Moderators of the Effects of mySmartSkin, a Web-Based Intervention to Promote Skin Self-examination and Sun Protection Among Individuals Diagnosed With Melanoma

BACKGROUND

Identifying the characteristics of persons who benefit more from behavioral interventions can help health care providers decide which individuals should be offered particular interventions because this is the subgroup of persons who are more likely to derive greater benefit from the intervention and refine the underlying constructs of the model guiding the intervention.

PURPOSE

This study evaluated possible demographic, medical, knowledge and attitudinal, and psychosocial variables that may moderate the impact of an online intervention, called mySmartSkin (MSS), on engagement in skin self-examination (SSE) and sun protection behaviors among melanoma survivors.

METHODS

Participants completed a baseline survey and were then randomized to the MSS condition or usual care. Follow-up surveys were completed by participants at 8-, 24-, and 48-week postrandomization.

RESULTS

A greater impact of MSS on SSE was illustrated among participants with more phenotypic skin cancer risk factors and participants reporting lower baseline self-efficacy in conducting SSE. A more favorable response of MSS on sun protection behaviors was shown when initial knowledge about abnormal lesions and sun protection barriers were high. Greater use of MSS and more favorable evaluations of it were also associated with higher intervention response.

CONCLUSIONS

Future studies seeking to improve SSE and sun protection among melanoma survivors might benefit from focusing on survivors who report more skin cancer risk factors, lower self-efficacy in conducting SSE, less knowledge about what abnormal skin lesions look like, more perceived barriers to sun protection behaviors, and less worry about recurrence and cancer-related distress.

Cost, reach, and representativeness of recruitment efforts for an online skin cancer risk reduction intervention trial for young adults

Despite its increasing use, few studies have reported on demographic representativeness and costs of research recruitment via social media. It was hypothesized that cost, reach, enrollment, and demographic representativeness would differ by social media recruitment approach. Participants were 18-25 year-olds at moderate to high risk of skin cancer based on phenotypic and behavioral characteristics. Paid Instagram, Facebook, and Twitter ads, unpaid social media posts by study staff, and unpaid referrals were used to recruit participants. Demographic and other characteristics of the sample were compared with the 2015 National Health Interview Survey (NHIS) sample. Analyses demonstrated significant differences among recruitment approaches regarding cost efficiency, study participation, and representativeness. Costs were compared across 4,274 individuals who completed eligibility screeners over a 7-month period from: Instagram, 44.6% (of the sample) = 1,907, $9 (per individual screened); Facebook, 31.5% = 1,345, $8; Twitter, 1% = 42, $178; unpaid posts by study staff, 10.6% and referred, 6.5%, $1. The lowest rates of study enrollment among individuals screened was for Twitter. Most demographic and skin cancer risk factors of study participants differed from those of the 2015 NHIS sample and across social media recruitment approaches. Considering recruitment costs and number of participants enrolled, Facebook and Instagram appeared to be the most useful approaches for recruiting 18-25 year-olds. Findings suggest that project budget, target population and representativeness, and participation goals should inform selection and/or combination of existing and emerging online recruitment approaches.

mySmartCheck, a Digital Intervention to Promote Skin Self-examination Among Individuals Diagnosed With or at Risk for Melanoma: A Randomized Clinical Trial

BACKGROUND

Regular skin self-examination (SSE) reduces melanoma mortality but is not often conducted.

PURPOSE

To promote SSE performance in individuals at increased risk for melanoma.

METHODS

One hundred sixteen individuals at heightened risk for development of melanoma (i.e., personal/family history of melanoma, high-risk mole phenotype) who did not conduct a thorough SSE during in the prior 3 months were randomly assigned to receive either an automated internet-based intervention (mySmartCheck) or usual care (UC). One hundred sixteen participants completed surveys before random assignment and 99 completed the follow-up survey 13-weeks afterward. The primary outcome was participant self-reported examination (SSE) of all 15 parts of the body in the last 3 months. Secondary outcomes were SSE of any part of the body in the last 3 months and number of body parts examined during the last SSE.

