Validity of self-reported sunscreen use by parents, children, and lifeguards

Patterns of Sun Protection Behaviours among Australian Adolescents and Adults over a Six-Year Period

The major cause for skin cancer is the excessive and unprotected exposure to ultraviolet radiation (UVR), which can be prevented by engaging in sun protection behaviours. As longitudinal studies on both adolescents' and adults' performances of sun protection behaviours are limited, the current study aimed to investigate changes in sun protection in these population segments in Western Australia, a region with high annual UVR. During six summer seasons (2015/16 to 2020/21), cross-sectional surveys were conducted among 1806 adolescents (14 to 17 years old) and 1808 adults (18-45 years old), investigating the frequency of five sun protection behaviours (wearing clothing, applying sunscreen, wearing a hat, wearing sunglasses, and seeking shade) and sun avoidance (staying indoors). Over the six-year period, staying indoors increased in both groups. Among adolescents, a decrease in wearing clothing and sunglasses and an increase in seeking shade was demonstrated, and hat and sunscreen use remained relatively stable. Among adults, an increase in sunscreen use was shown, whereas all other sun-related behaviours remained consistent over the six-year period. The results from this study can provide directions for health communications focusing on improving sun protection behaviours among both adolescent and adult populations.

Development of a Survey of Sunscreen Use and Attitudes among Adults in Two Coastal States, 2019

Skin cancer is the most common form of cancer in the United States, and regular use of broad-spectrum sunscreens can prevent skin cancer. However, a new law in Hawaii that limits sunscreen choices due to the belief that some UV (ultraviolet) filters may damage coral reefs may reduce sunscreen use and increase skin-cancer risk. Because of this, there is a need for measurement tools to help understand consumer behavior and determinants of sunscreen purchase and use. The objectives of this study were (1) to test new questionnaire measures relevant to the Hawaii Sunscreen Ban; and (2) to assess adults’ knowledge, attitudes, and habits related to sunscreen in two other coastal states. This survey of adult residents of California and Florida was conducted in the summer of 2019. Newly developed scales addressed beliefs about effects of sunscreens on aquatic/marine environments and awareness of the Hawaii sunscreen ban. Respondents completed the survey twice to evaluate the test–retest reliability. Respondents (n = 162) were mainly female, White, and college-educated. New scales had moderate-to-high internal consistency and high test–retest reliability. Sunscreen use was high, sunburn was common, and knowledge and attitudes about sunscreen were modest. Most respondents did not know the specifics of the Hawaii Sunscreen Ban. In multivariate models, significant predictors of sunscreen use were being older, female, and having higher sunscreen knowledge. Sunscreen beliefs were not significantly associated with sunscreen use or sunburn. The findings support the use of the newly developed survey and suggest that more education about sunscreen and sunscreen ingredients is needed.

Interventions to Increase Sunscreen Use in Adults: A Review of the Literature

Skin cancers are the most common malignancy in Australia. Regular sunscreen use can reduce the incidence of cutaneous squamous cell carcinomas and actinic keratoses and has been associated with reducing the incidence of basal cell carcinomas and melanomas. However, sunscreen effectiveness is limited by the failure of the population to use it routinely. Interventions that promote the daily application of sunscreen may reduce the morbidity, mortality, and economic burden associated with skin malignancies. We reviewed the literature that examines the effectiveness of interventions to increase routine sunscreen use and found that no one strategy has been shown to be clearly effective in adults and that relatively few studies have aimed to increase routine use in groups at extreme skin cancer risk. Future research should consider how interventions can be best designed and how sunscreen use is measured so that cost-effective, feasible strategies that result in improved sunscreen use in adults can be established.

Optimizing Texting Interventions for Melanoma Prevention and Early Detection: A Latin Square Crossover RCT

INTRODUCTION

Text messaging is an effective way to reach large populations with health promotion support. This study aims to establish the optimal text messaging intervention to achieve behavior change in young adults at risk of skin cancer.

STUDY DESIGN

Latin square crossover RCT.

SETTING/PARTICIPANTS

Participants were women and men aged 18-40 years living in Queensland, Australia who owned a smartphone and had ≥2 skin cancer risk factors.

INTERVENTION

Participants were enrolled from December 2018 to February 2019 and completed an eligibility survey. Eligible participants were randomized to 4 different text message interventions using a Latin square design with varying personalization, interactivity, and message frequency (February 2019‒July 2019). Each intervention lasted for 1 month; between interventions, participants had a 1-week washout period in which they completed an online questionnaire. Participants completed a 6-month follow-up online survey in January 2020.

MAIN OUTCOME MEASURES

Measures included self-reported sun protection habits and sunburns.

RESULTS

A total of 277 (71.2% response rate) participants completed the 6-month follow-up. The sun protection habits index was significantly higher in all the 4 text messaging interventions (p<0.01 for each intervention) than at baseline, with similar sun protection habits improvements among all interventions (p=0.27). Sunburn rates decreased significantly over time (p<0.01 each intervention), with all the 4 interventions achieving reductions in sunburn rates during the intervention periods (p=0.78). Overall, the sunburn rates decreased from 40.3% at baseline to 7.0% at the end of the intervention, and at 6-month follow-up, it remained significantly below baseline levels at 23.5% (p<0.01).

CONCLUSIONS

Regular text messaging interventions result in significantly increased sun protection and decreased sunburn in young adults.

TRIAL REGISTRATION

This study is registered at the Australian and New Zealand Clinical Trials Registry ACTRN12618001299291.

Sun protection changes among diverse elementary schoolchildren participating in a sun safety intervention: A latent transition analysis of a randomized controlled trial

Children are a priority population for skin cancer prevention as excessive sun exposure in childhood increases the risk of melanoma in adulthood. The complexity of sun protective behaviors has posed measurement challenges for trials testing intervention efficacy. The current study evaluated a sun safety intervention for schoolchildren using latent transition analysis (LTA) to examine patterns of sun protection behaviors over time. A three-armed randomized controlled trial was conducted between 2012 and 2016 with two intervention groups (N = 3368) and an observation-only control group (N = 342) among 4th and 5th graders from 24 public schools in Los Angeles County. Both interventions conditions were grouped and compared to controls. Five self-reported sun protective behaviors were measured at baseline and three-month follow-up: use of sunscreen, long sleeves, long pants, hats, and shade seeking. Participants comprised 3710 schoolchildren, mean age 9 years, 47% female and 69% Latino. At baseline, four patterns of sun protection behaviors were found: children who engaged in 1) all sun protective behaviors; 2) few protective behaviors; 3) protective clothing and shade only; and 4) hats only. Children in the control group were likely to remain in their baseline status or transition to a less protective status at three-month follow-up. By contrast, 30% of children in the intervention group transitioned to a more protective status at follow-up. In this RCT of a sun safety intervention, children in the intervention transitioned to more protective behaviors compared to controls. Using LTA enriches understanding of intervention efficacy by modeling the complexity of sun protection behaviors over time. TRIAL REGISTRATION: School-based Randomized Trial of SunSmart Interventions, ClinicalTrials.gov Identifier: NCT04176237 https://clinicaltrials.gov/ct2/show/NCT04176237?cond=School-based+Randomized+Trial+of+SunSmart+Interventions&draw=2&rank=1.

Identification of Relevant Sociocognitive Determinants Explaining Multiple Parental Sun Protection Behaviors

Background

Adequate sun safety during childhood is crucial for decreasing skin cancer risk in later life. Although parents are an essential target group in applying sun protection measures for their children, insight into the determinants associated with their sun protection behaviors is limited.

Aims

This study aims to identify the most relevant determinants in predicting multiple parental sun protection intentions and behaviors in different sun exposure situations.

Method

A longitudinal survey study with two measurements was conducted among Dutch parents (N = 670) of children (4–12 years old). Twenty-seven sociocognitive determinants were examined in terms of relevance regarding four parental sun protection behaviors in different sun exposure situations. The Confidence Interval-Based Estimation of Relevance approach was used to visualize room for improvement (sample means) on all determinants and their association strengths (correlations) with sun protection intentions and behaviors.

