Development and reliability of a brief skin cancer risk assessment tool

Designing a Culturally Relevant Digital Skin Cancer Prevention Intervention for Hispanic Individuals: Qualitative Exploration

BACKGROUND

In the past 2 decades, melanoma incidence among Hispanic individuals has risen by 20%. The mortality rate of Hispanic individuals is higher than that for non-Hispanic White individuals. Skin cancer can largely be prevented with regular sun protection, and skin cancer outcomes can be improved through early detection, for example, by skin self-examination. Alarmingly, Hispanic individuals are less aware of the symptoms and harms of skin cancers, tend to have misperceptions regarding the risks and benefits of skin cancer prevention behaviors, and engage in less sun protection behaviors than non-Hispanic White individuals.

OBJECTIVE

This study aimed to use a community-engaged approach and conduct both group and individual interviews among Hispanic individuals and relevant key stakeholders to explore the potential design of a mobile-based skin cancer prevention intervention for Hispanic individuals.

METHODS

This study used a qualitative design (focus groups and individual interviews). Participants were recruited from local community organizations' social media, local events, and contact lists (eg, email). Zoom interviews were conducted to examine whether Hispanic individuals would be interested in a mobile-based skin cancer intervention and to explore their preferences and suggestions to inform skin cancer prevention intervention design.

RESULTS

Five focus groups (2 in Spanish and 3 in English) among self-identified Hispanic individuals (n=34) and 15 semistructured, in-depth individual interviews among key stakeholders (health care providers and community leaders; eg, dermatologist, nurse practitioner, licensed social worker, and church leader) were conducted. The main themes and subthemes emerging from the group discussions and individual interviews were organized into the following categories: intervention platform, delivery frequency and format, message design, engagement plan, and activities. WhatsApp and Facebook were identified as suitable platforms for the intervention. Messages including short videos, visuals (eg, images and photographs), and simple texts messages were preferred. Recommendations for message design included personalized messages, personal stories and narratives, culturally relevant design (eg, incorporating family values), and community-trusted sources. Potential engagement and retention recommendations were also discussed. Additional details and exemplar quotes of each theme and subtheme are described.

CONCLUSIONS

This study provides important insights and directions for the design of a mobile, digital skin cancer intervention to modify Hispanic individuals' sun protection and skin self-examination behaviors to help improve skin cancer outcomes. Insights gathered from community leaders and health care providers provided valuable additions to the community-derived data. Leveraging popular digital platforms among Hispanic individuals such as WhatsApp or Facebook could be a promising approach to skin cancer prevention. Recommendations from the community included the use of concise videos, illustrative images, clear text messages, tailored communications, narratives featuring personal experiences, designs that reflect cultural significance, and information from sources that are trusted by the community, which provided useful strategies for future intervention design among Hispanic individuals.

Associations of Social Factors and Self-Efficacy with Skin-Self Examination Intentions Among Hispanics at Risk for Skin Cancer and Their Preferences for Digital Interventions

Skin cancer ranks as the most prevalent cancer in the United States. Over the past two decades, the incidence of melanoma, the deadliest form of skin cancer, among Hispanics has risen by 20%. Melanoma mortality rates are higher in Hispanics than in non-Hispanic Whites (NHW). Early detection of melanoma via skin self-examination may lead to diagnosis of melanoma at an earlier stage, when they are thinner, less invasive, and more easily treatable, resulting in improved survival rates. Given the gap in research addressing culturally relevant factors related to skin cancer prevention and detection among Hispanics and informed by the Preventive Health Model, this study tested the associations between social and normative factors and self-efficacy with thorough skin self-examination (TSSE) intentions and queried participants about their preferences for skin cancer-related interventions. Among respondents (n = 79), 55.7% were female (n = 44), and 89.9% held a college or higher degree (n = 71). Self-efficacy fully mediated the effects of descriptive norms, injunctive norms, and provider-patient communication on TSSE intentions among Hispanics. On average, respondents demonstrated considerable interest in participating in a skin cancer-related behavioral intervention using a mobile application (75.6%) and/or using WhatsApp (71.8%). These preliminary findings provide new insights for development of future digital skin cancer intervention programs among Hispanics targeting social factors, including social norms and provider-patient communication, and utilizing preferred digital tools.