RESULTS

More mySmartCheck participants examined all 15 body parts (32.6% vs. 7.1%, p = .001). More individuals in mySmartCheck reported conducting SSE on any body part than those in UC (81.4% vs. 62.5%, p = .04). Effect sizes were large (d = 1.19 all 15 body parts) to moderate (d = 0.55 for any body part). mySmartCheck participants examined more body areas than UC participants (12.7 vs. 10.3, p = 0.003) during the last SSE. Participants in mySmartCheck reported higher levels of knowledge of suspicious lesions, SSE benefits, SSE self-efficacy, and planning for SSE, and lower SSE barriers, than those assigned to UC.

CONCLUSIONS

mySmartCheck had a significant positive impact on SSE performance and behaviors. Additional research with a larger sample size, a longer follow-up, and more varied clinical settings is needed.

TRIAL REGISTRATION

ClinicalTrials.gov registration # NCT03725449 (https://clinicaltrials.gov/ct2/show/NCT03725449).

Randomized controlled trial of the mySmartSkin web-based intervention to promote skin self-examination and sun protection among individuals diagnosed with melanoma

Adherence to regular, thorough skin self-examination (SSE) and consistent sun protection behaviors among melanoma survivors is relatively low. This study reports on the impact of an online intervention, called mySmartSkin (MSS), on engagement in SSE and sun protection behaviors among melanoma survivors, as well as the mediators of the intervention effects. The intervention was compared with usual care (UC), and primary outcomes were assessed at 24 and 48 weeks. Short-term outcomes were also evaluated at 8 weeks postbaseline. Results demonstrate a significant effect on SSE and sun protection. At all three follow-up assessments, the proportion of participants reporting conducting a thorough SSE in the time since the previous assessment was significantly greater in MSS than in UC. In addition, both multivariate and univariate analyses indicated that engagement in sun protection behaviors was significantly higher in MSS than UC at 24 weeks, but the effect on sun protection at 48 weeks was significant only in multivariate analyses. Beneficial effects of MSS were significantly mediated by knowledge about melanoma and characteristics of suspicious lesions, as well as self-efficacy. Participant engagement in MSS was satisfactory, with approximately two-thirds of participants completing at least two of the three core components. Content was rated as highly trusted, easy to understand, easy to navigate, and helpful. In conclusion, MSS illustrated significant and durable effects on SSE and mixed results on sun protection. Future studies should consider ways to further enhance treatment effects and engagement in MSS.

Feasibility of Medical Student Mentors to Improve Transition in Sickle Cell Disease

OBJECTIVE

Advances in medical care have resulted in nearly 95% of all children with sickle cell disease (SCD) living to adulthood. There is a lack of effective transition programming, contributing to high rates of mortality and morbidity among adolescents and young adults (AYAs) during the transition from pediatric to adult healthcare. This nonrandomized study evaluated the feasibility, acceptability, and preliminary outcomes of a novel medical student mentor intervention to improve transition outcomes for AYA with SCD.

METHODS

Eligible participants were ages 18-25 years, either preparing for transition or had transferred to adult care within the past year. Twenty-four AYA with SCD (Mage = 20.3, SD = 2.6) enrolled in the program and were matched with a medical student mentor. Feasibility and acceptability of the intervention was assessed through enrollment rates, reasons for refusal, retention rates, engagement with the intervention, satisfaction, and reasons for drop-out. Dependent t-tests were used to evaluate the preliminary effects of the intervention on patient transition readiness, health-related quality of life, self-efficacy, SCD knowledge, medication adherence, and health literacy.

RESULTS

Participants (N = 24) demonstrated adequate retention (75.0%), adherence to the intervention (M = 5.3 of 6 sessions), and satisfaction with the intervention components. Participants demonstrated significant improvements in transition readiness (p = .001), self-efficacy (p = .002), medication adherence (p = .02), and health literacy (p = .05).

CONCLUSIONS

A medical student mentor intervention to facilitate transition from pediatric to adult care for AYA with SCD is both feasible and acceptable to patients and medical students. Preliminary results suggest benefits for patients, warranting a larger efficacy study.

Society of Behavioral Medicine Position Statement: promote sun-safety policies and practices for youth in educational, childcare, and recreational settings

Youth should be allowed and encouraged to engage in sun-safe behaviors in educational, childcare, and recreational settings, including use of sunscreen, wide-brimmed hats, other sun-protective clothing, and shade.

Physician skin cancer screening among U.S. military veterans: Results from the National Health Interview Survey

Introduction

Although military veterans are at increased risk for skin cancer, little is known about the extent to which they have been screened for skin cancer. The study objective was to examine the prevalence and correlates of physician skin cancer screening among U.S. military veterans.

