Successful behavioral interventions to prevent cancer: the example of skin cancer

On a Beam of Light: Photoprotective Activities of the Marine Carotenoids Astaxanthin and Fucoxanthin in Suppression of Inflammation and Cancer

Every day, we come into contact with ultraviolet radiation (UVR). If under medical supervision, small amounts of UVR could be beneficial, the detrimental and hazardous effects of UVR exposure dictate an unbalance towards the risks on the risk-benefit ratio. Acute and chronic effects of ultraviolet-A and ultraviolet-B involve mainly the skin, the immune system, and the eyes. Photodamage is an umbrella term that includes general phototoxicity, photoaging, and cancer caused by UVR. All these phenomena are mediated by direct or indirect oxidative stress and inflammation and are strictly connected one to the other. Astaxanthin (ASX) and fucoxanthin (FX) are peculiar marine carotenoids characterized by outstanding antioxidant properties. In particular, ASX showed exceptional efficacy in counteracting all categories of photodamages, in vitro and in vivo, thanks to both antioxidant potential and activation of alternative pathways. Less evidence has been produced about FX, but it still represents an interesting promise to prevent the detrimental effect of UVR. Altogether, these results highlight the importance of digging into the marine ecosystem to look for new compounds that could be beneficial for human health and confirm that the marine environment is as much as full of active compounds as the terrestrial one, it just needs to be more explored.

"We Don't Really Do Anything Unless it's Really Bad": Understanding Adolescent Sun Protective Knowledge, Attitudes and Behaviors in the U.S

Risk factors for melanoma, the deadliest form of skin cancer, include lifetime sun exposure and a history of sunburns. However, a minority of adolescents report consistent engagement in sun protective behaviors. The few sun protection interventions that have targeted adolescents have had little effect on behavior change, which suggests that a better understanding of the issue, especially from the adolescents' perspective, is needed. Although efforts to qualitatively examine adolescent sun protection have been carried out in a handful of countries, no studies to date have focused on U.S. adolescents. We conducted focus groups with 44 6th-8th grade students in Colorado to explore their sun protection knowledge, attitudes and behaviors. Results supported previous findings that adolescents do not engage in regular skin protection but have experienced the negative consequences of sun exposure (e.g., severe sun burns, and blistering). In addition, participants demonstrated limited and sometimes inaccurate knowledge about the long-term risks of sun exposure, as well as effective methods of sun protection. Barriers to engaging in sun protective behaviors included a desire to tan, inconvenience, and physical discomfort. Facilitators included peer and family encouragement, previous experience with sunburns and/or skin cancer, and knowledge of potential consequences. These findings provide valuable insights that can inform future intervention and research related to sun protection among U.S. adolescents.

Knowledge and practices of primary care providers on skin cancer and skin self-examination

OBJECTIVE

To determine the knowledge and practices related to skin cancer and skin self-examination of primary care providers.

METHOD

This cross-sectional descriptive study was conducted in Turkey. The study was carried out in primary health centers such as family health centers, community health centers, early cancer detection centers and family planning centers in 2016-2017. Participants' socio-demographic characteristics, their knowledge and practices related to skin cancer, skin cancer risk factors and skin self-examination were determined.

RESULTS

The study population included 94 primary care providers. The symptoms of which the participants were most aware were changes in the color of moles or skin spots (95.71%), and of which participants were the least aware was the itching of a mole (71.43%). Among participants, the most recognized risk factor was having fair skin (97.14%), whereas the least known was the presence of birthmarks (24.29%). The mean scores the participants obtained from the questionnaire were as follows: 5.39±1.61 for skin cancer risk factors and 10.47±2.73 for skin cancer symptoms. Of the participants, 14.29% received training on skin self-examination, 38.57% knew how to perform skin self-examination, and 67.14% did not perform skin self-examination. Of the participants, 61.7% did not perform skin self-examination because they did not know what to look for. Of the participants, 85.71% did not have continuing education/workshop about skin self-examination after graduation.

CONCLUSION

Although the primary care providers' knowledge of skin cancer symptoms was adequate, their knowledge of skin cancer risk factors was not sufficient. Primary care providers' knowledge of skin self-examination was good, but they did not perform skin self-examination adequately.