Digital Interventions to Modify Skin Cancer Risk Behaviors in a National Sample of Young Adults: Randomized Controlled Trial

BACKGROUND

Young adults engage in behaviors that place them at risk for skin cancer. Dissemination of digital health promotion interventions via social media is a potentially promising strategy to modify skin cancer risk behaviors by increasing UV radiation (UVR) protection and skin cancer examinations.

OBJECTIVE

This study aimed to compare 3 digital interventions designed to modify UVR exposure, sun protection, and skin cancer detection behaviors among young adults at moderate to high risk of skin cancer.

METHODS

This study was a hybrid type II effectiveness-implementation randomized controlled trial of 2 active interventions, a digital skin cancer risk reduction intervention (UV4.me [basic]) compared with an enhanced version (UV4.me2 [enhanced]), and an electronic pamphlet (e-pamphlet). Intervention effects were assessed over the course of a year among 1369 US young adults recruited primarily via Facebook and Instagram. Enhancements to encourage intervention engagement and behavior change included more comprehensive goal-setting activities, ongoing proactive messaging related to previously established mediators (eg, self-efficacy) of UVR exposure and protection, embedded incentives for module completion, and ongoing news and video updates. Primary outcome effects assessed via linear regression were UVR exposure and sun protection and protection habits. Secondary outcome effects assessed via logistic regression were skin self-exams, physician skin exams, sunscreen use, indoor tanning, and sunburn.

RESULTS

The active interventions increased sun protection (basic: P=.02; enhanced: P<.001) and habitual sun protection (basic: P=.04; enhanced P=.01) compared with the e-pamphlet. The enhanced intervention increased sun protection more than the basic one. Each active intervention increased sunscreen use at the 3-month follow-up (basic: P=.03; enhanced: P=.01) and skin self-exam at 1 year (basic: P=.04; enhanced: P=.004), compared with the e-pamphlet. Other intervention effects and differences between the Basic and Enhanced Intervention effects were nonsignificant.

CONCLUSIONS

The active interventions were effective in improving several skin cancer risk and skin cancer prevention behaviors. Compared with the basic intervention, the enhanced intervention added to the improvement in sun protection but not other behaviors. Future analyses will explore intervention engagement (eg, proportion of content reviewed).

TRIAL REGISTRATION

ClinicalTrials.gov NCT03313492; http://clinicaltrials.gov/ct2/show/NCT03313492.

A Social Media-Delivered Melanoma Prevention Program for Young Women Engaged in Frequent UV Tanning: Protocol for a Randomized Controlled Trial

BACKGROUND

Rates of melanoma have increased dramatically in the United States over the past 25 years, and it has become among the most prevalent cancers for young adult women. Intentional skin tanning leads to a pattern of intense and intermittent UV radiation exposure that is associated with increased risk of melanoma. Frequent tanning is most common among young women and is linked to a variety of sociocultural pressures that negatively impact body image and drive appearance control behaviors. Unfortunately, there are no established interventions designed for frequent tanners. This intervention addresses this gap with unique content informed by body image and acceptance-based interventions. The intervention is delivered using Facebook secret groups, an approach designed to support behavior change and ensure scalability.

OBJECTIVE

This study aims to describe the rationale and methodology of a randomized controlled trial of a melanoma prevention program targeting young women engaged in frequent indoor or outdoor UV tanning.