Results

Behavior-specific rather than generic determinants were most relevant in explaining all sun protection behaviors. Of these determinants, attitude, self-efficacy and action planning, and especially parental feelings of difficulty in performing sun protection behaviors, were most relevant. Altogether, the explained variance of all sociocognitive determinants was highest for shade-seeking behavior (R² = .41 and .43) and lowest for supportive behavior (R² = .19 and .29) in both planned and incidental sun exposure situations, respectively.

Discussion

This study provides detailed insight into relevant sociocognitive determinants of parental sun protection behaviors in various sun exposure situations and directions for composing parental skin cancer prevention interventions.

Conclusions

Future composition of sun safety interventions should emphasize on enhancing parental feelings of self-efficacy, especially for shade-seeking and clothing behaviors.

Changes in sun protection behaviours, sun exposure and shade availability among adults, children and adolescents in New South Wales, 2003-2016

OBJECTIVE

To inform skin cancer prevention policies and campaigns, we investigated changes over time in sun protection behaviours, sunburn, sun exposure and shade availability in public spaces among people living in New South Wales (NSW), Australia, between 2003 and 2016.

METHODS

We analysed cross-sectional data from the NSW Population Health Survey collected in 2003, 2007, 2014 and 2016, which included approximately 15,000 respondents of all ages in each year. Logistic regression models were used to analyse overall changes over time and for different age, sex and sociodemographic groups.

RESULTS

The use of sunscreen and protective clothing and the availability of shade increased between 2003 and 2016, but sunburn and sun exposure during peak times of ultraviolet radiation also increased. In subgroup analyses, there was no improvement in sun protection behaviours among adolescents and increases in sunburn and sun exposure were observed only among adults, particularly women and in areas with less social disadvantage.

CONCLUSIONS

Sun protection behaviours have improved over time among some population subgroups, but over-exposure to ultraviolet radiation remains prevalent. Implications for public health: Skin cancer prevention initiatives that specifically target adolescents and sun exposure during peak times are needed to help reduce population skin cancer risk.

Sun Protection Use at Work and Leisure by Outdoor Workers in Alberta, Canada

OBJECTIVE

To assess the prevalence and determinants of sun protection behaviours among outdoors workers at work and leisure in Alberta, Canada.

METHODS

We collected outdoor workers' demographics, skin cancer risk factors, job information, and sun habits at work and leisure using self-completed questionnaires. For both settings, we compared use of specific behaviours and modelled determinants of sun protection behaviour scores.

RESULTS

At work, wearing a sleeved shirt (81% often/always) and hat (73%) were most prevalent, while seeking shade (12%) and applying sunscreen (36%) were least prevalent. Workers had higher sun protection scores at work than leisure. Hours spent outdoors was a strong determinant for both models. Additional leisure model predictors were eye colour, sex, skin type, and job group.

CONCLUSIONS

Differences in behaviours across settings were observed and should be considered when developing solar UVR exposure reduction initiatives.

Sun Safe Partners Online: Pilot Randomized Controlled Clinical Trial

Background

Harnessing supportive influences in close relationships is an innovative and potentially effective strategy to improve sun protection behaviors.

Objective

This pilot randomized controlled clinical trial evaluates the feasibility and impact of Sun Safe Partners Online, a web-based, couples-focused intervention to improve sun protection behavior.

Methods

A total of 75 couples reporting suboptimal levels of sun protection recruited from Facebook advertisements were randomized to receive a web-based intervention called Sun Safe Partners Online or a Generic Online Sun Safety Information intervention. Sun Safe Partners Online had 4 individual-focused modules and 4 couples-focused modules. Feasibility was assessed by study enrollment, engagement, follow-up survey completion, and intervention evaluation. Participants completed baseline and a 1-month postintervention survey assessing sun protection and exposure, along with individual and relationship attitudes about the importance of sun protection.

Results

Using Facebook as a recruitment strategy resulted in rapid enrollment and higher acceptance than for the prior telephone and print trial. The follow-up survey completion was higher in the Generic Online condition (100%) than in the Sun Safe Partners Online condition (87.2%). Engagement in Sun Safe Partners Online was high, with more than two-thirds of participants completing all modules. Evaluations of Sun Safe Partners Online content and features as well as ease of navigation were excellent. Sun Safe Partners Online showed small effects on sun protection behaviors and sun exposure on weekends compared with the Generic Online intervention and moderate effect size increases in the Sun Safe Partners Online condition.

Conclusions

This study uses a novel approach to facilitate engagement in sun protection by harnessing the influence of relationships among spouses and cohabiting partners. A couples-focused intervention may hold promise as a means to improve sun protection behaviors beyond interventions focused solely on individuals by leveraging the concern, collaboration, and support among intimate partners and addressing relationship-based barriers to sun protection.

Trial Registration

ClinicalTrials.gov NCT04549675; https://clinicaltrials.gov/ct2/show/NCT04549675

Design and baseline data of a randomized trial comparing two methods for scaling-up an occupational sun protection intervention

Background

Successful methods for scaling-up evidence-based programs are needed to prevent skin cancer among adults who work outdoors in the sun.

Methods

A randomized trial is being conducted comparing two methods of scaling-up the Sun Safe Workplaces (SSW) intervention. Departments of transportation (DOTs) from 21 U.S. states are participating and their 138 regional districts were randomized following baseline assessment. In districts assigned to the in-person method (n = 46), project staff meets personally with managers, conducts trainings for employees, and provides printed materials. In districts assigned to the digital method (n = 92), project staff conduct these same activities virtually, using conferencing technology, online training, and electronic materials. Delivery of SSW in both groups was tailored to managers' readiness to adopt occupational sun safety. Posttesting will assess manager's support for and use of SSW and employees' sun safety. An economic evaluation will explore whether the method that uses digital technology results in lower implementation of SSW but is more cost-effective relative to the in-person method.

Results

The state DOTs range in size from 997 to 18,415 employees. At baseline, 1113 managers (49.0%) completed the pretest (91.5% male, 91.1% white, 19.77 years on the job, 66.5% worked outdoors; and 24.4% had high-risk skin types). They were generally supportive of occupational sun safety. A minority reported that the employer had a written policy, half reported training, and two-thirds, messaging on sun protection.

Conclusions

Digital methods are available that may make scale-up of SSW cost-effective in a national distribution to nearly half of the state DOTs.

Trial registration: The ClinicalTrials.gov registration number is NCT03278340.

Internet of Things Smart Sunscreen Station: Descriptive Proof-of-Concept Study

Background

Skin cancer is the most prevalent but also most preventable cancer in Australia. Outdoor workers are at increased risk of developing skin cancer, and improvements in sun protection are needed. Sunscreen, when applied at the recommended concentration (2 mg/cm²), has been shown to block the harmful molecular effects of ultraviolet radiation in vivo. However, sunscreen is often not applied, reapplied sufficiently, or stored adequately to yield protection and reduce sunburns.

Objective

The primary aim of this study was to test an Internet of Things approach by deploying a smart sunscreen station to an outdoor regional mining site.

Methods

We deployed a smart sunscreen station and examined the key technological considerations including connectivity, security, and data management systems.

Results

The smart sunscreen station was deployed for 12 days at a mining workplace (Dalby, Australia). The smart sunscreen station’s electrical components remained operational during field testing, and data were received by the message queuing telemetry transport server automatically at the end of each day of field testing (12/12 days, 100% connectivity).

Conclusions

This study highlights that an Internet of Things technology approach can successfully measure sunscreen usage and temperature storage conditions.