Methods

Data were drawn from the National Health Interview Survey. The study sample consisted of 2,826 individuals who reported being military veterans. Receipt of a physician skin examination was measured using a single question that asked participants whether they had ever had all of their skin from head to toe checked for cancer by a dermatologist or some other kind of doctor.

Results

Less than a third (30.88%) of participants reported ever having a physician skin examination. Factors positively associated with receipt of a physician skin examination in a multivariable logistic regression analysis included: older age, greater educational level, non-Hispanic white race/ethnicity, having TRICARE (military) health insurance, greater skin sensitivity to the sun, and engagement in more sun protection behaviors.

Conclusions

The majority of military veterans have never been screened for skin cancer by a physician. Screening rates were higher among individuals with one or more skin cancer risk factors. Future research is warranted to test targeted skin cancer screening interventions for this at risk and understudied population.

Correlates of sun protection behaviors among melanoma survivors

BACKGROUND

The study objective was to assess potential correlates of sun protection behaviors among melanoma survivors.

METHODS

Participants were 441 melanoma survivors recruited from three health centers and a state cancer registry in the United States. Sun protection behaviors (sunscreen, shade, protective shirts, and hats) were assessed through an online survey, as were potential correlates (demographic, melanoma risk, knowledge and beliefs, psychological and social influence factors). Hierarchical multiple regression analyses were conducted.

RESULTS

Correlates of sun protection behaviors included education, skin cancer risk factors, melanoma knowledge and beliefs, melanoma worry and distress, physician recommendation for sun protection, injunctive norms, and pro-protection beliefs (e.g., perceived barriers, self-efficacy).

CONCLUSIONS

Future efforts to improve sun safety among melanoma survivors may benefit from targeting individuals with lower education levels, and addressing sun protection social influence, barriers, and self-efficacy.

Correlates of Sun Protection Behaviors Among Adults in Puerto Rico

BACKGROUND

The incidence of skin cancer has been increasing in Puerto Rico in recent years. Sun protection behaviors are suboptimal among Puerto Ricans. However, there are limited data regarding major factors associated with Puerto Rican adults' sun protection behaviors. To examine factors associated with Puerto Rican adults' sun protection behaviors, a survey study was conducted in Puerto Rico.

METHOD

A population-based sample of 667 Puerto Rican adults completed a telephone survey in 2016. Survey items addressed potential correlates of sun protection behaviors. Hierarchical multiple regression analyses examining correlates of the sun protection behaviors index were conducted.

RESULTS

Higher levels of sun protection behaviors were found among English language acculturated compared to Spanish language acculturated individuals (p < .05) and among individuals with private versus no health insurance (p < .05). Higher levels of sun protection behaviors were found among individuals with greater skin cancer knowledge (p < .001), fewer sun protection barriers (p < .01), and greater sun protection self-efficacy (p < .001).

CONCLUSION

By identifying correlates of Puerto Rican adults' sun protection behaviors, this timely study provides insight on factors to target in future skin cancer interventions in this understudied population.

e-Health Interventions for Cancer Prevention and Control

Many terms have been used to describe technology-delivered behavioral and psychological treatments, including web-based treatments, online treatments, e-therapy, digital health interventions, cybertherapy, computer-mediated interventions, and eHealth/mHealth, among others. Attempts have been made to standardize terminology and definitions, although terms are continuously gaining and losing favor across the literature. This chapter provides an overview of eHealth in cancer prevention and control. Types of eHealth intervention methodologies are reviewed along with examples within the context of cancer prevention and control, such as sun safety behaviors and cancer screening. Future research directions, including issues related to the development and implementation of eHealth interventions, are addressed.

Effects of Website Interactivity on Skin Cancer-Related Intentions and User Experience: Factorial Randomized Experiment

BACKGROUND

Digital media technologies provide users with the ability to interact with content and to receive information based on their preferences and engagement.

OBJECTIVE

We used skin cancer and sun protection as a health topic to explore how modality interactivity, interface tools that afford users greater activity, resulting in greater depth and breadth of mentally representing and experiencing mediated content, and message interactivity, the extent to which the system allows users to exchange messages back and forth on health websites, influenced users' attitudes, knowledge, behavioral intentions, and experience.