METHODS

Participants are women aged 18-25 years who report high-risk tanning (ie, at least 10 indoor tanning sessions in the past 12 months or 10 outdoor sessions in the previous summer). After recruitment and screening, participants completed a baseline survey and were randomly assigned to receive the intervention or an attention-matched control condition. Both conditions were 8-week-long Facebook groups (approximately 25 members each) with daily posting of content. Follow-up surveys are administered at 3, 8, and 18 months after baseline. The primary trial outcome is the combined number of indoor and outdoor tanning sessions reported at the 8-month follow-up. Hypothesized intervention mediators are assessed at the 3-month follow-up.

RESULTS

This project was funded by a National Cancer Institute award (R01 CA218068), and the trial procedures were approved by the University of Kentucky Institutional Review Board in February 2020. Trial recruitment and enrollment occurred in 6 waves of data collection, which started in February 2022 and closed in May 2023. The study is closed to enrollment but remains open for follow-ups, and this protocol report was prepared before data analyses. As of February 2024, all participants have completed the 8-month follow-up assessment, and data collection is scheduled to close by the end of 2024 after the collection of the 18-month follow-up.

CONCLUSIONS

This trial will contribute unique knowledge to the field of skin cancer prevention, as no fully powered trials have examined the efficacy of an intervention designed for frequent indoor or outdoor tanning. The trial may also contribute evidence of the value in translating principles of body image and acceptance-based interventions into the field of skin cancer prevention and beyond. If successful, the use of the Facebook platform is intended to aid in dissemination as it provides a way to embed the intervention into individuals' everyday routines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03441321; https://clinicaltrials.gov/study/NCT03441321.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56562.

The Association of Skin Cancer Prevention Knowledge, Sun-Protective Attitudes, and Sun-Protective Behaviors in a Navy Population

INTRODUCTION

U.S. Navy service members are primarily between the ages of 18 and 30 years and often required to be outside for extended periods of time in geographical locations with increased and often unfamiliar ultraviolet indexes that collectively increase their risk for skin cancer. Skin cancer is the country's most common form of cancer, yet there is a paucity of skin cancer prevention literature, especially within the U.S. Navy. The purpose of this study was to describe skin cancer risk and skin cancer prevention "cues-to-action" and to determine if skin cancer prevention knowledge was associated with sun-protective attitudes (e.g., prevention perceptions, benefits, threats, barriers, and sun-protective behavior self-efficacy) and sun-protective behaviors (e.g., wearing long sleeve shirts and using sunscreen and not deliberately exposing skin for a tan) in a Navy population.

MATERIALS AND METHODS

A cross-sectional, descriptive, correlational design was utilized, and the study approval was obtained by the Naval Medical Center Portsmouth Institutional Review Board. Two-hundred twenty-nine active duty Navy service members aged 18-30 years who presented to primary care for their periodic health assessment completed the Brief Skin Cancer Risk Assessment and the Skin Cancer Survey. Descriptive statistics were utilized to assess service members' perceptions and knowledge regarding skin cancer prevention along with sociodemographic characteristics. The Spearman rank-order correlation and the Mann-Whitney U test were used to assess associations. P-values <.05 were used to determine statistical significance.

RESULTS

Skin cancer prevention knowledge was significantly related to sun-protective behavior self-efficacy (r = 0.218, P = .001), benefits (r = 0.271, P ≤ .001), sun protection behaviors (r = 0.152, P = .024), skin cancer risk (r = 0.256, P = .001), current frequency of high-risk sun behavior (r = 0.183, P = .006), past frequency of high-risk sun behavior (r = 0.219, P = .001), sun exposure (U = 4,813.50, P = .005), tanning bed use (U = 3,154.50, P = .031), and training (U = 4,099.50, P = .005).

CONCLUSIONS

Integrating skin cancer education into primary care visits (i.e., periodic health assessments) may improve Navy service members' modifiable sun-protective attitudes and behaviors and may contribute to lowering future skin cancer rates.