Assessing recall of personal sun exposure by integrating UV dosimeter and self-reported data with a network flow framework

BACKGROUND

Melanoma survivors often do not engage in adequate sun protection, leading to sunburn and increasing their risk of future melanomas. Melanoma survivors do not accurately recall the extent of sun exposure they have received, thus, they may be unaware of their personal UV exposure, and this lack of awareness may contribute towards failure to change behavior. As a means of determining behavioral accuracy of recall of sun exposure, this study compared subjective self-reports of time outdoors to an objective wearable sensor. Analysis of the meaningful discrepancies between the self-report and sensor measures of time outdoors was made possible by using a network flow algorithm to align sun exposure events recorded by both measures. Aligning the two measures provides the opportunity to more accurately evaluate false positive and false negative self-reports of behavior and understand participant tendencies to over- and under-report behavior.

METHODS

39 melanoma survivors wore an ultraviolet light (UV) sensor on their chest while outdoors for 10 consecutive summer days and provided an end-of-day subjective self-report of their behavior while outdoors. A Network Flow Alignment framework was used to align self-report and objective UV sensor data to correct misalignment. The frequency and time of day of under- and over-reporting were identified.

FINDINGS

For the 269 days assessed, the proposed framework showed a significant increase in the Jaccard coefficient (i.e. a measure of similarity between self-report and UV sensor data) by 63.64% (p < .001), and significant reduction in false negative minutes by 34.43% (p < .001). Following alignment of the measures, under-reporting of sun exposure time occurred on 51% of the days analyzed and more participants tended to under-report than to over-report sun exposure time. Rates of under-reporting of sun exposure were highest for events that began from 12-1pm, and second-highest from 5-6pm.

CONCLUSION

These discrepancies may reflect lack of accurate recall of sun exposure during times of peak sun intensity (10am-2pm) that could ultimately increase the risk of developing melanoma. This research provides technical contributions to the field of wearable computing, activity recognition, and identifies actionable times to improve participants' perception of their sun exposure.

Association of Skin Cancer Risk and Protective Behaviors with Health Literacy Among Young Adults in the USA

BACKGROUND

The goal of this study was to investigate the association of health literacy with skin cancer risk and protective behaviors among young adults at moderate to high risk of skin cancer, the most common cancer.

METHOD

A US national sample of 958 adults, 18-25 years old, at moderate to high risk of developing skin cancer, completed a survey online. Behavioral outcomes were ultraviolet (UV) radiation exposure (e.g., indoor and outdoor tanning, sunburn) and protective (e.g., sunscreen use, sunless tanning) behaviors. Multivariable regression analyses were conducted to determine whether health literacy (a four-item self-report measure assessing health-related reading, understanding, and writing) was associated with behavioral outcomes while controlling for demographic factors.

RESULTS

Higher health literacy was independently associated with less sunbathing, odds ratio (OR) = 0.77, 95% confidence interval (CI) = 0.60-0.98; less indoor tanning, OR = 0.38, CI = 0.31-0.48; and less use of tanning oils, OR = 0.54, CI = 0.43-0.69. However, health literacy was also associated with a lower likelihood of wearing long pants, OR = 0.76, CI = 0.58-0.99, or a hat, OR = 0.68, CI = 0.53-0.87, when outdoors. On the other hand, higher health literacy was associated with higher incidental UV exposure, OR = 1.69, CI = 1.34-2.14, and a greater likelihood of ever having engaged in sunless tanning, OR = 1.50, CI = 1.17-1.92.

CONCLUSION

Interestingly, higher health literacy was associated with lower levels of intentional tanning yet also higher incidental UV exposure and lower skin protection among US young adults. These findings suggest that interventions may be needed for young adults at varying levels of health literacy as well as populations (e.g., outdoor workers, outdoor athletes/exercisers) who may be receiving large amounts of unprotected incidental UV.

Differences in reported sun protection practices, skin cancer knowledge, and perceived risk for skin cancer between rural and urban high school students

PURPOSE

The purpose of the current study was to evaluate differences in reported use of sun protection, tanning behaviors, skin cancer-related knowledge, and perceived risk between rural and urban high school students in a geographic area with high rates of melanoma.

METHODS

A total of 1,570 high school students (56.8% female) from urban (6 schools) and rural (7 schools) geographic areas in Utah completed questionnaires assessing sun protection and tanning behaviors, skin cancer-related knowledge, and perceived risk for skin cancer. Analyses examined potential differences in these outcomes between rural and urban students and by gender.

RESULTS

Compared to students in urban areas, those in rural areas had lower odds of wearing sunscreen (OR 0.71; 95% CI 0.53, 0.95; p = 0.022), re-applying sunscreen (OR 0.61; 95% CI 0.74, 1.02; p = 0.002), wearing long-sleeved shirts (OR 0.63 95% CI 0.46, 0.86; p = 0.004), and seeking shade (OR 0.67; 95% CI 0.50, 0.88; p = 0.005).

CONCLUSIONS

Rural students reported less adequate use of sun protection than urban students. Rural male students reported lower knowledge scores compared to urban males. Future skin cancer prevention efforts targeting rural high schoolers are warranted.

Demographic-specific Validity of the Cancer Prevention Study-3 Sedentary Time Survey

PURPOSE

This study examined the 1-yr test-retest reliability and criterion validity of sedentary time survey items in a subset of participants from a large, nationwide prospective cohort.

METHODS

Participants included 423 women and 290 men age 31 to 72 yr in the Cancer Prevention Study-3. Reliability was assessed by computing Spearman correlation coefficients between responses from prestudy and poststudy surveys. Validity was assessed by comparing survey-estimated sedentary time with a latent variable representing true sedentary time estimated from the 7-d diaries, accelerometry, and surveys through the method of triads. Sensitivity analyses were restricted to 566 participants with an average of 14+ h of diary and accelerometer data per day for 7 d per quarter.

RESULTS

Reliability estimates for total sitting time were moderate or strong across all demographic strata (Spearman ρ ≥ 0.6), with significant differences by race (P = 0.01). Reliability estimates were strongest for the TV-related sedentary time item (Spearman ρ, 0.74; 95% confidence interval, 0.70-0.77). The overall validity coefficient (VC) for survey-assessed total sedentary time was 0.62 (95% confidence interval, 0.55-0.69), although VC varied by age group and activity level (P < 0.05). However, VC were similar across groups (P < 0.05) when restricting to highly compliant participants in a sensitivity analysis.

CONCLUSIONS

The Cancer Prevention Study-3 sedentary behavior questionnaire has acceptable reliability and validity for ranking or categorizing participants according to sedentary time. Acceptable reliability and validity estimates persist across various demographic subgroups.

Childhood sun safety at different ages: relations between parental sun protection behavior towards their child and children's own sun protection behavior

BACKGROUND

Sunburns during childhood are strongly associated with development of melanoma in later life. While parents play an important role in children's sun protection, insight in possible shifts in behavioral responsibility from parents towards their children and the possible effect of children's sex is important for targeting sun safety interventions throughout childhood and adolescence.

METHODS

This cross-sectional survey study was conducted among a representative sample of Dutch parents (N = 1053) of children aged between 4 and 13 years old. Questionnaires measured both parental and children's own sun safety behavior during planned (e.g. going to the beach) and incidental (e.g. bycicling) sun exposure situations. Analyses of variance were used to test for age group differences and linear regression models were computed to detect behavioral shifts in executive behavior.

RESULTS

Parents applied all sun safety behaviors (i.e. sunscreen use, wearing UV-protective clothing and seeking shade) more often on younger children, except for supportive behavior (facilitating children's own sun safety behavior), which remained relatively stable over the years. Older children and girls were more likely to execute sun safety behaviors themselves. A behavioral shift was found in wearing UV-protective clothing during planned situations among 11 year old children. For other behaviors, shifts were predicted after the age of 13.

CONCLUSIONS

Older children execute sun safety behaviors more often than younger children, although they still largely depend on their parents' protection. Specific attention for boys in the primary school years, and for both boys and girls in the years adjacent to adolescence is warranted in skin cancer prevention interventions.

