Environmental variables associated with vacationers' sun protection at warm weather resorts in North America

Warmer Temperatures Are More Predictive Than Solar Radiation for the Number of Skin Cancer Removal Procedures

BACKGROUND

Solar radiation is the primary risk factor for skin cancer, with personal exposure influenced by environmental and behavioral factors. At higher temperatures, behavioral changes increase solar radiation exposure.

OBJECTIVES

Examine the relationships between solar radiation, ambient temperature, age, and skin cancer.

METHODS

For the contiguous United States, we obtained the state mean global horizontal irradiance (GHI), daily maximum temperature, and number of skin cancer removals in the Medicare population. For skin cancer removals, we defined more sun-exposed skin as the head, neck, hands, and feet, and less sun-exposed skin as the trunk, arms, and legs.

RESULTS

By comparing the temperature thresholds 17°C, 20°C, 24°C, 27°C, 31°C, and 34°C, we found that the annual number of days above 24°C was the strongest temperature-related predictor of skin cancer removals. Multivariable linear regression showed that the number of days above 24°C predicted more skin cancer removals for all body locations and less sun-exposed skin (p = 0.008 and p = 0.003, respectively), while GHI did not (p = 0.1 and p = 0.8, respectively). GHI only predicted more skin cancer removals for more sun-exposed skin (p = 0.02).

CONCLUSION

More days above 24°C was a better predictor of skin cancer removals than GHI for all skin locations and less sun-exposed skin, suggesting that the behavioral changes occurring at warmer temperatures are more predictive of skin cancer removals than solar irradiance. Due to rising global temperatures, skin cancer incidence may further increase. Temperature-related behavioral changes represent a potential target for skin cancer prevention efforts.

Skin cancer prevention in extreme sports: Intervention in a 24-h race

INTRODUCTION

Excessive sun exposure and sunburns are the main preventable causes of skin cancer. The growing popularity of outdoor sports in developed countries has motivated the objective of this work to study the risk of photoexposure and the skin cancer prevention needs of athletes in an extreme race and evaluate an intervention targeted at this population.

METHODS

An observational study was conducted during the XXIII edition of the 101 km de Ronda race, which consisted of trail running and mountain biking categories. Environmental and personal dosimetry, monitoring of meteorological conditions, evaluation of the athletes' photoprotection and skin examination habits, a dermatological checkup, and a satisfaction questionnaire were performed.

RESULTS

The ultra-endurance race was carried out under adverse conditions (maximum ultraviolet index (UVI) = 9.2, temperatures above 30°C, and relative humidity >35%). The mean effective erythema dose received by race athletes (n = 11) was 2959.2 ± 404.2 J/m2 , equivalent to 29.6 standard erythema doses (SED). The CHACES questionnaire (n = 1145) showed a sunburn rate of 58% and poor protective habits: 62.9% of athletes do not usually use sunscreen and 67.2% do not self-examine their skin. Actinic keratoses (4.7%) and suspicious skin cancer lesions (4.2%) were found in dermatologic screening exams (n = 170). On the satisfaction questionnaire (n = 111), this intervention was rated as excellent (95.5%).

CONCLUSION

This research highlights the extreme risk of photoexposure that athletes are subjected to during ultra-endurance competitions. In the same way, it shows the need to carry out interventions aimed at the acquisition of healthy photoprotection habits and skin surveillance in this target group.

National and subnational burden of disease attributable to occupational exposure to solar ultraviolet radiation (SUVR) in Iran, 2005-2019

Overexposure to solar ultraviolet radiation (SUVR) can cause skin and eye adverse effects for outdoor workers. In this study, the burden of disease induced by occupational exposure to SUVR and its spatiotemporal trend at national and sub-national levels in Iran, 2005-2019 were assessed. The attributable burden of disease was assessed using the following five datasets: (1) distribution of occupational exposure to SUVR, (2) total incidences and deaths of health outcomes of SUVR exposure, (3) population attributable fractions of the health outcomes of SUVR exposure, (4) age-gender distribution of outdoor workers, and (5) disability-adjusted life year (DALY) calculation constants. During 2005-2019, the attributable DALYs increased from 2442 to 2907 and the attributable DALY rate (per 100,000 workers) slightly decreased from 11.94 to 11.91. The share of YLL in the attributable burden of disease was in the range of 43%-46%. Out of nine causes, about 90% of the attributable burden of disease in 2019 was related to cataracts (29.9%), malignant skin melanoma (27.4%), squamous-cell carcinoma (18.6%), and sunburn (17.2%). During the study period, the attributable DALY rate in women increased by 60.95% (from 5.04 to 8.11) and in men decreased by 2.06% (from 13.03 to 12.76). The total attributable DALYs and DALY rate rose by age during 2005-2019. The contributions of population growth, risk-deleted DALY rates, exposure risk, and population age structure in temporal changes of the attributable burden of disease were 19.27%, 9.13%, -1.35%, and -14.8%, respectively. The three highest attributable DALY rates in 2019 were observed in South Khorasan (21.28), Chahar Mahal and Bakhtiari (17.42), and Kordestan (17.26), respectively. The preventive interventions against SUVR overexposure, regular screenings, and early treatments with an emphasis on occupations with continuous sun exposure and provinces with increasing attributable DALY rates should be considered in the occupational health action plan in the country.