Visual Tailoring and Skin Cancer Prevention: Comparing Personalized, Stock, and Non-Ultraviolet Images

Past research has demonstrated that ultraviolet (UV) photos - which reveal skin damage as dark patches - can increase preventive behaviors. Emerging camera technology facilitates personalized UV photos for interventions, yet little is known about how personalized photos compare to other visuals and what cognitive or affective mechanism explains their persuasive impact. To engage this research line, the current study compared the impact of personalized UV (PUV), stock UV (SUV), and non-UV (NUV) photos and, to advance theorizing on fear appeals, explored underlying affective mechanisms including physiological fear. A sample of 169 undergraduate students participated in a 3 (Visual conditions: PUV, SUV, NUV) × 2 (Efficacy conditions: No efficacy and Efficacy) between-participants message experiment on a computer equipped with iMotions 6.4 that tracked real-time physiological responses (facial expression and skin conductance). Results demonstrated that PUV skin damage photos produced significantly greater self-reported fear and positive valence (detected by facial expression analysis) than NUV and SUV visuals. Mediation analysis demonstrated that fear had a significant indirect effect on the relationship between exposure to PUV skin damage visuals and behavior expectations.

Non-linear effects of absolute risk information on individuals'self-evaluation, affective responses, and behavioral intentionsof precautionary actions against skin cancer

OBJECTIVE

The current study explores non-linear effects of absolute risk and effects of comparative risk information about skin cancer on individuals' safety ratings, affective responses and behavioral intentions.

METHOD

An experimental survey was conducted among college students (N = 563) to test the effects of absolute and comparative risk information across a range of risk levels from 3.7% to 60%.

RESULTS

The non-linear model of absolute risk effect was confirmed by the data. Absolute risk information had detectable effects at low levels of risk, but the effects did not change appreciably at the highest absolute risk levels. Regarding comparative risk, the data did not support its effects on individuals' safety ratings, affective responses and behavioral intentions.

CONCLUSION

The study found the non-linear model fits well to the skin cancer related feelings and behavioral intentions. It suggests future research apply non-linear models to a variety of health communication areas.

Validity of a Self-Assessment Skin Tone Palette Compared to a Colorimeter for Characterizing Skin Color for Skin Cancer Research

Our goal is to determine whether our objective 9-point Self-Assessment Skin Tone Palette (SASTP) is correlated with a colorimeter’s assessment of a melanin index, so that Hispanic and Black people can be included in skin cancer research where scales were developed for White populations. Subjects were asked to self-identify their skin tones using the SASTP. This study assessed the criterion validity of the SASTP by measuring a range of skin colors compared to a melanin index reported from a colorimeter for the upper-inner arm (non-sun-exposed skin color), and the outer forearm (sun-exposed). Among 188 non-artificial tanners, 50% were White, 30% were Hispanic or White-Hispanic, and 20% were other racial categories. Meanwhile, 70% were female (30% male) and 81% were age 18–29 (19% age 30+). The mean melanin of the upper-inner arm decreased with lighter skin color and stronger tendency to burn. The SASTP in comparison to melanin index values was correlated for both the upper-inner arm (r = 0.81, p < 0.001) and the outer forearm (r = 0.77, p < 0.001). The SASTP provides a 9-point scale that can be considered as an alternative, less expensive method that is comparable to the objective colorimeter melanin index, which may be useful in studies on skin cancer among White, non-White, and Hispanic peoples.

Evaluation of a Brief, Tailored Skin Cancer Risk Assessment and Referral Intervention for Community-Based Health Educators: Brief Report

Skin cancer rates are rising and earlier detection through screening leads to better outcomes. Health educators in community centers are well-situated to assess skin cancer risk, deliver tailored health information, and refer high-risk patients to a dermatologist for a screening. This study describes the evaluation of a brief, tailored skin cancer risk assessment, and referral intervention training. The training was developed as part of a pilot feasibility study and seven health educators were trained in an interactive session. Knowledge, attitudes, and efficacy were assessed before and after training. Health educators showed overall improvements of 22% in skin cancer risk knowledge, 50% improvement in positive attitudes toward assessment and referral, and a 40% increase in efficacy to intervene with patients. Community-based health educators that completed the training were able to successfully assess their patients for skin cancer risk and refer high-risk patients for a screening with a healthcare provider.