Walking and Sun Protective Behaviors: Cross-Sectional Associations of Beneficial Health Factors

Sun protective behaviors and physical activity have the potential to reduce cancer risk. Walking is the most common type of physical activity in the United States, but it is unclear whether sun protective behaviors differ by categories of walking, such as leisure versus transportation walking. We examined whether sun protective behaviors varied by category or duration of walking in the 2015 National Health Interview Survey (N = 26,632), age ≥ 18 years. We used logistic regression to estimate sunscreen use, sun avoidance, and sun protective clothing use by four categories of walking (no reported walking, transportation only, leisure only, or walking for both) and separately for walking duration for the general population and sun-sensitive individuals. Prevalence of sunscreen use varied across walking categories and the odds of use were higher with longer walking duration for transportation and leisure compared to those who reported no walking. Sun avoidance varied across walking categories and the odds of avoidance were lower with longer duration leisure but not transportation walking. Sun protective clothing varied across walking categories and the odds of use were higher for longer duration transportation, but not leisure walking. Data on the concurrence of walking and sun protection is needed to further understand the relationship between these health behaviors. By examining leisure and transportation walking, we found variations in sun protective behaviors that may provide important insight into strategies to increase sun protection while promoting physical activity.

Association Between Sun Protection Behaviors and Sunburn Among U.S. Older Adults

BACKGROUND AND OBJECTIVES

Skin cancer incidence rates are highest among U.S. older adults. However, little is known about sun protection behaviors and sunburn among adults aged 65 years and older.

RESEARCH DESIGN AND METHODS

We used data from the 2015 National Health Interview Survey to examine the association between sun protection behaviors (sun avoidance, wearing protective clothing, and sunscreen use) and likelihood of having experienced sunburn in the past year.

RESULTS

Just over one in ten older adults (13.2%) had experienced sunburn in the past year; sunburn prevalence was nearly twice as high (20.4%) among sun-sensitive older adults. Men, ages 65-69 years, non-Hispanic whites, and those with skin that burns or freckles after repeated sun exposure were more likely to have been sunburned in the past year compared with the respective comparison groups. The only sun protection behavior significantly associated with sunburn was sunscreen use. None of the sun protection behaviors were significantly associated with a decreased risk of sunburn.

DISCUSSION AND IMPLICATIONS

The prevalence of sunburn among older adults suggests opportunities to reduce skin cancer risk within this demographic group by preventing overexposure to the sun. The lack of reduced sunburn risk among those who regularly used sun protection may be related to inadequate or inconsistent use of sun protection or the way the sun protection behaviors were measured. Multi-sector approaches to facilitate sun-safety among older adults are warranted and could include targeted efforts focused on those most likely to get sunburned, including men and those with sun-sensitive skin.

Compensation Behaviors and Skin Cancer Prevention

INTRODUCTION

Skin cancer prevention guidelines recommend practicing multiple behaviors to protect against harmful ultraviolet rays, yet few adults report practicing more than one recommended behavior. This study examines the extent to which skin cancer prevention behaviors are combined and may follow a pattern of compensation in which an individual's performance of one behavior (e.g., wearing sunscreen) precludes performing other protective behaviors (e.g., wearing a hat).

METHODS

Data from qualitative semi-structured interviews (n=80) in 2015 and a quantitative online national survey (n=940) in 2016 with non-Hispanic white adults aged 18-49 years from the U.S. were used to examine combinations of skin cancer prevention behaviors. Data were analyzed in 2017.

RESULTS

Protective behaviors like wearing sunglasses and sunscreen were a common approach to prevention, but protective, avoidant (i.e., seeking shade, avoiding outdoor tanning), and covering-up (i.e., wearing a hat, shirt) strategies were rarely used in combination. Regression analyses to determine correlates of protection, avoidance, and covering-up showed that age was positively associated with practicing each strategy; positive attitudes about tanning were negatively associated with avoidance and covering-up; and positive body image was positively associated with protection and negatively associated with avoidance. Demographics such as education, employment, and gender, but not skin cancer risk, were also related to the various strategies.

CONCLUSIONS

Although a full evaluation of compensation theory and skin cancer prevention was limited by the available data, the results suggest that application of the theory may yield clues for how to improve sun protection behaviors.

The Sun Solutions Intervention for Operating Engineers: A Randomized Controlled Trial

Background: Because Operating Engineers (heavy equipment operators) are outdoor workers at risk for skin cancer, interventions are needed to promote sun safety. The objectives were to determine changes in sunscreen use and sunburning among Operating Engineers randomized to four conditions in the Sun Solutions study: (i) education only; (ii) education and text message reminders; (ii) education and mailed sunscreen; and (iv) education, text message reminders, and mailed sunscreen.Methods: In this randomized controlled trial, Operating Engineers (N = 357) were recruited at required safety training sessions throughout Michigan during winter/spring of 2012 to 2013 and provided baseline surveys. The four interventions were delivered over the summer. Postintervention surveys were collected in the fall (82.1% follow-up).Results: Sunscreen use improved significantly from baseline to follow-up in all four conditions (P < 0.05), except sunscreen use among those receiving education and text message reminders was only marginally significant (P = 0.07). There were significantly greater increases in sunscreen use in the two conditions that were mailed sunscreen (P < 0.001). There was a significant decrease in the number of reported sunburns from baseline to follow-up in all four conditions (P < 0.001), but there were no significant differences in sunburns among the groups. Participant evaluated the interventions highly with those who received mailed sunscreen rating the intervention the highest.Conclusions: Providing proper sun-safety education and minimizing barriers to sunscreen use can increase sunscreen use and decrease reported sunburns.Impact: The implementation of the Sun Solutions intervention may be an effective method to modify skin cancer-related behaviors. Cancer Epidemiol Biomarkers Prev; 27(8); 864-73. ©2018 AACR.

Perceptions and Practices of the Iranian Population regarding Skin Cancers: A Literature Review

Despite being preventable, more than 15% of all cancer cases in Iran occur in the skin, making them the most commonly diagnosed malignancy in the country. The purpose of this study is to gain an insight into the current skin cancer related knowledge, attitudes, beliefs, and practices among the Iranian population. A systematic computer based literature search was conducted using databases for articles published through April 2017. Research studies included those that measured skin cancer or sun protection related knowledge, attitudes, beliefs, and behaviors in different Iranian population groups. Exclusion criteria for the articles included (1) irrelevant topics to the review article's aim, (2) articles that focused on the treatment of skin cancers instead of prevention practices, and (3) similar studies conducted on populations not indigenous to Iran. A total of 25 articles that met the eligibility criteria were included in the review. Predominant data were collected via questionnaires. Skin cancer related knowledge varied from low to high across the studies. Moreover, there was a pattern of low perceived skin cancer susceptibility and severity. Overall, there was low usage of sun protection methods among the Iranian population. The findings of this study show that efforts to prevent skin cancer are needed. Education concerning the dangers of sun exposure as well as strategies used to prevent or lower the risk of developing skin cancer should be stressed.

Results From a Tailored SMS and Behavior-Tracking Pilot Study on Sun-Safe Behaviors in Young Women

BACKGROUND

The elevated rates of ultraviolet radiation (UVR) exposure and low rates of sun protection in young adult women indicate a need for age- and gender-appropriate interventions that address these behaviors.

AIMS

To examine the effects of daily behavior tracking and individually tailored text messages on sun protection and UVR exposure behaviors in young adult women at moderate to high risk of developing skin cancer.

METHOD

One hundred and four young adult women at risk of skin cancer were randomized to receive the behavior-tracking intervention only, tailored text messages only, both interventions, or neither. Outcomes were self-reported UVR exposure and sun protection behaviors.

RESULTS

Those who received the behavior-tracking intervention reported significantly fewer UVR exposure behaviors at 4-week follow-up, relative to those who did not receive behavior tracking. At 4-week follow-up, those who received daily tailored text messages reported significantly greater UVR exposure behaviors but were more likely to report wearing a hat as a form of sun protection, relative to those who did not receive tailored messages.