Daily Minutes of Unprotected Sun Exposure (MUSE) Inventory: Measure description and comparisons to UVR sensor and sun protection survey data

One in five US adults will be diagnosed with skin cancer. As most skin cancers are attributable to sun exposure, this risk factor is an important target for research and intervention. Most sun exposure measures assess frequency of specific sun-protection behaviors, which does not account for the use of multiple, potentially overlapping sun-protection methods. In contrast, the Daily Minutes of Unprotected Sun Exposure (MUSE) Inventory assesses sun-protection behavior during self-reported activities, providing several useful metrics, including duration of unprotected sun exposure on 17 body sites, combined to yield an overall MUSE score weighted by percent of body exposed. The present study was conducted July–September 2017, in Chicago, IL USA. For 10 days, participants (39 melanoma survivors; M_age = 58.59, 64.5% female) wore an ultraviolet radiation (UVR) sensor and completed the Daily MUSE Inventory each evening. The Sun Habits Survey was completed at the end of the study. Outdoor time reported in the MUSE Inventory significantly predicted outdoor time recorded by UVR sensors, B = 0.53, p < .001. For all sun-protection behaviors except shade, reports from the Daily MUSE Inventory (i.e., percentage of outdoor time a particular strategy was used) correlated with frequency ratings of the same strategy from the Sun Habits Survey (rs = 0.66–0.75, p < .05). In sum, the Daily MUSE Inventory corresponds with sensor and survey data, and provides a novel metric of unprotected sun exposure that will be useful for evaluating overall extent of sun exposure, including exposure on several smaller body sites that are at high risk for skin cancer.

Facilitating Sunscreen Use Among Chinese Young Adults: Less-Motivated Persons Benefit from a Planning Intervention

BACKGROUND

The effect of a self-regulatory intervention with its focus on planning sunscreen use is evaluated in comparison to a standard educational condition.

PURPOSE

This paper studied whether planning mediates between the experimental conditions and the behavioral outcome. Further, it is examined who benefits more: already motivated or unmotivated individuals.

METHOD

College students (N = 253) were randomly assigned to two groups: a self-regulatory and a standard-care condition. Sunscreen use, intention to use sunscreen, and planning were assessed at two points in time, 1 month apart.

RESULTS

The self-regulatory intervention improved planning to use sunscreen but not the behavior directly. Planning emerged as the mediator between conditions and later sunscreen use, controlling for baseline behavior. Moreover, participants who were less motivated benefited more from the intervention.

CONCLUSIONS

Although it is generally assumed that planning interventions are best designed for already motivated persons, the present findings suggest that less prepared individuals might have more to gain from a brief self-regulatory intervention.

Effects of a short messaging service-based skin cancer prevention campaign in adolescents

BACKGROUND

Skin cancer prevention emphasizes early adoption and practice of sun protection behaviors. Adolescence represents a high-risk period for ultraviolet radiation exposure, presenting an opportunity for intervention. The ubiquity of mobile phones among teens offers an engaging medium through which to communicate prevention messages.

PURPOSE

To evaluate a skin cancer prevention intervention using short messaging service (SMS, or text messages) to impact sun-related knowledge, beliefs, and behaviors among adolescents.

METHODS

The intervention was conducted in middle school youth (N=113) recruited in April or October 2012. Participants were English speakers, 11-14 years old, routinely carried a mobile phone, and completed a 55-minute sun safety education program. Participants were sent three sun safety-themed SMS messages each week for 12 weeks. Skin and sun protective knowledge, beliefs, behaviors, and post-intervention program satisfaction were collected and analyzed at baseline and end of intervention (April/June 2012; October 2012/January 2013). Paired responses were tested for equality using Wilcoxon signed-rank tests.

RESULTS

Ninety-six students (85%) completed the study. At 12 weeks, significant positive changes were reported for sun avoidance during peak ultraviolet radiation, sunscreen application, wearing hats and sunglasses, and knowledge about skin cancer risk. Participants expressed moderately high satisfaction with the program, and 15% shared messages with family or friends.

CONCLUSIONS

A brief, SMS-based intervention affected youth skin cancer prevention behaviors and knowledge. Future research will determine whether program effects were sustained at 24 weeks and explore how sun safety parenting practices inform these effects.