Facebook Intervention for Young-Onset Melanoma Survivors and Families: Protocol for a Randomized Controlled Trial

BACKGROUND

Individuals diagnosed with melanoma before the age of 40 years (young-onset melanoma survivors) and their first-degree relatives (FDRs) are a growing population at risk for developing recurrent melanoma or new melanomas. Regular surveillance using clinical skin examination (CSE) and skin self-examination (SSE) and engagement in preventive behaviors including sun protection are recommended. Given the growing population of survivors and their families who are at increased risk, it is surprising that no behavioral interventions have been developed and evaluated to improve risk-reduction behaviors.

OBJECTIVE

We describe the rationale and methodology for a randomized controlled trial evaluating the efficacy of a Facebook intervention providing information, goal setting, and peer support to increase CSE, SSE, and sun protection for young-onset melanoma survivors and their FDRs.

METHODS

Overall, 577 survivors and 577 FDRs will be randomly assigned to either the Young Melanoma Family Facebook Group or the Melanoma Family Healthy Lifestyle Facebook Group condition. Participants will complete measures of CSE, SSE, and sun protection, and mediator measures of attitudes and beliefs before and after the intervention. The primary aim is to evaluate the impact of the Young Melanoma Family Facebook intervention versus the Melanoma Family Healthy Lifestyle Facebook intervention on CSE, SSE frequency and comprehensiveness, and sun protection among FDRs. The secondary aims examine the efficacy of the Young Melanoma Family Facebook intervention on survivors' SSE frequency and comprehensiveness and sun protection behaviors and mechanisms of intervention efficacy for intervention impact on FDR and survivor outcomes. The exploratory aim is to evaluate the efficacy of the 2 interventions on perceived stress, physical activity, and healthy eating.

RESULTS

This project was funded by the National Institutes of Health (R01CA221854). The project began in May 2018, and recruitment started in January 2019. We anticipate completing enrollment by November 2023. Power calculations recommended a sample size of 577 survivors and 577 FDRs. Multilevel modeling treating family as the upper-level sampling unit and individual as the lower-level sampling unit will be the primary data analytic approach. Fixed effect predictors in these models will include condition, role, sex, all 2- and 3-way interactions, and covariates.

CONCLUSIONS

The Young Melanoma Family Facebook intervention aims to improve primary and secondary skin cancer prevention for young-onset melanoma survivors and their family members. The intervention's delivery via a popular, freely available social media platform increases its impact because of the potential for dissemination in many contexts. If efficacious, this program could be disseminated by dermatologist practices, public health or nonprofit organizations focused on melanoma, and existing melanoma and skin cancer Facebook groups, thereby expanding its reach. This project will produce a content library of posts and a moderation guide for others.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03677739; https://clinicaltrials.gov/ct2/show/NCT03677739.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39640.

Factors associated with suspected nonmelanoma skin cancers, dysplastic nevus, and cutaneous melanoma among first-time SpotMe screening program participants during 2009-2010

BACKGROUND

There have been no studies of the American Academy of Dermatology's SpotMe skin cancer screening program to collectively analyze and determine the factors associated with suspected basal cell carcinoma (BCC), squamous cell carcinoma (SCC), dysplastic nevus (DN), and cutaneous melanoma (CM) diagnoses.

OBJECTIVE

Describe the demographics, risk factors, and access to care profiles associated with suspected diagnoses of BCC, SCC, DN, and CM among first-time SpotMe screenees during 2009-2010.