DISCUSSION

Daily behavior tracking may be repetitive, but repetition may facilitate cognitive processing and the development of healthy habits. Health messages that are less interactive, on the other hand, need to be adequately tailored and delivered with the most advantageous timing to be impactful.

CONCLUSION

Future research should continue to examine how these interventions differentially affect behavior and how they can be adapted to apply to other health behaviors.

Sun Exposure and Protection Behaviors among Long-term Melanoma Survivors and Population Controls

Introduction: Melanoma is considered a generally preventable cancer, with excessive ultraviolet radiation (UVR) exposure being a strong causal factor. UVR exposure following a melanoma diagnosis can be modified to reduce risk of second primary melanomas. The goal of this study was to compare measures of UVR exposure and protection behaviors between long-term melanoma survivors and controls.Methods: Participants from a previously conducted case-control study were recruited for a cross-sectional survey. Melanoma cases were 25 to 59 years old at diagnosis; controls were age and sex matched. Participants were asked about UVR exposure and protection measures used in the past year, and comparisons between melanoma survivors and controls were conducted using logistic regression models, adjusting for potential confounders.Results: A total of 724 (62.0%) long-term melanoma survivors and 660 (59.9%) controls completed the follow-up survey. Melanoma survivors were significantly less likely to report high sun exposure on a typical weekday [OR, 0.72 (0.55-0.94)], sunburns [OR, 0.40 (0.30-0.53)], or indoor tanning [OR, 0.20 (0.09-0.44)] than controls; however, high sun exposure on a typical weekend day was similar. Report of optimal sun protection behaviors was higher in melanoma survivors compared with controls. However, a few melanoma survivors reported indoor tanning, 10% reported intentionally seeking sun to tan, and 20% reported sunburns.Conclusions: Although long-term melanoma survivors reported healthier UVR exposure and protection behaviors compared with controls, a sizeable proportion still reported elevated sun exposure, sunburns, and suboptimal UVR protection behaviors.Impact: Opportunities remain for improving sun protection to reduce future melanoma risk among melanoma survivors. Cancer Epidemiol Biomarkers Prev; 26(4); 607-13. ©2017 AACR.

Photoprotection in specific populations: Children and people of color

Improved education on appropriate photoprotection in children is vital. Photoprotection for these individuals should include seeking shade, the use of physical agents (clothing, hat, sunglasses), and application of sunscreens on exposed areas. Avoidance of the use of tanning beds is an important component of education for teenagers. Ultraviolet radiation exposure induces DNA damage and photoaging in all skin types, including people of color. The extent of such damage is inversely related to constitutive skin pigmentation. Therefore, personalized photoprotection recommendations concerning skin cancer risk factors, desired treatment outcomes, health needs (eg, vitamin D), and photoaging based on the needs and preferences of the patient are essential. It is clear that additional research is needed on optimal levels of protection against ultraviolet radiation for people of color.

Can skin cancer prevention be improved through mobile technology interventions? A systematic review

OBJECTIVE

Print-based health promotion interventions are being phased out to bring forth more appealing and assessable new technology applications. This review aimed to evaluate the current literature on the use of mobile text messaging and similar electronic technology interventions in the area of skin cancer prevention.

METHOD

A search of studies guided by Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) was conducted on mobile technology interventions for improving skin cancer prevention in the electronic databases PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO.

RESULTS

Overall, 136 articles were screened for eligibility between 2001 (earliest relevant article found) and November 2015. Eight studies fulfilled the inclusion criteria and were reviewed according to the PRISMA guidelines. Of these, five were randomised controlled trials (RCTs), two were controlled clinical trials, and one was a cohort study. Five studies used text messages as an intervention, two used mobile phone applications, and another used electronic messages via email. All studies resulted in self-reported behaviour change in at least one of their outcome measures (e.g., sunscreen application, seeking shade).

CONCLUSION

While the behaviour change outcomes are promising, the lack of change in more objective measures such as sunburn indicates a need to further improve mobile phone technology-delivered interventions in order to have a greater impact on skin cancer prevention. Future studies may consider the use of objective outcome measures (e.g., sunscreen weight), electronic diaries, or behavioural outcomes in social networks.

Urinary benzophenone concentrations and their association with demographic factors in a South Korean population

Benzophenone (BP) and its derivatives are widely used in various cosmetics, personal care products, and food packaging ink. The use of BP has raised concerns about the potential health risks associated with its endocrine-disrupting effects. This study evaluated urinary concentrations of BP derivatives in a national sample of the South Koreans population aged 6-89 years. From July to September in each 2010 and 2011, 1576 urine samples were collected. Urinary concentrations of benzophenone-1 (BP-1), benzophenone-2 (BP-2), benzophenone-3 (BP-3), benzophenone-4 (BP-4), benzophenone-8 (BP-8), and 4-hydroxybenzophenone (4-OH-BP) were analyzed using liquid chromatography-mass spectrometry. The detection rate for BP-1 and 4-OH-BP were 56% [limit of detection (LOD) 0.59ng/mL] and 88% (LOD 0.04ng/mL), respectively, whereas those for BP-2, BP-3, BP-4, and BP-8 were all below 25%. The geometric means of urinary BP-1 and 4-OH-BP concentrations were 1.24ng/mL and 0.45ng/mL, respectively. Multiple linear regression analysis indicated that concentrations of BP-1 in and of 4-OH-BP in adults were associated with sex and age. The BP-1 and 4-OH-BP concentration of children and adolescents was associated with sex, age, income, and current area of residence. The correlation was observed between urinary concentrations of BP derivatives, which is an important indication of exposure biomarkers and the metabolic pathways from BP-3. This is the first national study to evaluate the presence of BP derivatives in urine samples from the South Korean population, stratified by demographic factors.

Efficacy of an Intervention to Alter Skin Cancer Risk Behaviors in Young Adults

INTRODUCTION

Skin cancer is the most common cancer, and its incidence is increasing. Young adults expose themselves to large amounts of ultraviolet radiation (UV) and engage in minimal skin protection, which increases their risk. Internet interventions are effective in modifying health behaviors and are highly disseminable. The current study's purpose was to test an Internet intervention to decrease UV exposure and increase skin protection behavior among young adults.

STUDY DESIGN

RCT conducted in 2014, with data analyzed in 2015.

SETTING/PARTICIPANTS

A national sample of adults aged 18-25 years at moderate to high risk of developing skin cancer by a self-report measure was recruited online.

INTERVENTION

Participants were randomized to one of three intervention conditions: assessment only, the website of a skin cancer organization, or a tailored interactive multimedia Internet intervention program (UV4.me) based on the Integrative Model of Behavioral Prediction.

MAIN OUTCOME MEASURES

Self-reported overall UV exposure and skin protection assessed at 3 and 12 weeks after baseline. Secondary outcomes were self-reported intentional and incidental UV exposure, sunburns, sunscreen use, and skin cancer screening.

RESULTS

For the intervention arm, there were significant decreases in UV exposure and increases in skin protection at both follow-up time points compared with the assessment-only condition (p<0.001). The effect sizes (Cohen's d) comparing the experimental and assessment-only arm for exposure behaviors were 0.41 at 3-week follow-up and 0.43 at 12-week follow-up. The effect sizes for protection behaviors were 0.41 at 3-week follow-up and 0.53 at 12-week follow-up. The control condition was not significantly different from the assessment only condition. All three conditions exhibited decreased exposure and increased protection at both follow-ups (p<0.01), but the effect was much stronger in the intervention group. Secondary outcomes were generally also significantly improved in the intervention condition compared with the other conditions.

CONCLUSIONS

This is the first published report describing the results of an RCT of an Internet intervention to modify skin cancer risk behaviors among young adults. The UV4.me intervention significantly improved self-reported skin cancer prevention behaviors. Future research will investigate mechanisms of change and approaches for dissemination.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02147080.