METHODS

We employed a 2×2 (modality interactivity: high vs low; message interactivity: high vs low) between-subject online experiment for which 4 websites were created. Participants (n=293) were recruited using Amazon Mechanical Turk and randomly assigned into to 1 of 4 conditions. After browsing the website, participants completed an online survey regarding their experience and cognitive perceptions. General linear models and path analysis were used to analyze the data.

RESULTS

Both modality interactivity (P=.001) and message interactivity (P<.001) had an impact on intention to use sun protection. Attitudes toward health websites and perceived knowledge mediated the effects of modality interactivity and message interactivity on sun protection use intention, individually. Participants in the high modality interactivity and high message interactivity condition felt more satisfied (P=.02). Participants in the low message interactivity condition had more interest in the experience with health websites than participants in the high message interactivity condition (P=.044).

CONCLUSIONS

Findings suggested that modality interactivity influenced intention to use sun protection directly as well as via attitudes toward the websites. Message interactivity impacted intention to use sunscreen directly and also through perceived knowledge. Implications for designing health websites and health intervention content are discussed.

Prevalence and Location of Indoor Tanning Among High School Students in New Jersey 5 Years After the Enactment of Youth Access Restrictions

Importance

Several state governments have enacted bans on the use of indoor tanning beds at tanning salons among minors, but studies of the association of such restrictions with tanning behavior have produced mixed results. Little is known about the prevalence of tanning in nonsalon locations that are typically not covered by restrictions. Evidence that age bans are associated with a reduction in tanning bed use is needed to support policy makers' efforts to expand tanning regulations.

Objective

To determine the prevalence and location of indoor tanning among New Jersey youths after a 2013 statewide indoor tanning ban for minors younger than 17 years.

Design, Setting, and Participants

This survey study comprised 4 biennial (2012-2018) and representative cross-sectional surveys conducted among 12 659 high school students (grades 9-12) in New Jersey.

Main Outcomes and Measures

The main outcome was the frequency of indoor tanning in the past year. Location of tanning bed use (ie, tanning salons or nonsalon locations, such as private residences or gyms) was also assessed.

Results

Survey responses from a total of 12 659 high school students (6499 female [51%]; mean [SD] age, 15.8 [1.3] years) were analyzed across the 4 survey waves. Tanning prevalence among students younger than 17 years (ie, younger than the legal tanning age) was 48% lower in 2018 compared with 2012 (adjusted odds ratio, 0.52; 95% CI, 0.33-0.81; P = .002). Tanning prevalence was 72% lower among female students 17 years or older (adjusted odds ratio, 0.28; 95% CI, 0.18-0.44; P < .001). Prevalence rates were not significantly different for male students 17 years or older and for racial/ethnic minority students. The prevalence of tanning in salons and private residences was similar among students younger than 17 years.

Conclusions and Relevance

This study suggests that the prevalence of tanning in New Jersey has begun to decrease among all youths younger than the legal tanning age and among female students of legal age in the 5 years after a statewide tanning ban. These findings provide valuable evidence to policy makers to support ongoing state-level efforts to enact age-specific bans on indoor tanning. The unique assessment of tanning location demonstrates the need for both greater enforcement of existing tanning salon regulations to ensure compliance and broadening restrictions to cover nonsalon tanning locations.

Associations of Social Media Use, Patient-centered Communication, and Knowledge with Perceived Human Papillomavirus Vaccine Effectiveness

Objectives: Given the effectiveness of human papillomavirus (HPV) vaccination in preventing cervical cancer and other diseases, as well as the low rates of HPV vaccination in the United States, it is important to examine the determinants of perceived HPV vaccine effectiveness. In this study, we examined the associations between potential factors associated with perceived HPV vaccine effectiveness. Methods: We utilized data (N = 718) from the nationally representative 2017 Health Information National Trends Survey (HINTS). We examined the associations of health-related social media use, patient-centered communication, and HPV knowledge with perceived HPV vaccine effectiveness in preventing cervical cancer. We reported descriptive statistics, and conducted bivariable analyses, multivariable analysis, and mediation analyses. Results: Perceived HPV vaccine effectiveness was associated with sex, age, education, health-related social media use, and HPV knowledge. Additionally, HPV knowledge mediated the associations of health-related social media use and patient-centered communication with perceived HPV vaccine effectiveness. Conclusions: Improving health-related information from social media, patient-centered communication, and HPV knowledge may increase perceived HPV vaccine effectiveness and ultimately, vaccine adoption.