Reactivity to UV Radiation Exposure Monitoring Using Personal Exposure Devices for Skin Cancer Prevention: Longitudinal Observational Study

BACKGROUND

Emerging UV radiation (UVR) monitoring devices may present an opportunity to integrate such technology into skin cancer prevention interventions. However, little is known about the effects of using a wearable UVR monitor on adults' and children's sun protection-related behaviors and attitudes (eg, cancer worry and perceived risk). Understanding the potential role of reactivity and seasonal effects will help inform the use of objective monitors in the context of skin cancer prevention research, including intervention studies.

OBJECTIVE

The aim of this study is to examine the potential reactivity associated with a wearable personal UVR monitor, specifically the effects associated with reported sun-protective behaviors and skin cancer-related attitudes, which are often the targets of skin cancer preventive interventions.

METHODS

Child-parent dyads (n=97 dyads) were asked to wear a UVR monitoring device during waking hours for 2 weeks. Participants were asked to sync the device daily with a smartphone app that stored the UVR exposure data. Participants were blinded to their UVR exposure data during the 2-week period; thus, the smartphone app provided no feedback to the participants on their UVR exposure. Participants completed self-report questionnaires assessing sun-protective behaviors, sunburn, tanning, skin self-examination, skin cancer-related knowledge, perceived risk, cancer worry, response efficacy, and intentions to change behaviors over the 2-week period. Linear regressions were conducted to investigate changes in the outcomes over time and to account for the role of the season of study participation.

RESULTS

Regression results revealed that there was a significant decrease over time for several sun protection outcomes in children, including time spent outdoors on weekends (P=.02) and weekdays (P=.008), sunscreen use (P=.03), reapplication (P<.001), and unintentional tanning (P<.001). There were no significant changes over time in children's and parents' UVR exposure, sunburn occurrence, or sun protection attitudes. Season of participation was associated with several outcomes, including lower sunscreen use (P<.001), reapplication (P<.001), sunburns (P=.01), intentions to change sun-protective behaviors (P=.02), and intentional (P=.008) and unintentional tanning (P=.01) for participants who participated in the fall versus the summer.

CONCLUSIONS

The findings from this study suggest that daily use of a UVR monitoring device over a 2-week period may result in changes in certain sun-protective behaviors. These results highlight the importance of identifying and addressing potential reactivity to UVR monitoring devices, especially in the context of skin cancer preventive intervention research. Ultimately, objectively assessed UVR exposure could be integrated into the outcome assessment for future testing of skin cancer prevention interventions.

Environmental changes and their impact on human behaviour - Case study of the incidence of skin cancer

Climatological research over the past two decades makes it clear that the Earth's climate will change. Climate change has many, mostly adverse, effects on the human health. Environmental anthropogenic changes represent significant health risks including factors that may increase probability and seriousness of skin cancer diseases. There are many scientific studies on skin cancer but only a few of them are focused on environment changes and their influence on the behaviour of humans, which may lead to skin cancer. The goal of the research was to analyse environment changes in the city of Brno (Czech Republic) and their influence on the behaviour of people and some skin diseases. A research hypothesis was set up that total increase in the incidence of skin diseases would be monitored. 1757 patients aged 25-65 years participated in the research. The analysis was performed based on measured (mean annual temperatures, average monthly temperatures, ultraviolet index values, and numbers of sunny days and sunny hours) data in 2011-2019. In order to monitor the trend, temperature data from 1961 to 2019 were evaluated too. The analysed data indicate that the trend of average monthly and annual temperatures observed was increasing in recent years. Moreover, based on data obtained from the analysed doctor's office it was found out that the incidence of skin diseases increased in the studied period. The main reasons to increase include excessive exposure to sun, extended average age of the population, ozone layer depletion, climatic and weather changes, increased migration and behaviour of people.