Trends in sun-protection behaviour in Australian adults 2007-2012

BACKGROUND

Almost all skin cancers are the result of overexposure to UV radiation and could be prevented by adhering to a number of simple behavioural guidelines to minimise exposure to the sun. The present study examined trends in sun-protection behaviour among adults living in Western Australia, a region with high levels of UV radiation.

METHODS

During five summers from 2008 to 2012, 2076 Western Australian adults participated in annual, cross-sectional telephone surveys that assessed how often they engaged in a range of sun-protection behaviour (seeking shade, staying inside and wearing a hat, protective clothing, sunscreen or sunglasses).

RESULTS

Apart from an increase in sunscreen use and a consistently high use of sunglasses, most sun-protection behaviour remained stable at moderate levels during the 5-year period. Seeking shade, staying inside and wearing a hat were all practised at levels ranging between 'sometimes' and 'usually' on sunny days in summer during peak UV hours, with little to no variability across the survey years. Wearing protective clothing was the least frequent behaviour across all survey years and was significantly lower in the most recent survey year relative to baseline.

CONCLUSIONS

Further efforts are required to encourage greater enactment of sun-protection behaviour, especially on the use of protective clothing and seeking shade during periods of high UV radiation.

Skin Protection Behaviors among Young Male Latino Day Laborers: An Exploratory Study Using a Social Cognitive Approach

Latino Day Laborers (LDLs) are employed in occupations where multiple work hazards exist. One such hazard is the overexposure to solar ultraviolet radiation for continuous periods of time. Regular sun exposure can put individuals at increased risk of developing skin cancers, especially without adequate protection. The purpose of this cross-sectional exploratory study was to use a social cognitive framework to assess skin protective behaviors among LDLs. A community-based nonrandom and purposive sample of LDLs was recruited in two states: Mississippi and Illinois. The study sample consisted of 137 male participants, of which the majority were of Mexican ancestry (72%). The average age was 35.40 (SD = 9.89) years. Results demonstrated that a substantial number of LDLs do not adequately practice sun protection behaviors on a regular basis. The skin cancer knowledge scores were very modest. The most frequently indicated barriers towards sun protection were “inconvenient,” “forget to use,” and “not being able to reapply sunscreen.” Overall, LDLs had moderate confidence in their abilities to adopt successful sun protection strategies. This study underscores the need for intervention programs aimed at LDLs to reduce extended time in the sun and increase use of sun protective measures when working outdoors.

Awareness of Skin Cancer, Prevention, and Early Detection among Turkish University Students

Objective:

The aim of this study was to determine the awareness about skin cancer, prevention, and early detection among university students.

Methods:

This descriptive cross-sectional study was carried out with 404 students in a university located in Ankara, the capital city of Turkey. A 35-item questionnaire was used for data collection.

Results:

Less than half of the students (37.9%) had knowledge about skin cancer mostly through the internet (24.5%) and media (24.1%). Half of them aware of the risk factors; mostly as avoiding direct exposure to the Sun between 10 am and 4 pm (45.3%); smoking and alcohol (38.4%); having fair skin color (34.9%); and ultraviolet light exposure (25.7%). Only one-third of them (32.9%) are knowledgeable about skin cancer signs and symptoms, such as a change in color and appearance of the nevus/moles (24%). The majority of the responders (77.3%) did not know about screening tests for skin cancer and only 18 (4.5%) students were practicing skin self-examination.

Conclusions:

This study showed a lack of knowledge about skin cancer, prevention, and early detection among university students and reported the need for educational interventions to raise awareness in this target group.

Skin cancer prevention practices among malignant melanoma survivors: a systematic review

PURPOSE

This systematic review was conducted to evaluate and summarize the existing literature on prevalence of ultraviolet radiation (UVR) exposure, sun protection, and screening behaviors among individuals diagnosed with malignant melanoma (MM).

METHODS

The search was performed in PubMed, CINAHL, PsycINFO, ScienceDirect, EMBASE, and ERIC from inception of each database through July 2014. Studies were included if (1) individuals diagnosed with MM were the primary sample, (2) measured UVR exposure, primary and secondary preventive behaviors, (3) original research communication that constitutes an entire set of empirical data, (4) observational design, and (5) English peer-reviewed. Studies were excluded if (1) all of the inclusion criteria were not met and (2) duplicates, conference abstracts, editorials, news, letters to the editor, comments, reviews, feature articles, white papers, and guidelines.

RESULTS

The search resulted in 255 articles that were screened for relevance; however, only 15 articles met all of the inclusion criteria. Most of the studies were cross-sectional (n = 10), used self-administered surveys (n = 8), and were conducted in North America (n = 10). The sample sizes ranged considerably, but were mostly Caucasian (n = 6) and included a higher proportion of women (n = 8). Evidence demonstrated that individuals with MM still engaged in sunbathing, indoor tanning, and reported sunburns. Moreover, survivors reported inadequate levels of both sun protection and skin self-examinations.

CONCLUSIONS

The findings highlight the need for intensifying intervention strategies to reduce the risk of new primary MMs in this group. Future research should increase in rigor and include more diverse populations and regions.

Self-reported sunscreen use and urinary benzophenone-3 concentrations in the United States: NHANES 2003-2006 and 2009-2012

BACKGROUND

Sunscreens protect against skin cancer and other harmful effects of solar ultraviolet radiation (UVR). Epidemiologic and public health surveys often rely on self-reported sunscreen use to estimate sun exposure and avoidance, but questions remain about the validity of self-reports. Benzophenone-3 (BP-3), a common sunscreen ingredient, can be detected in the urine. Prior studies suggest that BP-3 concentrations increase after application of sunscreen.

OBJECTIVES

The goal of this study was to assess the validity of self-reported frequency of sunscreen use in relation to urinary BP-3 concentrations in a representative sample of the general US population, including in sub-groups defined by age, sex and race/ethnicity.

METHODS

To assess the relationship between categorical self-reported sunscreen use and creatinine-corrected urinary BP-3 concentrations, we conducted a linear regression adjusted for age, sex, race/ethnicity, six-month time period, body mass index, education, and sun avoidance behaviors. We tested for effect modification by age, sex, ethnicity and time period of measurement using multiplicative interaction terms and a F test.

RESULTS

BP-3 was positively associated with self-reported frequency of sunscreen use across all ages, sexes, race/ethnicities, and time periods. Crude and multivariate adjusted models were all statistically significant. R-square was relatively low for all models, ranging from 0.15 to 0.43.

CONCLUSIONS

Urinary BP-3 is positively associated with self-reported frequency of sunscreen use in the general US population, even in groups with overall low sunscreen use. These results suggest that self-report is a valid, although weak, way of assessing relative frequencies of sunscreen usage in a population-based study.

Sun protection practices and sun exposure among children with a parental history of melanoma

BACKGROUND

First-degree relatives of melanoma survivors have a substantially higher lifetime risk for melanoma than individuals with no family history. Exposure to ultraviolet radiation (UVR) is the primary modifiable risk factor for the disease. Reducing UV exposure through sun protection may be particularly important for children with a parental history of melanoma. Nonetheless, limited prior research has investigated sun protection practices and sun exposure among these children.

METHODS

The California Cancer Registry was used to identify melanoma survivors eligible to participate in a survey to assess their children's sun protection practices and sun exposure. The survey was administered by mail, telephone, or web to Latino and non-Latino white melanoma survivors with at least one child (0-17 years; N = 324).

RESULTS

Sun exposure was high and the rate of sunburn was equivalent to or higher than estimates from average-risk populations. Use of sun protection was suboptimal. Latino children were less likely to wear sunscreen and hats and more likely to wear sunglasses, although these differences disappeared in adjusted analyses. Increasing age of the child was associated with lower sun protection and higher risk for sunburn, whereas higher objective risk for melanoma predicted improved sun protection and a higher risk for sunburns. Perception of high barriers to sun protection was the strongest modifiable correlate of sun protection.

CONCLUSIONS

Interventions to improve sun protection and reduce sun exposure and sunburns in high-risk children are needed.