Be smart against cancer! A school-based program covering cancer-related risk behavior

Background

Several studies suggest that most school-age children are poorly informed about cancer risk factors. This study examines the effectiveness of the ‘Be smart against cancer’ (BSAC) program in promoting cancer awareness and intentions to engage in health-promoting behavior.

Methods

235 seventh-grade students were randomized to either the intervention (N = 152) or the wait-control group (N = 83). The intervention included the modules: “What is cancer?,” “Sun protection,” “Non smoking,” and “Physical activity, Healthy nutrition, and Limited alcohol consumption.” Outcomes measured at baseline and at the end of the one week BSAC program included knowledge of cancer and its behavioral risk factors, health-promoting intentions, and reported risk behavior.

Results

BSAC was effective in increasing knowledge about cancer and risk factors for cancer (p < .001), as well as in increasing intentions to engage in health-promoting behavior (p < .001), independent of a student’s risk profile. Knowledge did not serve as a mediator for intention building.

Conclusions

The BSAC is an effective school-based program for raising awareness of cancer, associated risk factors and intentions to engage in cancer-preventive behavior. The results indicate that the effectiveness of BSAC is independent of a student’s risk profile. Therefore, it holds considerable promise as a broadly applicable program to raise cancer awareness and promote healthy behavior intentions.

Study protocol: a randomised controlled trial of a theory-based online intervention to improve sun safety among Australian adults

BACKGROUND

The effects of exposure to ultraviolet radiation are a significant concern in Australia which has one of the highest incidences of skin cancer in the world. Despite most skin cancers being preventable by encouraging consistent adoption of sun-protective behaviours, incidence rates are not decreasing. There is a dearth of research examining the factors involved in engaging in sun-protective behaviours. Further, online multi-behavioural theory-based interventions have yet to be explored fully as a medium for improving sun-protective behaviour in adults. This paper presents the study protocol of a randomised controlled trial of an online intervention based on the Theory of Planned Behaviour (TPB) that aims to improve sun safety among Australian adults.

METHODS/DESIGN

Approximately 420 adults aged 18 and over and predominantly from Queensland, Australia, will be recruited and randomised to the intervention (n = 200), information only (n = 200) or the control group (n = 20). The intervention focuses on encouraging supportive attitudes and beliefs toward sun-protective behaviour, fostering perceptions of normative support for sun protection, and increasing perceptions of control/self-efficacy over sun protection. The intervention will be delivered online over a single session. Data will be collected immediately prior to the intervention (Time 1), immediately following the intervention (Time 1b), and one week (Time 2) and one month (Time 3) post-intervention. Primary outcomes are intentions to sun protect and sun-protective behaviour. Secondary outcomes are the participants' attitudes toward sun protection, perceptions of normative support for sun protection (i.e. subjective norms, group norms, personal norms and image norms) and perceptions of control/self-efficacy toward sun protection.

DISCUSSION

The study will contribute to an understanding of the effectiveness of a TPB-based online intervention to improve Australian adults' sun-protective behaviour.

TRIALS REGISTRY

Australian and New Zealand Trials Registry number ACTRN12613000470796.

The role of emotions in UV protection intentions and behaviors

Two studies examined the role of emotions, relative to cognitions, in predicting sun protection intentions and practices. In Study 1, 106 females were assessed for baseline sun protection, ultraviolet (UV) radiation exposure-related cognitions (perceived susceptibility to skin damage, self-efficacy for regular sunscreen use, perceived costs of sun protection use, perceived rewards of tanning), anticipated negative mood following future risky UV behavior, and future sun protection intentions. Self-reported sun protection behavior was then assessed in the same participants five weeks later. The results of Study 1 demonstrated that the extent to which participants' expected to experience negative feelings if they engaged in future risky UV behavior predicted their intentions to sun protect and their subsequent sun protection behaviors independent of their UV radiation exposure-related cognitions. In Study 2, in addition to the assessments collected in Study 1, participants were exposed to an appearance-based intervention that included visual images of their existing skin damage and were then assessed for their emotional reactions to the intervention. The results replicated those of Study 1 and, in addition, showed that negative emotional reactions to the intervention predicted future sun protection intentions and self-reported behaviors at follow-up, independent of the various cognitive factors that are central to prominent models of health behavior. These studies provide preliminary support for the development of expanded health behavior models that incorporate anticipated and experienced emotions.