Solar Ultraviolet Exposure in Individuals Who Perform Outdoor Sport Activities

BACKGROUND

Skin cancer is the most common cancer in the USA. Therefore, it is important to review the contribution of ultraviolet radiation (UVR) exposure to skin cancer in individuals with the highest risk. Documenting the relationship between outdoor sports solar ultraviolet exposure and their risk of skin cancer along with appropriate risk mitigation strategies can help inform clinicians of practical information for counseling sun protective behaviors in this population.

METHODS

We conducted a review of the current evidence using PubMed to answer the following research questions: (1) How is ultraviolet radiation measured? (2) What is the modern utility of the ultraviolet index in modifying recreational sun protection behaviors? (3) What is the risk of developing skin cancer for outdoor sport participants? (4) What is the prevalence of skin cancer in sport participants? and (5) Is the number of nevi and solar lentigines elevated in outdoor sport participants?

RESULTS

Based on the literature, individuals who practice outdoor sport-related activities receive high ultraviolet radiation exposure, have a high risk for skin cancer, have a high prevalence for pigmented lesions, and may benefit from electronic sun protection educational interventions.

CONCLUSIONS

Individuals who practice outdoor sports experience substantially higher ultraviolet radiation exposure, routinely exceed the recommended exposure limits, and are at a higher risk of developing skin cancer. Therefore, those who are frequently engaged in outdoor leisure activities should be coached about efficient sun protective practices and relevant mobile technologies that may facilitate adherence.

Examining Health-Related Effects of Refurbishment to Parks in a Lower Socioeconomic Area: The ShadePlus Natural Experiment

Degraded parks in disadvantaged areas are underutilized for recreation, which may impact long-term health. Using a natural experiment, we examined the effects of local government refurbishments to parks (n = 3 intervention; n = 3 comparison) in low socioeconomic areas (LSEA) of Melbourne on park use, health behavior, social engagement and psychological well-being. Amenities promoting physical activity and sun protection included walking paths, playground equipment and built shade. Outcomes were measured via systematic observations, and self-report surveys of park visitors over three years. The refurbishments significantly increased park use, while shade use increased only in parks with shade sails. A trend for increased social engagement was also detected. Findings infer improvement of quality, number and type of amenities in degraded parks can substantially increase park use in LSEA. Findings support provision of shade over well-designed playgrounds in future park refurbishments to enhance engagement and sun protection behavior. Further research should identify park amenities to increase physical activity.

Protection-adjusted UV dose estimated for body areas: Daily self-reported sun protection modification of wearable UV sensor dose

BACKGROUND

During the last 20 years, 50% of adults with sun-sensitive skin have sunburned annually. Reducing the proportion of people who sunburn requires understanding the circumstances and outdoor activities during which at-risk people sunburn.

METHODS

A 7-day observational study of melanoma survivors (n = 20) and young adult first-degree relatives of melanoma survivors (FDRs) (n = 20) captured daily UV exposure, sun protection, and sunburns during spring and summer in the Midwest of the United States (latitude 41.8°N). Participants wore UV and physical activity sensors and completed a daily self-reported survey of sun protection, sunburn, and physical activities. The estimated protection-adjusted UV dose was calculated for each body area by integrating self-reported sun protection with UV sensor dose.

RESULTS

In 254 days, at least one body area in 9 of 20 (45%) melanoma survivors and 11 of 20 (55%) FDRs was sunburned (erythema at 24 hours). Sunburns were associated with spring and walking for transportation or leisure, especially walking the dog. Melanoma survivors used sunscreen daily on the face; however, forearms and lower legs were not protected during walking. Young adults did not use sun protection on the face, forearms or lower legs during walking for transportation and use was ineffective during sports.

CONCLUSION

The sun protection patterns of daily living identified in this study may promote recognition of erythema as sunburn and inform the development of tailored sun protection mobile applications promoting self-monitoring with wearable UV sensors.