IMPACT

Intervening in high-risk populations may help reduce the burden of melanoma in the United States.

Sun protection among Spanish beachgoers: knowledge, attitude and behaviour

This study aims to investigate the level of awareness on the risks related to sun exposure, attitude towards sun protection and sun protection behaviour in Spanish beachgoers. During the summer of 2009, trained assistants conducted a structured interview with 630 sunbathers at the beaches of Valencia, Spain, via administrating a questionnaire including the following: (a) general data (age, gender, education, profession), (b) "knowledge" and "attitude" items and (c) self-assessed sun sensitivity, sun exposure and sun protection characteristics. The health belief model was used to evaluate factors that may influence on engaging healthy behaviour. The median age was 30 (2-82) years; the M/F ratio was 0.60. Despite the widespread regular ("often" or "always", 80%) use of high (>15) sun-protective factor sunscreens, current recommendations on sun protection were not regularly followed, and a history of sunburns is very common (70%). At multivariate analysis, female gender, age, fair hair, freckles, all-day use of sunscreens and wearing sunglasses were independent factors associated with having sunburn history. A high knowledge and a fairly good attitude emerged (median scores, 6/7 and 22/30, respectively). Age class (p = 0.032), educational level (p < 0.0001), sunscreen use (p = 0.048) and adequate timing of the first application of sunscreens (p = 0.015) were predictors of awareness, while factors associated with a more favourable attitude were educational level (p < 0.0001) and regular use of hats (p = 0.001). Wrong beliefs mainly concern sunscreens (false safety); the attractiveness of a tanned look is the main unfavourable attitude. Physical and motivational barriers are common (80%). The findings by highlighting constitutional and psychosocial factors involved in unhealthy behaviour provide useful information to promote sun-safe interventions in this population.

Can skin cancer prevention and early detection be improved via mobile phone text messaging? A randomised, attention control trial

OBJECTIVE

To test the impact of a theory-based, SMS (text message)-delivered behavioural intervention (Healthy Text) targeting sun protection or skin self-examination behaviours compared to attention control.

METHOD

Overall, 546 participants aged 18-42 years were randomised using a computer-generated number list to the skin self-examination (N=176), sun protection (N=187), or attention control (N=183) text messages group. Each group received 21 text messages about their assigned topic over 12 months (12 weekly messages for 3 months, then monthly messages for the next 9 months). Data were collected via telephone survey at baseline, 3, and 12 months across Queensland from January 2012 to August 2013.

RESULTS

One year after baseline, the sun protection (mean change 0.12; P=0.030) and skin self-examination groups (mean change 0.12; P=0.035) had significantly greater improvement in their sun protection habits (SPH) index compared to the attention control group (reference mean change 0.02). The increase in the proportion of participants who reported any skin self-examination from baseline to 12 months was significantly greater in the skin self-examination intervention group (103/163; 63%; P<0.001) than the sun protection (83/173; 48%) or attention control (65/165; 36%) groups. There was no significant effect of the intervention for participants' self-reported whole-body skin self-examination, sun tanning, or sunburn behaviours.

CONCLUSION

The Healthy Text intervention was effective in inducing significant improvements in sun protection and any type of skin self-examination behaviours.

TRIAL REGISTRATION

The Australian and New Zealand Clinical Trials register (ACTRN12612000577819).

FUNDING

Cancer Australia 1011999.

Effects of tailored risk communications for skin cancer prevention and detection: the PennSCAPE randomized trial

BACKGROUND

Prevention and early detection measures for melanoma, such as sun avoidance and skin examinations, are important, but are practiced inconsistently. In this replication of the Project SCAPE trial, we sought to determine whether tailored print materials were more effective at improving adherence than generic print materials for patients at increased risk of skin cancer.

METHODS

Participants were randomized to receive personalized mailed communications about their skin cancer risk and recommended sun protection, or generic mailings. Participants were Caucasian adults, at moderate or high risk for skin cancer, recruited in outpatient primary care. The main outcomes were overall sun protection behaviors and specific protective behaviors including use of sunscreen, shirt, hat, sunglasses, shade, and sun avoidance; recent sunburns; and skin self-examination and provider skin examination.

RESULTS

One hundred ninety-two (93.2%) subjects completed the study. Six outcome variables showed significant intervention condition effects in mixed effects models: overall sun protection behavior (P = 0.025); sunscreen use (P = 0.026); use of sunglasses (P = 0.011); sunburns in the past three months (P = 0.033); recency of last skin self-exam (P = 0.017); and frequency of skin exams by health care provider (P = 0.016).

CONCLUSIONS

Relative to generic communications, tailored risk communications resulted in improved adherence to six skin cancer protective behaviors, including a composite sun protection behavior measure, sunburns, and health care provider skin examinations.

IMPACT

Tailored interventions can be more effective in improving patient prevention behaviors than nontailored, generic information for patients at moderate to high risk of skin cancer.

Skin cancer preventative behaviors in state park workers: a pilot study

OBJECTIVES

Considering the potential for occupational sun exposure among state park workers, the purpose of this pilot study was to identify skin cancer knowledge, health beliefs, self-efficacy, and sun protection behaviors (SPBs) among state park employees.

METHODS

The current study used a cross-sectional survey research design with state park workers in a Southern state. Of the 94 possible employees who could have participated in the study, 87 completed the survey.

RESULTS

Assessment of the participants' skin cancer knowledge demonstrated an average correct response rate of 68.8 %. While the vast majority (87.4 %) believed that skin cancer is a serious disease, a minority (42.5 %) believed they would develop skin cancer sometime during their lifetime, and even fewer (35.6 %) believed their risk was higher than average. Collectively, workers reported low levels of SPBs. The most commonly reported barriers to sun protection were "inconvenient," "too hot to wear," and "forget to protect." Half of the participants (50.6 %) were highly confident in their ability to wear long pants while in the sun. About the same proportion of participants was highly confident they could wear a wide-brimmed hat (21.8 %) and sunscreen (20.7 %).

CONCLUSIONS

Based on available evidence, a need exists to develop individual and worksite programs and interventions to increase skin cancer prevention behaviors among this occupational group. This data could serve as a baseline to monitor and evaluate the efficacy of these interventions.

Sun exposure and protection behavior of Danish farm children: parental influence on their children

Healthy sun habits acquired in childhood could reduce skin cancer incidence. We examined the sun exposure and protection behavior of an expected high-exposure group of children, and the association to their parents. Open, prospective cohort study. One hundred and thirty nine participants (40 families) kept daily sun behavior diaries (sun exposure, sunscreen use, sunburns) over a 4-month summer period (15,985 diary days). The Pigment Protection Factor (PPF), an objective measure of sun exposure, was measured at two body sites, before and after summer. All participants presented data from the same 115 days. Risk behavior (sun exposure of upper body) took place on 9.5 days (boys) and 15.6 days (girls). Sunburn and sunscreen use were infrequent. Boys' sun exposure resulted in an increased photo protection over the study period of 1.7 SED (upper arm) and 0.8 SED (shoulder) to elicit erythema. Corresponding values for girls were as follows: 0.9 SED (upper arm) and 0.5 SED (shoulder). Boys' sunscreen use correlated to their mothers' (r = 0.523, P = 0.02). Girls' number of risk days (r = 0.552, P = 0.005) and sun exposure (upper arm: r = 0.621, P < 0.001) correlated to their mothers'. The children's sun exposure was substantial. Only mothers influenced children's sun behavior and exposure. This may be of relevance in future sun protection campaigns.

