Effects of smartphone diaries and personal dosimeters on behavior in a randomized study of methods to document sunlight exposure

Wearable ultraviolet radiation sensors for research and personal use

Skin cancers are strongly linked to personal exposure to ultraviolet (UV) radiation, yet UV exposure is also the most preventable risk factor. People are exposed to UV rays when they engage in outdoor activities, particularly exercise, which is an important health behavior. Thus, researchers and the general public have shown increasing interest in measuring UV exposure using wearable sensors during outdoor physical activity. However, minimal research exists at the intersection of UV sensors, personal exposure, adaptive behavior due to exposures, and risk of skin damage. Recent years have seen an influx of new consumer-based and research-based UV-sensing technologies with wide-ranging form factors and purposes to fill this research gap, yet a thorough review of available sensors for specific purposes does not exist. Hence, the overall goal of this state-of-the-art review is to synthesize the current academic and gray literature surrounding personal UV-sensing technologies. Peer-reviewed journal articles and "gray literature," such as working papers, manuals, and UV sensor websites, were reviewed, assessing attributes of UV wearables marketed for research use, personal use, or both. Overall, 13 wearable UV sensors are available for personal use and/or research applications. These sensors vary from electronic to photochromic, with large differences in price, data outputs, accuracy, and precision. Recommendations are provided for which sensors are most suitable for various types of research or public use. Notably, the review findings will help guide researchers in future studies assessing UV exposure during physical activity.

Novel sunprotection interventions to prevent skin cancer: A randomized study targeting Danes going on vacation to destinations with high UV index

Background

In Denmark, 16,500 cases of melanoma and keratinocyte cancers were registered in 2015, of which 90% could have been avoided by behavioral changes. We aimed to test novel interventions in a randomized design. The interventions targeted Danes going on vacation to high UVI destinations aiming to decrease sunburn by increasing use of sun protection to prevent skin cancer in the Danish population.

Methods

We report a randomized behavioral intervention during May-Dec 2018 with 1548 Danish adults on vacation in 2018 for a period of 1–3 weeks. The study population was population-based and aged 18–65 years. We tested two protection routines against minimal intervention control group (2-by2-factorial design): 1) Avoidance of the sun during peak hours and shade, use of the UV-index and planning of indoor/outdoor activity respectively and, 2) Coverage by increasing use of the hat advice and increasing sunscreen amount by application routine. Outcome was use of protection and sunburn.

Results

There were no differences in sunburn prevalence between intervention and control groups. Protection routine 1 and 2 both increased the overall protection score compared to non-users. Protection routine 1 increased the reported use of shade and decreased time exposed in the sun. Protection routine 2 increased the use of hat and sunscreen amount.

Conclusion

Simple measures can help avoid the majority of one of the most widespread cancers worldwide. Vacations to high UVI destinations is a major influence on the annual Danish UV-exposure. We influenced travelers to protect themselves better and to increase sun protection behavior.

Benefit-Cost Analysis of the Danish Sun Safety Campaign 2007-2015: Cost Savings from Sunburn and Sunbed Use Reduction and Derived Skin Cancer Reductions 2007-2040 in the Danish Population

BACKGROUND

Ninety percent of skin cancers are avoidable. In Denmark, 16,500 cases of melanoma and keratinocyte cancers were registered in 2015. The Danish Sun Safety Campaign has campaigned since 2007, targeting overexposure to ultraviolet radiation. During 2007-2015, the key indicators of skin cancer, i.e. sunbed use and sunburn, showed annual reductions of 6% and 1%, respectively.

OBJECTIVES

We aimed to examine the financial savings to society as a result of the campaign reductions in skin cancer cases (2007-2040), and to examine the campaign's cost-benefit and return on investment (ROI).

METHODS

The analysis is based on existing data: (1) annual population-based surveys regarding the Danish population's behavior in the sun; (2) skin cancer projections; (3) relative risks of skin cancers from sunburn and sunbed use and (4) historical cancer incidences, combined with new data; (5) benefits from the avoided costs of skin cancer reductions; and (6) the costs of the Danish Sun Safety Campaign.

RESULTS

The results were based on a reduction of 9000 skin cancer cases, saving €29 million of which €13 million were derived from sunburn reductions and €16 million from reductions in sunbed use. The ROI was €2.18.

CONCLUSION

Skin cancer prevention in Denmark is cost effective. Every Euro spent by the Danish Sun Safety Campaign saved the Danish health budget €2.18 in health expenses.

A Mobile Technology Intervention With Ultraviolet Radiation Dosimeters and Smartphone Apps for Skin Cancer Prevention in Young Adults: Randomized Controlled Trial

Background

Skin cancer is the most prevalent and most preventable cancer in Australia. Despite Australia’s long-running public health campaigns, young Australian adults continue to report high levels of ultraviolet radiation (UVR) exposure and frequent sunburns. Young people are now increasingly turning away from traditional media, such as newspapers and TV, favoring Web-based streaming, which is challenging the health care sector to develop new ways to reach this group with targeted, personalized health promotion messages. Advances in technology have enabled delivery of time- and context-relevant health interventions.