METHODS

We conducted a cross-sectional analysis of data from the SpotMe skin cancer screenings conducted in 2009 and 2010. We performed multivariable logistic regression analysis for each diagnosis, incorporating standard demographic, access to care, and risk factor variables in the models.

RESULTS

Men, those without a regular dermatologist, persons reporting recently changing moles, and those with a personal history of melanoma were at increased risk for each of the suspected diagnoses analyzed. Uninsured persons were at increased risk for suspected malignancies (BCC, SCC, and CM).

LIMITATIONS

Lack of histologic confirmation for diagnoses and cross-sectional design.

CONCLUSION

Among first-time SpotMe participants, suspected diagnoses of BCC, SCC, DN, and CM shared several associated factors, which may be considered when planning outreach and screening for populations at risk for skin cancer.

Digital Educational Strategies to Teach Skin Self-examination to Individuals at Risk for Skin Cancer

Skin cancer is the most common cancer in the United States, and early detection of melanoma may lead to diagnosis of thinner and more treatable cancers, resulting in improved survival rates. This study examined the effects of message interactivity (high vs. low) and imagery (cartoon, real human character, or customized imagery preference) on accuracy of identifying abnormal skin lesions (ASL) and skin self-examination (SSE) intention. This study employed a 3 (cartoon character vs. real person vs. customization) x 2 (high interactivity vs. low interactivity) between-subjects online experimental design. Participants at risk for skin cancer were randomly assigned to one of the six conditions and completed a survey after reviewing the educational materials. Univariate analyses were conducted to detect group differences on the accuracy of identifying ASL and intention to conduct SSE in the next 3 months. Among 321 participants who completed the study, the mean age was 36.61 years, 56.7% were females, 76.1% had a college or higher degree, and over 60% self-identified as non-Hispanic White. Individuals in the high interactivity and customization group (compared to the low interactivity and cartoon group) were more likely to accurately identify ASL. Individuals in the high interactivity and customization or low interactivity and real person imagery groups (compared to the low interactivity and cartoon group) reported higher intention to conduct SSE in the next 3 months. These results suggest that customization and interactivity may be beneficial for educational programs or intervention design to improve both melanoma identification and SSE intention.

Beliefs Associated with Sunscreen use among non-Hispanic white Older Adults

This study examines beliefs about sunscreen use among non-Hispanic white adults aged 50 years or older using online survey data (n=237). Multiple logistic regression analyses were conducted to examine beliefs associated with sunscreen use, adjusted by age, gender, education, geographic location, and skin cancer risk score. Those who believed sunscreen use would prevent them from getting sunburned (odds ratio [OR]=1.84) and those who believed that their romantic partners thought they should use sunscreen (OR=1.72) were more likely to report sunscreen use. Those who believed sunscreen use would "take too much time" were less likely to report sunscreen use (OR=0.65). These findings can inform future research and messaging efforts, including the evaluation of intervention approaches that highlight the immediate benefits of sunscreen use, address concerns about sunscreen use taking too much time, and tap into the potential influence that older adults may have on the sunscreen use of their romantic partners.

Does it matter if a story character lives or dies?: a message experiment comparing survivor and death narratives

OBJECTIVE

In narratives, characters often face threats where they either live (survivor narratives) or die (death narratives). Both outcomes have the potential to persuade, and are frequently utilised in mass communication campaigns, yet more research is needed examining the relative effectiveness and underlying mechanisms of each strategy.

DESIGN

U.S. adults (N = 1010) were randomly assigned to a 2 (survivor, death) × 2 (non-foreshadowed, foreshadowed) × 2 (within-study replication: narrative 1, narrative 2) between-participants experiment with melanoma stories as stimuli.

MAIN OUTCOME MEASURES

Intentions to engage in sun safe behaviour and skin self-examination behaviour were assessed in the pre- and posttest, and then transformed into change scores.

RESULTS

Death narratives increased sun safe behaviour intentions. Consistent with the entertainment overcoming resistance model, foreshadowed death narratives were found to increase sun safe behaviour intentions via increased transportation and decreased counterarguing.