Approach/avoidance motivation, message framing and skin cancer prevention: a test of the congruency hypothesis

The congruency hypothesis posits that approach-orientated individuals are persuaded to engage in prevention behaviours by positively framed messages; conversely, negatively framed messages are more persuasive in encouraging those who are avoidance-orientated. A 2 (frame: loss vs gain) × 2 (motivation: avoidance vs approach) design examined the effects of skin cancer information on sun-protective intentions and free sunscreen sample requests among 533 young adults. Gain-framed messages had the strongest effect on sun-protective intentions for approach-oriented individuals, whereas loss-framed messages had the strongest effect on avoidance-oriented individuals. Message framing effects on precautionary sun behaviour intentions were moderated by motivational differences.

Effective inhibition of skin cancer, tyrosinase, and antioxidative properties by astaxanthin and astaxanthin esters from the green alga Haematococcus pluvialis

Astaxanthin mono- (AXME) and diesters (AXDE) were characterized and examined for anticancer potency with total carotenoids (TC) and astaxanthin (AX) against UV-7,12-dimethylbenz(a)anthracene (DMBA)-induced skin cancer model in rat. At 200 μg/kg bw, AXDE and AXME reduced UV-DMBA-induced tumor incidences up to 96 and 88%, respectively, when compared to AX (66%) and TC (85%). UV-DMBA has been known to generate high levels of free radicals and tyrosinase enzyme, leading to characteristic symptoms of skin pigmentation and tumor initiation. Intriguingly, ~7-fold increase in tyrosinase and 10-fold decrease in antioxidant levels were normalized by AXDE and AXME as opposed to only ~1.4-2.2-fold by AX and TC, respectively. This result together with the appearance of 72 and 58 ng/mL of retinol in the serum of respective AXE-treated (AXDE + AXME) and AX-treated animals suggested that better anticancer potency of AXEs could be due to increased bioavailability.

Indoor Tanning within UK Young Adults: An Extended Theory of Planned Behaviour Approach

The indoor tanning industry poses a long-term public health risk. Despite the adverse health effects, indoor tanning seems to be gaining considerable popularity. The study examined indoor tanning intentions and behaviour within UK young adults using an extended theory of planned behaviour model, which included variables on “appearance reasons to tan,” “perceived susceptibility to damaging appearance,” “perceived susceptibility to health consequences,” and “tanning knowledge.” The model was successful in predicting indoor tanning intentions and behaviour (explained 17% and 71%, resp.). An interesting outcome was the magnitude of the variable “appearance reasons to tan.” A current tanned appearance therefore seemed to outweigh any adverse future appearance or health consequences caused by indoor tanning. Appearance-focused interventions to reduce such behaviour may now prove to be efficacious within a UK sample.

Enhancing planning strategies for sunscreen use at different stages of change

To promote sun safety by implementing different plans for sunscreen use, different psychological interventions are compared. Self-regulatory strategies such as action planning and coping planning are seen as proximal predictors of actual behavior. The study compares a pure planning intervention with a broader resource communication and examines differential effects at different stages of change. A sun safety online study was designed with two intervention groups (resource communication versus planning) and one control group at two assessment points, 2 weeks apart. Participants (N = 292) were grouped post hoc according to their stage of change, resulting in 51 pre-intenders (no intention to use sunscreen), 102 intenders (high intention but no regular use of sunscreen) and 139 actors (sunscreen use on a regular basis). No overall treatment effects on planning, but an interaction between time, stage and intervention emerged. The resource communication was more effective for pre-intenders, whereas the planning intervention proved more effective for intenders. A planning treatment was more beneficial in motivated individuals, whereas a broader approach was better for unmotivated ones. Findings highlight the potential that stage-matched interventions might have in the context of sun safety promotion.

Evaluating a skin cancer education program for the Deaf community

Skin cancer is the most common, preventable, and treatable cancer, so public education has been a priority. Unfortunately, for the Deaf community, most skin cancer information is difficult to access, so tailored approaches are needed. Participants (N=136) were randomly assigned to view either a skin cancer education video in American Sign Language (n=75) or an alternate video (n=61). All participants completed skin cancer knowledge questionnaires at baseline, immediately post-intervention, and 2-month post-intervention. Control group participants could then transfer to the experimental condition, using their 2-month follow-up data as their baseline. Participants who saw the skin cancer video gained significantly more knowledge than control participants, demonstrating the video's effectiveness in increasing skin cancer control knowledge. There was no difference between the original experimental group and the delayed intervention group on knowledge gains.