Worry about skin cancer mediates the relation of perceived cancer risk and sunscreen use

Preventive health behaviors are believed to be motivated in part by a person's perception of risk for a particular health problem. Risk contains a cognitive component, beliefs about the chances of a health problem occurring, and an affective component, fear or worry about the health problem. Although both have been shown to influence behavior, the nature of their interrelation as an influence on behavior has not been examined. Data from the 2005 Health Information National Trends Survey, a US nationally-representative telephone survey was analyzed. Participants reported perceived absolute and comparative risk for skin cancer, feelings of worry about skin cancer, and sunscreen use behavior. Analyses examined main effects models for the relation between perceived risk, worry, and sunscreen use, as well as both moderated and mediated models. For both absolute and comparative risk, the relation between cognitively-based perceived risk for skin cancer and sunscreen use was fully mediated by feelings of worry, as evidenced by significant direct effects of worry (bs > 0.046, ps < 0.01) and indirect effects of risk through worry (bs > 0.19, ps < 0.01). When worry was included in the models, direct effects of risk perceptions were non-significant (bs < 0.11, ps < 0.10). No evidence was found for moderated effects of worry on the relation between risk and behavior. While cognitive risk appraisals do influence decision making and may be addressed by interventions, these findings demonstrate that affectively-based risk components play a key role in behavior regulation. Affectively-based risk might be an effective target for interventions and should be incorporated more fully in decision-making models.

Determinants of inadequate parental sun protection behaviour in their children--results of a cross-sectional study in Germany

OBJECTIVE

Unprotected sun exposure especially during childhood is a risk factor for skin cancer. A combined use of sun protection measures is recommended to protect children. However, the prevalence and determinants for combined use have been scarcely studied in children. The objective of this study was to identify determinants of parental sun protection behaviour.

METHODS

A cross-sectional survey was performed in five regions in Bavaria (Germany) during school entrance health examination (2010/2011). Parents of 4579 children (47% female, aged 5-6 years) completed a self-administered questionnaire (response 61%).

RESULTS

Most children were regularly protected with single measures (shade (69%), clothes (80%), hat (83%), sunscreen (89%), sunglasses (20%)). However, regarding regular and combined use, >50% of children were inadequately protected. Larger family size, lower household equivalent income, darker skin and sunburn history were associated with inadequate use of different sun protection measures. The less frequent use of one sun protection measure was associated with less frequent use of the others. Child's sex, migration background, parental education and sun exposure showed inconsistent results regarding the different sun protection outcomes.

CONCLUSION

Based on our results a regular, combined and correct use of multiple sun protection for children should be promoted independent of sociodemographic characteristics. Priority of shade, clothes and hat before sunscreen should be clarified.

Randomized trial of tailored skin cancer prevention for children: the Project SCAPE family study

This study evaluated a tailored intervention to promote sun protection in parents and their children, hypothesizing that the tailored intervention would lead to improved skin cancer prevention behaviors compared to generic materials. Families were recruited through schools and community centers and were included if there was 1 child in Grades 1-3 at moderate to high risk for skin cancer. Participants were randomized into one of two intervention groups: a tailored intervention, in which they received personalized skin cancer education through the mail; or a control group who received generic skin cancer information materials. Before and after intervention, parents completed questionnaires about their and their children's skin cancer risk and prevention knowledge and behaviors. Parents also completed 4-day sun exposure and protection diaries for their child and themselves. Tailored group participants demonstrated significantly greater positive changes in prevention behavior after the intervention, including children's use of sunscreen, shirts, and hats, and parents' use of shade, and skin examinations. Effect sizes were small and perceived benefits and social norms mediated intervention effects. Findings from this study support the efficacy of focusing tailored communications to families in order to change skin cancer prevention practices in young children.

The HealthyTexts study: a randomized controlled trial to improve skin cancer prevention behaviors among young people

Several randomized trials have found behavior change programs delivered via text messaging to be efficacious to improve preventive health behaviors such as physical activity and stopping smoking; however few have assessed its value in skin cancer prevention or early detection. The HealthyTexts study enrolled 678 participants 18-42 years, and assigned them to receive 21 text messages about skin cancer prevention, skin self-examination or physical activity (attention control) over the course of one year. Baseline data have been collected and outcomes will be assessed at three months and twelve months post-intervention. The trial aims to increase the mean overall sun protection habits index score from 2.3 to 2.7 with a standard deviation of 0.5 (effect size of 0.5) and the proportion of people who conduct a whole-body skin self-examination by an absolute 10%. This paper describes the study design and participants' baseline characteristics. In addition, participants' goals for their health, and strategies they apply to achieve those goals are summarized.

Assessing population-wide behaviour change: concordance of 10-year trends in self-reported and observed sun protection

OBJECTIVES

Increases in socially desirable responses in self-reports might occur in the context of ongoing public education. We examine concordance of trends in two long-term studies monitoring population impact for SunSmart.

METHODS

One study employed telephone interviews of Melbourne residents; the other entailed observations at public recreation venues across Melbourne. The studies assessed people's sun protection on identical weekend dates (Nw = 33 dates). Data from five summers between 1992 and 2001 (n ~ 23,000 individuals) were analysed. A body cover index score was calculated for participants on each date. Outcomes were aggregated separately for Saturdays and Sundays by date and year. Regression analyses tested whether these trends differed by survey method.

RESULTS

The pattern of change in body cover over time was similar for both surveys. Self-reported body cover was consistently higher than observed body cover, suggesting that social desirability bias may be present. Regression analyses showed no divergence between self-reported and observed trends in mean body cover, suggesting no evidence of significant increased social desirability bias in self-reporting over time.

CONCLUSION

Findings suggest that self-report offers a valid means of assessing change in a population's sun protection compliance over time, at least when self-reports are precisely focussed for time and activity context.

A mediator model to predict workplace influenza vaccination behaviour--an application of the health action process approach

PURPOSE

Applying the health action process approach (HAPA) to vaccination behaviour as a single-event health behaviour to study vaccination adherence and its predictors in a worksite flu vaccination programme.

METHODS

A total of N = 823 employees participated in a longitudinal survey. Predictors (risk perception, self-efficacy, positive and negative outcome expectancies, intention and planning) were assessed at Time 1, and behaviour was assessed five months later at Time 2. Intention and planning were specified as mediators in a path analytical logistic regression model.

RESULTS

Risk perception, self-efficacy and positive as well as negative outcome expectancies predicted intention (R² = .76). Intention and planning predicted subsequent behaviour, and planning mediated the relation between intention and vaccination behaviour (R² = .67). In addition, results suggested the adjustment of the theoretical model: risk perception and negative outcome expectancies showed direct effects on behaviour resulting in a significantly better model fit.

CONCLUSIONS

Findings support the general applicability of the HAPA to vaccination behaviour and the importance of planning for translating intentions into behaviour. However, the adjusted model was superior and underlined the particular role of risk perception and negative outcome expectancies for vaccination behaviour to explain underlying mechanisms in vaccination behaviour.

‘I do not need a flu shot because I lead a healthy lifestyle’: Compensatory health beliefs make vaccination less likely

Compensatory health beliefs, a self-defence strategy, were examined in a theory-guided intervention promoting influenza vaccination at the workplace. In total, 851 employees were randomised to one group aimed at enhancing intention formation (standard group) or to another one assisting self-regulation (intervention group). Assessments took place after the intervention and 5 months later, investigating whether the intervention would interfere with compensatory health beliefs. The intervention generated an indirect effect via planning on vaccination. Compensatory health beliefs mediated between intention and behaviour. An interaction between intervention group and compensatory health beliefs on behaviour transpired. At low compensatory health belief levels, the intervention group resulted in more vaccinations than the standard group.

Process and outcomes of a skin protection intervention for young adults

Efforts to reduce skin cancer risk behaviors using appearance-oriented interventions (e.g. ultraviolet (UV) light photos showing skin damage) or motivational interviewing (MI) have shown promise in recent trials. In the study a randomized 2 (UV photo versus no UV photo) x 2 (MI versus no MI) factorial design with longitudinal follow up was used. Results showed that progression in stage of change (SOC) was significantly more likely in the photo than the education condition. Treatment credibility as rated by participants and counselor perceived positive therapeutic alliance predicted SOC progression. There was also preliminary evidence for differential intervention effectiveness by baseline SOC. The implications are discussed.