CONCLUSION

Compared to survivor narratives, death narratives increase intentions to engage in sun safe behaviour. The findings offer support for character death as a key feature of narrative persuasion, and narrative transportation and counterarguing as important mediational pathways.

Skin Cancer Risk Perception and Tanning Bed Use: A Population-Based Survey to Identify Persons at Risk for Melanoma in Olmsted County, Minnesota

BACKGROUND

Cutaneous melanoma is strongly associated with tanning bed use.

OBJECTIVE

To describe local residents' knowledge, attitudes, and behavior regarding skin cancer and tanning bed use and to estimate prevalence of high risk for melanoma.

MATERIALS AND METHODS

A survey was mailed to 886 local residents (549, aged 18-39 years; 337, aged ≥40 years). Logistic and linear regression and univariate and multivariable analysis were used to assess perceived risk and skin cancer knowledge.

RESULTS

The response rate was 21%; 55% of the younger group and 37% of the older group had used indoor tanning, and prevalence of high risk for melanoma according to a skin cancer risk calculator was 18% in the younger group and 33% in the older group. Individuals with high risk scores were more likely to correctly perceive that they were at high risk for skin cancer. Most participants with high risk scores and those who previously used tanning beds reported low likelihood of future indoor tanning.

CONCLUSION

Female sex, high risk score, and previous indoor tanning were associated with participants' views of higher skin cancer risk. No specific knowledge gaps were identified. Understanding community residents' attitudes about skin cancer and indoor tanning can help guide interventions.

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.

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

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

"Repeatability of Repeatability": the stability of self-reported melanoma risk factors in two independent samples

OBJECTIVE

To determine the test-retest repeatability of a self-completed survey with items capturing skin cancer risk factors.

METHODS

We invited 238 randomly selected participants of the QSkin II cohort to complete the baseline survey a second time. Responses were compared using kappa statistics and intraclass correlation coefficients to quantify agreement for categorical and continuous variables, respectively. We compared the performance of key items with that observed in an earlier repeatability study using the same survey instrument in an independent cohort.

RESULTS

Measures of phenotypic characteristics had moderate to almost-perfect test-retest repeatability (e.g. eye colour weighted kappa (κ_w ) = 0.87, 95% confidence interval [CI]: 0.81, 0.92). Items measuring sun exposure showed lower agreement (κ_w range 0.36-0.54) compared with phenotypic characteristics (κ_w range 0.59-0.87). Items relating to treatment of skin cancers demonstrated almost-perfect test-retest repeatability (e.g. excisions for skin cancers κ_w 0.85, 95%CI: 0.80, 0.89). In aggregate, the repeatability of key items was very similar across the two independent repeatability samples.

CONCLUSION

Fair to almost-perfect repeatability for self-reported skin cancer risk factors was robust across independent and temporally distant cohorts. Implications for public health: These self-assessed risk factors for skin cancer are repeatable and suitable for use in clinical practice and research.

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.

Sun Safe Partners Online: Pilot Randomized Controlled Clinical Trial

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

Revisiting nutrition backlash: Psychometric properties and discriminant validity of the nutrition backlash scale

OBJECTIVES

Nutrition backlash is a disposition defined by negative feelings about dietary recommendations. Past research has measured nutrition backlash using the nutrition backlash scale (NBS) and found that it is negatively related to the consumption of fruits and vegetables. The aim of this study was to examine several aspects of the NBS, including factor structure, discriminant validity, and relationship to demographic characteristics and health behaviors.

METHODS

Adults were recruited to participate in two studies. Study 1 (N = 480) included measures of nutritional backlash, information overload, worry, fatalism, and nutrition-related behaviors. Study 2 (N = 399) was a follow-up that examined the factor structure of the NBS in a separate sample.