Prevalence and correlates of skin self-examination practices among cutaneous malignant melanoma survivors

Melanoma patients are at elevated risk for recurrence of the primary cancer as well as second primary melanomas. Regular skin self-examination (SSE) is recommended as part of follow-up surveillance. In this study, we examined SSE performance and comprehensiveness as well as knowledge and attitudinal correlates of SSE performance and comprehensiveness. Four hundred forty-one melanoma survivors completed measures of SSE performance as well as knowledge and attitudes about SSE and melanoma. Approximately two-thirds of the sample reported having conducted an SSE in the past two months; the average number of body parts examined was 10.64 (out of 15 maximum). Only 7.5% of the sample checked all 15 body parts. Greater worry about recurrence, fewer barriers to SSE, more planning for when to conduct SSE, and more confidence in the ability to conduct SSE and recognize a suspicious growth were associated with both SSE performance and greater SSE comprehensiveness. Physician influence was positively associated with SSE performance. Survivor education efforts may benefit from reminding survivors to check hard-to-see and sensitive areas, develop a plan for how to ask for assistance in conducting exams, as well as use mirrors to see hard-to-reach areas. Addressing perceived SSE barriers, fostering SSE planning, and improving SSE self-efficacy may be important foci for intervention efforts to enhance SSE performance and comprehensiveness.

Digital Health Interventions for Adolescent and Young Adult Cancer Survivors

This narrative review describes the evidence regarding digital health interventions targeting adolescent and young adult (AYA) cancer survivors. We reviewed the published literature for studies involving Internet, mHealth, social media, telehealth, and other digital interventions for AYA survivors. We highlight selected studies to illustrate the state of the research in this unique patient population. Interventions have used various digital modalities to improve health behaviors (eg, physical activity, nutrition, tobacco cessation), enhance emotional well-being, track and intervene on cancer-related symptoms, and improve survivorship care delivery. The majority of studies have demonstrated feasibility and acceptability of digital health interventions for AYA survivors, but few efficacy studies have been conducted. Digital health interventions are promising to address unmet psychosocial and health information needs of AYA survivors. Researchers should use rigorous development and evaluation methods to demonstrate the efficacy of these approaches to improve health outcomes for AYA survivors.

An Experimental Investigation of Human Presence and Mobile Technologies on College Students' Sun Protection Intentions: Between-Subjects Study

Background

Health promotion and education programs are increasingly being adapted and developed for delivery through digital technologies. With this shift toward digital health approaches, it is important to identify design strategies in health education and promotion programs that enhance participant engagement and promote behavior change.

Objective

This study aimed to examine the impact of an experiment testing various mobile health (mHealth) skin cancer prevention messages on sun protection intentions and message perceptions among American college students.

Methods

A sample of 134 college students aged 18 years or older participated in a 2×2×2 between-subjects experimental study, designed to examine the individual and combinatory effects of multiple dimensions (human presence, screen size, and interactivity) of digital technologies. The primary study outcome was intention to use sun protection; secondary outcomes included attitudes toward the information, two dimensions of trust, and information processing.

Results

Generally, intention to use sun protection was positively associated with the presence of human characters in the health educational messages (P<.001), delivering educational health messages on a large screen (ie, iPad; P<.001), and higher interactivity (P<.001). Only human presence produced more favorable attitudes (P=.02). Affective trust was positively associated with human presence (P=.006) and large screen size (P<.001), whereas cognitive trust was positively associated with human presence (P<.001) and small screen size (P=.007). Moreover, large screen size led to more heuristic processing (P=.03), whereas small screen size led to more systematic processing (P=.04).

Conclusions

This experimental study demonstrates that the impact of mHealth skin cancer prevention messages differs based on platform and delivery design features. Effects on behavioral intentions, attitudes, and trust were found for conditions with human presence, highlighting the importance of including this feature in mHealth programs. Results from this experimental study can be used to optimize the design of mHealth educational interventions that promote sun protection.