Facial photoprotection in xeroderma pigmentosum (XP) patients: Validation of a new self-reported questionnaire of adherence

BACKGROUND/PURPOSE

Adherence to photoprotection is the only way to prevent skin cancers and eye disease in xeroderma pigmentosum (XP). No validated self-report questionnaire exists for assessing adherence to photoprotection practices in individuals with XP. We sought to validate a self-reported measure of adherence to face photoprotection in this population.

METHODS

Sixty six XP patients recruited from the patient list of the XP specialist service in London, UK, completed a questionnaire of adherence to specific photoprotection behaviours. We measured objective ultraviolet radiation (UVR) exposure to the face continuously for 21 days with a wristworn UVR electronic dosimeter combined with a daily photoprotection diary. Reliability and convergent validity of the questionnaire were tested in relation to overall UVR exposure, UVR dose to the face, daily photoprotection activities, other self-reported photoprotection practices and clinical ratings of patient's protection.

RESULTS

Internal consistency of the questionnaire was satisfactory. Questionnaire total scores were concordant with objective UVR exposure and UVR dose to the face. However, not all participants who reported good/excellent face photoprotection on the questionnaire recorded high levels of photoprotection in the daily diary. Correlations between the questionnaire and other practices and the clinical rating ranged from small to large in size. There was no correlation between the level of face photoprotection and self-reported avoidance of going outside.

CONCLUSIONS

Our questionnaire was reliable and had good convergent validity with other indicators of photoprotection. This questionnaire could assist clinicians to detect low levels of adherence, and the methodology used to develop validated questionnaires for other photosensitive conditions.

Psychological correlates of adherence to photoprotection in a rare disease: International survey of people with Xeroderma Pigmentosum

OBJECTIVES

Xeroderma pigmentosum (XP) is an extremely rare genetic disorder (approximately 100 known cases in the United Kingdom), where DNA damage caused by ultraviolet radiation in daylight cannot be repaired. Adherence to photoprotection is essential to prevent skin cancer. We investigated psychological correlates of photoprotection in the XP population of Western Europe and the United States.

DESIGN

Cross-sectional survey of adults with XP and caregivers of patients <16 years and those with cognitive impairment in the United Kingdom, Germany, the United States, and France (n = 156).

METHODS

Photoprotection activities to protect the face and body when outdoors; avoidance of going outside during daylight hours; intention; self-efficacy; and social support were assessed using measures developed for this study. Participants answered questions about their illness representations of XP (BIPQ); beliefs about photoprotection (BMQ); automaticity (i.e., without conscious effort) (SRBAI); clinical and demographic characteristics. Ordinal logistic regressions determined factors associated with photoprotection.

RESULTS

One third did not achieve optimal face photoprotection. After controlling for demographic and clinical factors, modifiable correlates of higher photoprotection included greater perceived control of XP, stronger beliefs in necessity and effectiveness of photoprotection, and higher intention. Avoidance of going outside was associated with greater photoprotection concerns, more serious illness consequences, and higher XP-related distress. Greater automaticity and higher self-efficacy were associated with better protection across all outcomes.

CONCLUSIONS

Approximately half of all known cases across three European countries participated. Identified modifiable predictors of photoprotection may be targeted by interventions to reduce the incidence of skin cancers in the immediate future, when a treatment breakthrough is unlikely. Statement of contribution What is already known on this subject? Adherence to photoprotection in other populations at elevated risk from skin cancer is poor; however, the level in XP is unknown. Research across chronic conditions shows that adherence to treatment and lifestyle recommendations are influenced by illness perceptions, self-efficacy, and treatment beliefs. Studies on photoprotection conducted with the general population have found that perceived risk, perceptions of ultraviolet radiation (UVR) protection, self-efficacy for the behaviour, and automaticity (behaviours that are enacted with little conscious awareness) are related to better photoprotection. What does this study add? This is the first international survey to examine adherence and its correlates in people with XP (an under-researched group at very high risk of fatal skin cancer). Adherence varies and at least one third have potential for improvement. Perceptions about XP, photoprotection beliefs, self-efficacy, intention, and automaticity were associated with photoprotection of the face and body when outdoors. Negative emotional representations of XP were associated with avoidance of going outside during daylight hours.