Facilitating sunscreen use in women by a theory-based online intervention: a randomized controlled trial

This study compares a motivational skin cancer prevention approach with a volitional planning and self-efficacy intervention to enhance regular sunscreen use. A randomized controlled trial (RCT) was conducted with 205 women (mean age 25 years) in three groups: motivational; volitional; and control. Sunscreen use, action planning, coping planning and coping self-efficacy were assessed at three points in time. The volitional intervention improved sunscreen use. Coping planning emerged as the only mediator between the intervention and sunscreen use at Time 3. Findings point to the role played by coping planning as an ingredient of sun protection interventions.

Appearance matters: the frame and focus of health messages influences beliefs about skin cancer

OBJECTIVES

This study sought to ascertain whether the health message 'framing effect', which has been observed for several diseases, occurs for messages concerning the consequences of skin cancer for one's appearance or one's health. Specifically, the effect of the frame and focus of health messages on intentions to perform skin protection behaviours and the perceived threat of skin cancer was investigated.

DESIGN

Consistent with previous research and to avoid carry-over effects, a two-factor, between-groups (message frame: gain vs. loss × message focus: appearance vs. health) design was used.

METHODS

Participants (N= 390) were recruited using convenience sampling and presented with one of four health messages, which were embedded in a questionnaire concerning beliefs about skin cancer (intentions to perform different skin protection behaviours, the perceived threat of skin cancer) and body consciousness. The health messages were framed in terms of loss (risks of sun exposure) or gain (benefits of skin protection) and focused on the consequences of sun exposure for one's appearance or one's health. The primary outcome measures were responses on rating scales concerning the perceived threat of skin cancer, intentions to perform different skin cancer protection behaviours, and body consciousness.

RESULTS

Perceived threat of skin cancer was found to be greater for appearance-focused messages and intentions to perform different skin protection behaviours were greater for loss-framed messages. These findings held when individual differences in body consciousness were controlled for.

CONCLUSIONS

These findings suggest that, for the communication of information about skin cancer to be effective, messages must focus on the impact of sun exposure and inadequate skin protection for people's appearance, not just their health. Moreover, to maximize effectiveness, health messages about skin cancer should take account of dispositional differences in the importance placed upon one's appearance.

Effects of upward and downward social comparison information on the efficacy of an appearance-based sun protection intervention: a randomized, controlled experiment

This experiment examined the impact of adding upward and/or downward social comparison information on the efficacy of an appearance-based sun protection intervention (UV photos and photoaging information). Southern California college students (N = 126) were randomly assigned to one of four conditions: control, intervention, intervention plus upward social comparison, intervention plus downward social comparison. The results demonstrated that all those who received the basic UV photo/photoaging intervention reported greater perceived susceptibility to photoaging (d = .74), less favorable tanning cognitions (d = .44), and greater intentions to sun protect (d = 1.32) relative to controls. Of more interest, while the basic intervention increased sun protective behavior during the subsequent 5 weeks relative to controls (d = .44), the addition of downward comparison information completely negated this benefit. Upward comparison information produced sun protection levels that were only slightly (and nonsignificantly) greater than in the basic intervention condition and, as such, does not appear to be a cost-effective addition. Possible mechanisms that may have reduced the benefits of upward comparison information and contributed to the undermining effects of downward comparison information are discussed.

Body Consciousness Moderates the Effect of Message Framing on Intentions to Use Sunscreen

The objective of this study was to investigate the impact of messages differing in focus (health vs appearance) and frame (gain vs loss) on intentions for sunscreen use and sunbed use, and the potential moderating role of body consciousness. Questionnaire data from 390 young adults were analysed using factorial ANOVA. Results showed a significant interaction between message frame and body consciousness, such that gain-framed health or appearance messages had the strongest effect on sunscreen use intentions for those high in body consciousness, compared to those low in body consciousness. We conclude that message framing effects on precautionary sun behaviour intentions are moderated by body consciousness.

