21.27
	Kosovo and Metohija	2.45	33.33	30.00	16.67	20.00
Settlement	Rural	33.06	14.85	28.47	38.61	18.07	23.251, <0.0001, 0.138
	Urban	66.94	7.95	23.72	42.30	26.04
School	Gymnasium	49.92	8.36	26.56	41.64	23.44	18.741, 0.028, 0.072
	Four-year vocational secondary school	36.09	10.43	23.81	41.04	24.72
	Three-year vocational secondary school	11.70	18.18	27.27	36.36	18.18
	Art school	2.29	7.14	10.71	53.57	28.57
Family income	Below average	6.55	13.75	33.75	37.50	15.00	29.794, <0.0001, 0.110
	Average	80.61	11.07	25.79	41.12	22.03
	Above average	12.85	3.18	17.83	42.68	36.31
Knowledge	L	18.66	11.40	27.19	39.04	22.37	11.801, 0.225, 0.057
	M-L	18.82	15.22	23.91	39.57	21.30
	M-H	33.80	7.75	25.18	43.83	23.24
	H	28.72	9.12	25.07	40.17	25.64
Motivation	L	19.56	16.32	32.22	34.73	16.74	97.967, <0.0001, 0.164
	M-L	24.47	11.37	31.44	39.80	17.39
	M-H	35.27	9.51	25.75	44.08	20.65
	H	20.70	4.35	10.67	43.48	41.50

Table 5

The Chi-square and Fisher’s exact test statistics for protection and sociodemographic data, personal characteristics, and skin health status data. Blue (red) values indicate significantly (p < 0.05) lower (higher) observed frequencies compared to the theoretical value. χ², p, and Cramer’s V in italics indicate statistical significance (p < 0.05).

Variables	Categories	Count (%)	Protection (%)				χ2, p, Cramer’s V
			L	M-L	M-H	H
Gender	Male	32.65	37.09	25.56	31.58	5.76	40.070, <0.0001, 0.181
	Female	67.35	21.63	25.27	41.80	11.30
Skin type	I	11.95	21.92	23.29	35.62	19.18	31.231, 0.0003, 0.092
	II	44.84	23.36	24.82	42.88	8.94
	III	38.22	31.05	26.55	35.12	7.28
	IV	4.99	34.43	26.23	31.15	8.20
Family skin cancer history	No	96.15	27.23	24.94	38.55	9.28	7.363, 0.061, 0.077
	Yes	3.85	12.77	36.17	36.17	14.89
Region	City of Belgrade	15.22	28.49	27.96	32.26	11.29	24.136, 0.019, 0.081
	Eastern and Southern Serbia	26.35	25.78	23.91	39.13	11.18
	Western Serbia and Šumadija	14.81	33.70	22.10	37.57	6.63
	Vojvodina	41.16	22.86	26.64	41.95	8.55
	Kosovo and Metohija	2.45	46.67	23.33	16.67	13.33
Settlement	Rural	33.06	32.67	26.98	32.92	7.43	16.284, 0.001, 0.115
	Urban	66.94	23.72	24.57	41.20	10.51
School	Gymnasium	49.92	20.16	23.77	45.41	10.66	74.632, <0.0001, 0.143
	Four-year vocational secondary school	36.09	29.93	26.30	36.73	7.03
	Three-year vocational secondary school	11.70	46.85	27.27	16.78	9.09
	Art school	2.29	14.29	35.71	25.00	25.00
Family income	Below average	6.55	36.25	25.00	31.25	7.50	6.669, 0.353, 0.052
	Average	80.61	25.89	26.09	38.68	9.34
	Above average	12.85	26.75	21.02	40.76	11.46
Knowledge	L	18.66	41.23	25.00	26.75	7.02	59.956, <0.0001, 0.128
	M-L	18.82	29.13	31.74	31.30	7.83
	M-H	33.80	24.70	25.18	40.44	9.69
	H	28.72	17.95	21.65	48.43	11.97
Motivation	L	19.56	24.69	24.27	36.40	14.64	20.637, 0.014, 0.075
	M-L	24.47	29.77	25.08	35.45	9.70
	M-H	35.27	25.06	22.97	43.62	8.35
	H	20.70	27.67	30.83	35.18	6.32

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/atmos16060673/s1, The questionnaire.

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