Awareness, understanding, use, and impact of the UV index: A systematic review of over two decades of international research

The ultraviolet radiation index (UVI) was adopted internationally to raise awareness about and encourage the public to protect their skin from skin cancer. The current paper is a systematic review of over 20 years of research investigating awareness, comprehension, use, and impact of the UVI. Thirty-one studies were included from the USA, Canada, Europe, Australia, New Zealand, and elsewhere. Awareness of the UVI varies by country, with samples from some countries demonstrating high awareness. However, comprehension and use of the UVI to inform sun safety behaviors are typically much lower. In fact, greater UVI awareness has sometimes been associated with riskier UV-related behaviors such as intentional tanning. Fewer studies have evaluated interventions, and their results have been mixed. In summary, more research is needed to determine how to help the public understand and use the UVI for effective skin protection. This review offers suggestions for future use of and research with the UVI.

Influence of Air Temperature on the UV Exposure of Different Body Sites Due to Clothing of Young Women During Daily Errands

Clothing is one of the main influencing factors for personal ultraviolet radiation (UVR) exposure. Despite that, little attention was put on this topic till now. In this study, the clothing habits of young females have been investigated in dependence of meteorological conditions. Observations were made from spring to autumn during daylight in the urban region of Vienna, Austria. For this, a scheme dividing the body into six different sections was developed as well as a coding scale that corresponds to the different garments and indicates the body sites that are exposed. It was found that air temperature is the dominating factor for exposure. With increasing temperature, the first area of the body to be exposed to solar UVR is, aside from face and hands, the décolleté, followed by nape, ankles, instep and forearms. Observations further indicate that the frequency of people's being outdoors decreases significantly at temperatures higher than 30°C. This paper provides detailed frequency distributions of uncovered body sites in dependence of temperature. These can be used together with measurements of temperature and UVR to calculate the relative exposure at any time and at many locations, and could help to explain the body distribution of UVR caused skin alterations.

Reliability and consistency of a validated sun exposure questionnaire in a population-based Danish sample

An important feature of questionnaire validation is reliability. To be able to measure a given concept by questionnaire validly, the reliability needs to be high.

The objectives of this study were to examine reliability of attitude and knowledge and behavioral consistency of sunburn in a developed questionnaire for monitoring and evaluating population sun-related behavior.

Sun related behavior, attitude and knowledge was measured weekly by a questionnaire in the summer of 2013 among 664 Danes. Reliability was tested in a test-retest design. Consistency of behavioral information was tested similarly in a questionnaire adapted to measure behavior throughout the summer.

The response rates for questionnaire 1, 2 and 3 were high and the drop out was not dependent on demographic characteristic. There was at least 73% agreement between sunburns in the measurement week and the entire summer, and a possible sunburn underestimation in questionnaires summarizing the entire summer. The participants underestimated their outdoor exposure in the evaluation covering the entire summer as compared to the measurement week. The reliability of scales measuring attitude and knowledge was high for majority of scales, while consistency in protection behavior was low.

To our knowledge, this is the first study to report reliability for a completely validated questionnaire on sun-related behavior in a national random population based sample. Further, we show that attitude and knowledge questions confirmed their validity with good reliability, while consistency of protection behavior in general and in a week's measurement was low.

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Objectively validated questionnaires tested for reliability/behavioral consistency.

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Strong reliability of the knowledge and attitude items was shown.

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Knowledge about behavioral consistency between questionnaire measurement periods

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A recommendable design for short term evaluation of skin cancer prevention campaigns

Assessment of temperature and ultraviolet radiation effects on sunburn incidence at an inland U.S. Beach: A cohort study

BACKGROUND

Increases in outdoor temperature may lead to increases in sunburn, outdoor exposure, and skin cancer in human populations.

OBJECTIVE

This study aimed to quantify sunburn incidence and risk for Ohio beachgoers exposed to varying outdoor conditions.

METHODS

Sunburn incidence data were obtained through a prospective cohort study at East Fork Lake (Cincinnati, Ohio, USA). Recruitment occurred over 26 weekend days. Beach interviews and follow-up telephone interviews obtained exposure and health information. New sunburns were self-reported 8-9 days post-enrollment. Survey data were paired with ultraviolet radiation (UVR) index and temperature data for statistical analysis.

RESULTS

Among 947 beachgoers, new sunburns were reported in 18% of swimmers. Sunburn incidence was associated with temperature (odds ratio = 1.2; 95% CI: 1.1 - 1.4) and UVR index (odds ratio = 1.6; 95% CI: 1.0 - 2.5) in models adjusted for water exposure, arrival time, and beach visit frequency. Some evidence of a temperature+UVR interaction was observed.