Prevention of skin cancer in primary healthcare: an evaluation of three different prevention effort levels and the applicability of a phototest

BACKGROUND/OBJECTIVE

The high skin cancer incidence in western society, and its known association with sun exposure habits, makes the area an important target for prevention. We investigated, in a primary healthcare setting, differentiated levels of prevention efforts directed at the propensity of the patient to change his/her sun habits, sun protection behaviour, and attitudes, after information intervention. Additionally, the impact of the performance of a phototest to determine individual sun sensitivity was evaluated.

METHODS

308 patients visiting a primary healthcare centre in southern Sweden completed a questionnaire concerning sun habits, sun protection behaviour, and attitudes, and were randomized into one of three groups, representing increasing levels of prevention effort in terms of resources. Feedback on their questionnaire and general preventive sun protection advice was given, in the first group by means of a letter, and in the second and third groups by a doctor's consultation. Group 3 also underwent a phototest, with a self-reading assessment and a written follow-up of the phototest result. Change of sun habits, behaviour, and attitudes, based on the Transtheoretical Model of Behaviour Change and on Likert scale scorings, was evaluated after 6 months, by a repeated questionnaire.

RESULTS

Prevention mediated by a doctor's consultation had a clearly better impact on the subjects. The addition of a phototest did not further reinforce this effect in the group as a whole, but it did for a subgroup of individuals with high ultraviolet (UV) sensitivity, as determined by the phototest itself, suggesting that this might actually be a tool to improve outcome in this high-risk group.

CONCLUSION

A personal doctor's consultation is a valuable tool in the effective delivery of preventive information in the general practice setting. In individuals with high UV-sensitivity and thus high risk for skin cancer the performance of a photo-test reinforces a positive outcome in habits, behaviour and attitudes.

Acculturation and sun-safe behaviors among US Latinos: findings from the 2005 Health Information National Trends Survey

OBJECTIVES

We examined the relationship between acculturation and sun safety among US Latinos.

METHODS

We used linear regression models to analyze data from 496 Latino respondents to the 2005 Health Information National Trends Survey. Using sunscreen, seeking shade, and wearing protective clothing were the primary outcomes and were assessed by frequency scales. Acculturation was assessed with a composite index.

RESULTS

In bivariate models, acculturation was negatively associated with use of shade and protective clothing and positively associated with sunscreen use (all, P < .004). In adjusted models, acculturation was negatively associated with seeking shade and wearing protective clothing across gender and region of residence (all, P < .05).

CONCLUSIONS

Our results demonstrated both adverse and beneficial effects of acculturation on Latinos' risk behaviors relating to skin cancer. Education about sun safety is needed for all Latinos and should be tailored to different levels of acculturation. Initiatives for Latinos who are not yet acculturated could focus on reinforcing existing sun-safe behaviors and presenting new ones, such as use of sunscreen; initiatives for highly acculturated Latinos might require more resources because the objective is behavior modification.

Social norms information enhances the efficacy of an appearance-based sun protection intervention

This experiment examined whether the efficacy of an appearance-based sun protection intervention could be enhanced by the addition of social norms information. Southern California college students (N=125, predominantly female) were randomly assigned to either an appearance-based sun protection intervention that consisted of a photograph depicting underlying sun damage to their skin (UV photo) and information about photoaging or to a control condition. Those assigned to the intervention were further randomized to receive information about what one should do to prevent photoaging (injunctive norms information), information about the number of their peers who currently use regular sun protection (descriptive norms information), both injunctive and descriptive norms information, or neither type of norms information. The results demonstrated that those who received the UV photo/photoaging information intervention expressed greater sun protection intentions and subsequently reported greater sun protection behaviors than did controls. Further, the addition of both injunctive and descriptive norms information increased self-reported sun protection behaviors during the subsequent month.

Psychosocial Mediators of a Nurse Intervention to Increase Skin Self-examination in Patients at High Risk for Melanoma

This prospective study examines psychosocial mediators of an efficacious skin self-examination (SSE) intervention that includes provision of a whole-body digital photography book depicting the entire skin surface. Individuals (n = 100) with established risk factors for melanoma were recruited from the Memorial Sloan-Kettering Cancer Center Pigmented Lesion Clinic during their initial dermatologist visit and were randomized to receive a photobook immediately (n = 49) or 4 months after intervention delivery (n = 51). Potential mediators included self-efficacy and response efficacy drawn from Social Cognitive Theory, melanoma worry, and SSE anxiety drawn from Self-Regulation Theory, and skin cancer knowledge, and skin awareness. Only self-efficacy was a significant mediator, accounting for 8% of the total effect of photobook enhancement on SSE adherence at 4 months.