Objective

The primary aim of this randomized controlled trial was to test the effect of UVR feedback from a smartphone app or a UVR dosimeter feedback device on sun protection habits, sun exposure behaviors, sunburn, and physical activity levels in young adults.

Methods

Young adults aged 18-35 years (n=124) were recruited from Queensland, Australia, between September 2015 and April 2016, via social or traditional media campaigns and outreach activities in the local community. Participants were randomized into 3 groups for a 4-week intervention: (1) no intervention control group; (2) UVR monitor group, who were asked to wear a UVR dosimeter feedback device set to their skin type; and (3) a SunSmart app group, who were asked to download and use the SunSmart phone app. Data were self-assessed through Web-based surveys at baseline and 1 week and 3 months postintervention.

Results

Complete data were available for 86.2% (107/124) of participants (control group, n=36; UVR monitor group, n=36; and SunSmart app group, n=35). Intervention uptake in the UVR monitor group was high, with 94% (34/36) of participants using the device all or some of the time when outdoors. All SunSmart app group participants downloaded the app on their smartphone. There was no significant difference in the change in the sun protection habits (SPH) index (main outcome measure) across the 3 groups. However, compared with the control group, a significantly greater proportion of the participants in the UVR monitor group reduced their time unprotected and exposed to UVR on weekends during the intervention compared with the baseline (odds ratio [OR]: 2.706, 95% CI 1.047-6.992, P=.04). This significant effect was sustained with greater reductions observed up to 3 months postintervention (OR: 3.130, 95% CI 1.196-8.190, P=.02). There were no significant differences between the groups in weekday sun exposure, sunscreen use, sunburn, suntan, or physical activity.

Conclusions

Using technology such as apps and personal UVR monitoring devices may improve some sun exposure behaviors among young adults, but as the SPH index did not increase in this study, further research is required to achieve consistent uptake of sun protection in young people.

Trial Registration

The Australian and New Zealand Clinical Trials register ACTRN12615001296527; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368458 (Archived by WebCite at http://www.webcitation.org/731somROx)

Review on Nonoccupational Personal Solar UV Exposure Measurements

Solar ultraviolet (UV) radiation follows people during their whole life. Exposure to UV radiation is vital but holds serious risks, too. The quantification of human UV exposure is a complex issue. UV exposure is directly related to incoming UV radiation as well as to a variety of factors such as the orientation of the exposed anatomical site with respect to the sun and the duration of exposure. The use of badge-sensors allows assessing the UV exposure of differently oriented body sites. Such UV devices have been available for over 40 years, and a variety of measuring campaigns have been undertaken since then. This study provides an overview of those studies which reported measurements of the personal UV exposure (PE) during outdoor activities of people not related to their occupation. This overview is given chronologically to show the progress of knowledge in this research and is given with respect to different activities. Special focus is put on the ratio of personal exposure to ambient UV radiation. This ratio, when given as a function of solar elevation, allows estimating PE at any other location or date if ambient UV radiation is known.

Capturing Ultraviolet Radiation Exposure and Physical Activity: Feasibility Study and Comparison Between Self-Reports, Mobile Apps, Dosimeters, and Accelerometers

Background

Skin cancer is the most prevalent cancer in Australia. Skin cancer prevention programs aim to reduce sun exposure and increase sun protection behaviors. Effectiveness is usually assessed through self-report.

Objective

It was the aim of this study to test the acceptance and validity of a newly developed ultraviolet radiation (UVR) exposure app, designed to reduce the data collection burden to research participants. Physical activity data was collected because a strong focus on sun avoidance may result in unhealthy reductions in physical activity. This paper provides lessons learned from collecting data from participants using paper diaries, a mobile app, dosimeters, and accelerometers for measuring end-points of UVR exposure and physical activity.

Methods

Two participant groups were recruited through social and traditional media campaigns 1) Group A—UVR Diaries and 2) Group B—Physical Activity. In Group A, nineteen participants wore an UVR dosimeter wristwatch (University of Canterbury, New Zealand) when outside for 7 days. They also recorded their sun exposure and physical activity levels using both 1) the UVR diary app and 2) a paper UVR diary. In Group B, 55 participants wore an accelerometer (Actigraph, Pensacola, FL, USA) for 14 days and completed the UVR diary app. Data from the UVR diary app were compared with UVR dosimeter wristwatch, accelerometer, and paper UVR diary data. Cohen kappa coefficient score was used to determine if there was agreement between categorical variables for different UVR data collection methods and Spearman rank correlation coefficient was used to determine agreement between continuous accelerometer data and app-collected self-report physical activity.