LIMITATIONS

Exposure and sunburn data were self-reported without clinical diagnosis and date of onset. The follow-up period enabled sunburns to be reported from a variety of days rather than only the beach visit day thereby limiting interpretation. Sun protection behaviors were not evaluated.

CONCLUSIONS

Temperature and UVR influence sunburn frequency. Temperature, however was more strongly associated with sunburn in beachgoers than the nearest measured UVR index, suggesting future investigations are needed to better understand how temperature effects sunburn development. Interventions for decreasing sunburn are needed.

A Randomized Trial of an Advanced Sun Safety Intervention for Vacationers at 41 North American Resorts

Taking vacations in sunny locations is associated with the development of skin cancer. This study tested a multi-component sun protection intervention based on diffusion of innovations theory and transportation theory designed to increase vacationers' comprehensive sun protection, i.e., use of clothing, hats, and shade, and use, pre-application, and reapplication of sunscreen. The trial enrolled 41 warm weather resorts in North America in a pair-matched group randomized pretest-posttest design and assessed samples of adult vacationers at resort outdoor recreation venues regarding sun protection at pretest (n = 3,531) and posttest (n = 3,226). While results showed no overall effect of the intervention on comprehensive sun protection across venues, the intervention produced statistically significant improvements in sun protection at waterside venues (pools and beaches). The intervention's overall effects may have been impeded by a lack of uniformly robust implementation, low interest in skin cancer prevention by guests, or shortcomings of the theories used to create prevention messages. The intervention may have worked best with guests in the highest-risk recreation venue, i.e., waterside recreation where they exposed the most skin. Alternative approaches that alter resort organizations, such as through changes in policy, environmental features, or occupational efforts might be more effective than targeting vacationers with behavior-change messages.

Study protocol for a natural experiment in a lower socioeconomic area to examine the health-related effects of refurbishment to parks including built-shade (ShadePlus)

INTRODUCTION

Parks in disadvantaged suburbs often have low quality and few amenities, which is likely to result in them being underutilised for recreation and physical activity. Refurbishment of parks, including shade, walking paths and other amenities, may have broad health-related benefits.

METHODS AND ANALYSIS

The study design, methods and planned analyses for a natural experiment examining the effects of refurbishments including built-shade added to parks in disadvantaged outer suburbs of Melbourne are described. Three intervention parks and three comparison parks matched for equivalence of park and neighbourhood characteristics were selected. Using mixed methods, the outcomes will be assessed during three consecutive spring-summer periods (T1: 2013-2014; T2: 2014-2015: T3: 2015-2016). Primary outcomes included: observed park use, physical activity and shade use. Self-reported social connectedness, community engagement and psychological well-being were assessed as secondary outcomes.

ETHICS AND DISSEMINATION

This study was approved by Cancer Council Victoria's Human Research Ethics Committee. Studies such as ShadePlus can improve understanding of the broader effects of park refurbishments (including physical activity levels and sun protection behaviours, as well as social connectedness and psychological well-being). The study findings will be disseminated through established urban planning and parks and recreation networks, peer review publications and conference presentations.

Rationale, design, and baseline data of a cross-national randomized trial on the effect of built shade in public parks for sun protection

Environments can be structured to reduce solar ultraviolet radiation (UV) exposure to prevent skin cancer. A prospective randomized trial is being conducted to test whether introducing shade sails in passive recreation areas (PRAs) in public parks will increase use and decrease UV exposure in the shaded compared to unshaded PRAs. Shade effects will be compared between Melbourne, Australia and Denver, USA. The trial enrolled 145 public parks with PRAs suitable for shade construction and randomized parks to intervention or control in a 1:3 ratio. Use of PRAs and UV levels were recorded at each park by trained observers during 30-minute periods on four weekend days in each of two summers (pretest and posttest). Shade sails were constructed between the summers. Given low numbers of users at pretest, the outcome measure was modified to use of the PRA (use vs. no use) and unit of analysis to the individual observation. Observations (n=580) occurred on average 29days from the summer solstice and 55min from solar noon in warm weather (mean=26.2°C) with some cloud cover but only slight or no wind. Typically, PRAs had benches and picnic tables and were located near playgrounds. PRAs were in use during 13.3% of observations (mean=0.41 users). UV over 30-minutes at the PRA boundary (mean=3.2 standard erythemal dose [SED]) and center (mean=3.3 SED) was high. Shade for skin cancer prevention has been understudied. This study will address this gap by determining whether purpose-built shade structures promote greater use of shaded areas within public parks.