Evaluation of a multicomponent appearance-based sun-protective intervention for young women: Uncovering the mechanisms of program efficacy

An appearance-based sun-protection intervention program was developed, implemented, and evaluated in a sample of 211 Caucasian women (ages 18-25) randomly assigned to the sun-protection program or to a stress management (control) program. The sun-protection program incorporated a novel construct of image norms of aspirational peers (i.e., female media figures, fashion models) approving paleness. The authors targeted these image norms as well as the advantages of tanning, health beliefs about photoaging and skin cancer, and self-efficacy for sun protection. The intervention produced significant differences across conditions favoring sun protection on all constructs but severity of skin cancer and barriers to sun protection. At follow-up, treatment participants exceeded controls both in intention to sun protect and sun-protective behavior and reported lower intention to sunbathe and fewer hours of sunbathing. A mediational model of intervention outcomes revealed distinct mediators for sun protection versus sunbathing.

Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review

The relationship between skin cancer and ultraviolet radiation is well established. Behaviors such as seeking shade, avoiding sun exposure during peak hours of radiation, wearing protective clothing, or some combination of these behaviors can provide protection. Sunscreen use alone is not considered an adequate protection against ultraviolet radiation. This report presents the results of systematic reviews of effectiveness, applicability, other harms or benefits, economic evaluations, and barriers to use of selected interventions to prevent skin cancer by reducing exposure to ultraviolet radiation. The Task Force on Community Preventive Services found that education and policy approaches to increasing sun-protective behaviors were effective when implemented in primary schools and in recreational or tourism settings, but found insufficient evidence to determine effectiveness when implemented in other settings, such as child care centers, secondary schools and colleges, and occupational settings. They also found insufficient evidence to determine the effectiveness of interventions oriented to healthcare settings and providers, media campaigns alone, interventions oriented to parents or caregivers of children, and community-wide multicomponent interventions. The report also provides suggestions for areas for future research.

Examination of the efficacy of an appearance-focused intervention to reduce UV exposure

This study designed and implemented an appearance-based skin cancer prevention intervention in college-aged females. One hundred and forty-seven respondents were randomly assigned to treatment or control groups. Treatment respondents received a short workbook describing the appearance damaging effects of indoor tanning. At short-term follow-up (2 weeks later) treatment respondents had significantly more negative attitudes toward indoor tanning, and reported fewer intentions to indoor tan. At 2-month follow-up, treatment respondents reported indoor tanning one-half as much as control respondents in the previous 2 months. This appearance-based intervention was able to produce clinically significant changes in indoor tanning use tendencies that could have a beneficial effect on the future development of skin cancer.

Skin cancer in organ transplant recipients: Epidemiology, pathogenesis, and management

In the United States more than 100,000 people are living with solid organ transplants. The intense immunosuppressive regimens necessary for prolonged survival of allografts significantly increase the rates of both internal and cutaneous malignancies in recipients of solid organ transplants. Skin cancer is the most common cancer in patients after transplantation. Because of the early onset and high tumor burden in transplant recipients, dermatologists have significant challenges in managing the treatment of these patients. This article describes the epidemiology and clinical presentation of skin cancer during posttransplantation immunosuppression, discusses pathogenic cofactors, and reviews the optimal management for mild and severe skin cancer in transplant recipients.

[Behavior and beliefs in amateur open water activities. Study of beliefs and attitudes with respect to health risks]

OBJECTIVE

The objective of this study was to explore beliefs, attitudes and suggestions concerning effective interventions to promote the use of sun protection, the use of personal flotation devices (PFDs) and the avoidance of contact with water unfit for swimming.

METHOD

Interviews were conducted with 36 users and 2 river park activity coordinators on a river in the Greater Montreal area.