Wanting more: A look at preclinical students' desires for increased clinical experiences and interest in mentoring young adults with chronic illness

A growing population of children with chronic illness must transition from pediatric to adult healthcare. Medical students receive little formal training about the needs of these young patients. Strategies for educating students about how to address medical and psychosocial consequences of these conditions are needed. Interventions pairing medical students as mentors for young adults with chronic illness may provide dual benefit for both patient and student. To establish the feasibility of developing this type of program, we surveyed 165 medical students about their extra-curricular and clinical experiences as well their interest in and expectations for a patient mentoring experience.

Randomized controlled trial of the mySmartSkin web-based intervention to promote skin self-examination and sun protection behaviors among individuals diagnosed with melanoma: study design and baseline characteristics

>1.2 million people in the United States have a personal history of melanoma skin cancer and are at increased risk for disease recurrence and second primary melanomas. Many of these individuals do not follow recommendations to conduct regular, thorough skin self-examinations that facilitate early disease detection and do not sufficiently engage in sun protection behaviors. In this project, we are conducting a randomized controlled trial of an innovative, tailored, theory-driven Internet intervention-called mySmartSkin-to promote these behaviors among melanoma patients. This paper outlines the study design and characteristics of the study sample. A total of 441 patients were recruited (40.9% response rate) and randomized to the mySmartSkin or a Usual Care condition. Participants complete surveys at baseline and 8 weeks, 24 weeks, and 48 weeks later. The primary aim of the project is to examine the impact of mySmartSkin versus Usual Care on skin self-examination and sun protection behaviors. The secondary aim focuses on identifying mediators of the intervention's effects. In an exploratory aim, we will examine potential moderators of the impact of the intervention. At baseline, the recruited participants had a mean age of 61 years, 49% were female, 7.5% met criteria for having conducted a recent, thorough skin self-examination, and the mean score on the index of sun protection behaviors was 3.3 (on a scale from 1 to 5). The results of the project will determine whether the mySmartSkin intervention is efficacious in promoting skin self-examination and sun protection behaviors among individuals diagnosed with melanoma. Trial registration: ClinicalTrials.govNCT03028948.

Prevalence and correlates of intentional outdoor and indoor tanning among adolescents in the United States: Findings from the FLASHE survey

A body of research has focused on adolescents' indoor tanning behaviors but relatively little is known about the prevalence of adolescents' intentional outdoor tanning (time spent outdoors to get a tan). The present study used data from the National Cancer Institute's 2014 Family Life, Activity, Sun, Health and Eating (FLASHE) cross-sectional survey to examine the prevalence and correlates of intentional outdoor and indoor tanning among adolescents in the United States. Both unadjusted (bivariate) and adjusted (multi-variate) logistic regressions were performed to test the associations between demographic variables, time spent on media (e.g., using computers), emotional status and outdoor or indoor tanning. The overall prevalence of frequent outdoor tanning among adolescents in the U.S. was 15.6% (95% CI 13.8-17.4%) and the rate of indoor tanning in the past 12 months was 3% (95% CI 2.2-3.9). The adjusted odds of intentional outdoor tanning were significantly higher among girls (AOR 2.39, 95% CI 1.75-3.27), Non-Hispanic Whites (AOR 2.85, 95% CI 1.99-4.07), and those who spent more time on cell phones (AOR 1.40, 95% CI 1.25-1.57). The adjusted odds of indoor tanning were significantly higher among those who spent more time on computers (AOR 1.38, 95% CI 1.09-1.74) and cell phones (AOR 1.49, 95% CI 1.19-1.87). This study provides evidence for the relationship between media use and tanning behaviors among adolescents.

Recall of indoor tanning salon warnings and safety guidelines among a national sample of tanners

Indoor tanning (IT) is a known carcinogen, and regulation has increased across the USA. However, there is minimal point-of-sale regulation for adult users. The purpose of the present study is to explore whether IT users recall being provided with warnings or safety guidelines at tanning salons. A national sample of 273 young adult, female IT users (mean age = 22.26, SD = 2.38) was surveyed regarding the frequency that they recalled being provided with six different warnings and safety guidelines when at tanning salons. Between 65 and 90.1 % of participants reported recalling the various warnings and guidelines. Having very fair skin was reported by 16.8 % of participants, and these high-risk individuals were less likely to recall having read and signed a consent form than other IT users (p = .002). The current level of regulation is insufficient to provide IT users with consistent warnings and safety guidelines at tanning salons.