Results

The mean age of participants in Groups A (n=19) and B (n=55) was 29.3 and 25.4 years, and 63% (12/19) and 75% (41/55) were females, respectively. Self-reported sun exposure data in the UVR app correlated highly with UVR dosimetry (κ=0.83, 95% CI 0.64-1.00, P<.001). Correlation between self-reported UVR app and accelerometer-collected moderate to vigorous physical activity data was low (ρ=0.23, P=.10), while agreement for low-intensity physical activity was significantly different (ρ=-0.49, P<.001). Seventy-nine percent of participants preferred the app over the paper diary for daily self-report of UVR exposure and physical activity.

Conclusions

This feasibility study highlights self-report using an UVR app can reliably collect personal UVR exposure, but further improvements are required before the app can also be used to collect physical activity data.

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

Knowledge deficit, attitude and behavior scales association to objective measures of sun exposure and sunburn in a Danish population based sample

The objective of this study was to develop new scales measuring knowledge and attitude about UVR and sun related behavior, and to examine their association to sun related behavior objectively measured by personal dosimetry. During May-August 2013, 664 Danes wore a personal electronic UV-dosimeter for one week that measured their UVR exposure. Afterwards, they answered a questionnaire on sun-related items. We applied descriptive analysis, linear and logistic regression analysis to evaluate the associations between the questionnaire scales and objective UVR measures. Perceiving protection as routine and important were positively correlated with protective behavior. Knowledge deficit of UV and risk of melanoma, perceived benefits and importance of protection behavior was also correlated with use of protection. ‘Knowledge deficit of UV and risk of melanoma and Perceived barrier towards sun avoidance between 12 and 15’ were both associated with increased risk of sunburn. Attitude towards tan was associated to both outdoor time and exposure as well as use of protection, but not to sunburn. The results regarding Knowledge deficit of UV and risk of melanoma associated to UVR exposure and Perceived barrier towards sun avoidance between 12 and 15 emphasize the importance of awareness of melanoma risk and the priority of the skin cancer prevention advice. Shifting activities to outside the suns peak-hours could be an approach for structural and campaign preventive measures. Knowledge of items predicting exposure to UVR, use of protection and sunburn are important for planning of preventive interventions and melanoma research.

Schoolyard Shade and Sun Exposure: Assessment of Personal Monitoring During Children's Physical Activity

Childhood exposure to ultraviolet radiation (UVR) is a major risk factor for the development of melanoma later in life. However, it is challenging to accurately determine personal outdoor exposure to UVR, specifically erythemally weighted UVR (UV_Ery ), due to technological constraints, variable time-activity patterns, and the influence of outdoor environmental design. To address this challenge, this study utilized mobile and stationary techniques to examine the UV_Ery exposures of 14 children in a schoolyard in Lubbock, TX, in spring 2016. The aims of the study were to examine the influence of artificial shade on personal UV_Ery exposures and to assess full sun exposure ratios (ERs) within the same playground microenvironment. On average, personal wrist dosimeters worn during play in the sun measured 18% of the total onsite UV_Ery measured by a stationary UV pyranometer. Shade was found to significantly reduce the personal UV_Ery exposures by 55%, UVB_{280-315 nm} exposures by 91%, and the overall solar radiation by 84%. Substantial benefits can be garnered through focused design of children's recreational space to utilize shade-both natural and artificial-to reduce UVR exposures during play, and to extend safe outdoor stays. Finally, although the wrist is a practical location for a dosimeter, it often underestimates full exposures, particularly during physical activity.

The validated sun exposure questionnaire: association of objective and subjective measures of sun exposure in a Danish population-based sample

BACKGROUND

Few questionnaires used in monitoring sun-related behaviour have been tested for validity.

OBJECTIVES

We established the criteria validity of a questionnaire developed for monitoring population sun-related behaviour.

METHODS

During May-August 2013, 664 Danes wore a personal electronic ultraviolet radiation (UVR) dosimeter for 1 week that measured their outdoor time and dose of erythemal UVR exposure. In the following week, they answered a questionnaire on their sun-related behaviour in the measurement week.

RESULTS

Outdoor time measured by dosimetry correlated strongly with both outdoor time and the developed exposure scale measured in the questionnaire. Exposure measured in standard erythema dose (SED) by dosimetry correlated strongly with the exposure scale. In a linear regression model of UVR (SED) received, 41% of the variation was explained by skin type, age, week of participation and exposure scale, with exposure scale as the main contributor. The weekly sunburn fraction correlated strongly with the number of ambient sun hours (r = 0·73, P < 0·001).

CONCLUSIONS

This criteria-validated questionnaire provides evidence of the exposure that the questionnaire aimed to measure. The evidence provided showed a strong link between the objectively measured behaviour and the behaviour measured by this survey construct. The questionnaire is the first validated tool to measure the UVR exposure in a national population-based sample.