RESULTS

The respondents recognized the existence of a certain number of negative beliefs and barriers associated with the adoption of safe behaviours, in particular the pointlessness and inconvenience of means of protection against the sun and the wearing of PFDs, the negligible effects of polluted water on health and the thrill of defying bans. To help change beliefs, attitudes and behaviours, the respondents suggested legislative, organizational and individual interventions.

INTERPRETATION

The data gathered during this study will help to determine intervention strategies and to set up programs promoting behavioural change among the target population.

[The habits and perceptions of participants in water and other outdoor activities in terms of risk behaviors]

OBJECTIVE

The objective of this study was to explore the habits and perceptions of participants in water and other outdoor activities in terms of health risk behaviours.

METHOD

A survey was undertaken of 1,200 users of a river in the Greater Montreal area.

RESULTS

Only about 30% of respondents used some form of protection against the sun during every outing. Fewer respondents who used some form of motorized water craft wore personal flotation devices (PFDs) compared with those who used non-motorized water craft (63% vs. 83%). Almost half of the respondents avoided all contact with water unfit for swimming, and this was the only instance of behaviour influenced by a perception of serious health risks. The data also indicate that men and respondents under 25 years of age are not inclined to practise the safe behaviours studied.

INTERPRETATION

These results suggest that effective interventions must be developed for the population in general and for certain sub-groups in particular in order to promote the adoption of safe behaviours during water and other outdoor activities.

Photoprotection

Protection from solar ultraviolet radiation is discussed. Methods of protection include avoiding outdoor activities during times of greatest ultraviolet radiation insolation, seeking shade while outdoors, and wearing appropriate clothing. Sunscreens are reviewed, including newer compounds that may also offer photoprotection.

Prospects for cancer prevention

As in many other countries, the New Zealand Cancer Society produces guidelines for cancer prevention. These recommend avoiding asbestos, smoking, sunlight, alcohol, fatty food and obesity. Women are advised to have a regular cervical smear test. Additional 'probably helpful' suggestions include eating plenty of fresh fruit and vegetables and dietary fibre. However, considerable data from animal studies and more slowly accumulating data from human intervention studies suggest additional and more specific advice may be appropriate. Fruit and vegetable servings should total a minimum of five each day. Some specific fruits and vegetables (e.g., tomato, broccoli, onions) may have particular benefits against individual cancer types. Positive human evidence on potential benefits of increasing dietary fibre comes from studies where wheat bran was added to the diet. This is not a dietary fibre per se, but merely a good fibre source. Indeed, our own studies suggest that it could be various phytochemicals in the bran, rather than dietary fibre, which is beneficial. An increase either in whole wheat or wheat bran, rather than fibre, would be a sounder recommendation. Although there is some evidence that multivitamin supplementation can protect against cancer, this may be only in the special situation where the population is already significantly vitamin-deficient. For example, a combination of beta-carotene, vitamin E and selenium significantly reduced cancer mortality in a Chinese population, whereas lung cancer risks (in already high risk groups) were increased in Finnish and American trials with high dose beta-carotene. Various other chemopreventive drugs are being actively developed and at various stages in clinical trials. The enhanced cancer incidence in the beta-carotene trial illustrates the potential benefit of utilising surrogate endpoints of malignant disease rather than incident cancer as a trial endpoint.

Health psychology: mapping biobehavioral contributions to health and illness

Our evolving understanding of how psychosocial and behavioral factors affect health and disease processes has been marked by investigation of specific relationships and mechanisms underlying them. Stress and other emotional responses are components of complex interactions of genetic, physiological, behavioral, and environmental factors that affect the body's ability to remain or become healthy or to resist or overcome disease. Regulated by nervous, endocrine, and immune systems, and exerting powerful influence on other bodily systems and key health-relevant behaviors, stress and emotion appear to have important implications for the initiation or progression of cancer, HIV, cardiovascular disease, and other illnesses. Health-enhancing and health-impairing behaviors, including diet, exercise, tobacco use, and protection from the sun, can compromise or benefit health and are directed by a number of influences as well. Finally, health behaviors related to being ill or trying to avoid disease or its severest consequences are important. Seeking care and adhering to medical regimens and recommendations for disease surveillance allow for earlier identification of health threats and more effective treatment. Evidence that biobehavioral factors are linked to health in integrated, complex ways continues to mount, and knowledge of these influences has implications for medical outcomes and health care practice.