RESULTS

In study 1, a six-item version of the NBS was found to be a good fit for the data and discriminant from overload, worry, and fatalism. NBS was higher for those with less education, non-white participants, and men. Individuals with higher backlash were less likely to look at nutritional labels and to use sunscreen. Study 2 confirmed the factor structure from study 1.

CONCLUSIONS

A six-item version of the NBS was found to be reliable, discriminant from related measures, higher in underserved groups (less-educated, non-white, and male participants), and related to nutrition label use.

Operationalization of skin self-examination in randomized controlled trials with individuals at increased risk for melanoma: A systematic review

OBJECTIVE

To investigate how skin self-examination was operationalized and the psychometric properties of the scales used to assess this behavior in randomized controlled trials (RCTs) testing interventions that promote SSE among individuals at increased risk for melanoma.

METHOD

Eight scientific databases (e.g., Medline, EMBASE, CINAHL, PsycINFO) and four trial registries (e.g., Clinicaltrials.gov, UK Clinical Trails Gateway) were searched from inception through April 2, 2019. Three reviewers carried out the selection of relevant trials and conducted data extraction.

RESULTS

The review identified 13 unique RCT's. The definition of skin self-exams, extrapolated from instructions provided to participants during the trials and reported in only 6/13 trials, included periodically checking the skin of the entire body, individually or with partners/mirrors, with or without tracking or monitoring tools, and using the ABCDE criteria to identify early signs of melanoma. There was variability in how skin self-examination behavior was measured with respect to item content, number of items, response format, and type of outcome variable used: continuous or binary). No validity evidence and minimal reliability evidence for the measures were identified.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Future studies are needed to establish the psychometric properties of measures assessing skin self-examination.

Cancer information overload: Discriminant validity and relationship to sun safe behaviors

OBJECTIVE

Past research suggests a large number of adults feel overwhelmed by the amount of cancer information - a phenomenon labeled cancer information overload (CIO). The current study examines whether CIO is discriminant from other negative message perceptions (reactance, information avoidance) and related to sun safe behaviors.

METHODS

U.S. adults (N = 2,219) completed survey questions assessing CIO, dispositional reactance, defensive/information avoidance, sun safe behavior, and knowledge.

RESULTS

The results demonstrated that CIO was discriminant from dispositional reactance, information avoidance, and defensive avoidance, and individuals with higher overload were more likely to tan, less likely to have an annual checkup with a healthcare provider, and less knowledgeable about sun safe protection. Unexpectedly, individuals with higher CIO were more likely to wear wide-brimmed hats.

CONCLUSION

CIO is distinct from reactance and avoidance, and related to performance/knowledge of sun safe behaviors, and receiving annual healthcare checkups.

PRACTICE IMPLICATIONS

The correlation between CIO and sun safe behavior differs by behavior; a pattern which suggests practitioners might benefit from adapting their communication strategy based on the target population and behavior.

Testing General Versus Specific Behavioral Focus in Messaging for the Promotion of Sun Protection Behaviors

BACKGROUND

Recommendations for skin cancer prevention include behaviors such as using sunscreen, seeking shade, and wearing a shirt with sleeves, but the best way to persuasively communicate this information to the public is not clear.

PURPOSE

To test whether a messaging strategy using videos that focus on one specific behavior at a time versus a more general or multibehavior sun protection message is effective at changing attitudinal beliefs and intention with regard to sun protection behaviors.

METHODS

Online experiment among non-Hispanic white 18-49 year old adults in the USA. Participants were randomly assigned to one of four conditions, each one with health messages on a different sun protection prevention behavior: "using sunscreen" (Condition 1, n = 259), "seeking shade" (Condition 2, n = 245), or "covering up" (Condition 3, n = 289). Condition 4 (the control, n = 251) is a multibehavior message that equally promotes sunscreen, seeking shade, and covering up and features a general message on sun safety.

RESULTS

ANOVA and path analysis results suggest that messages which emphasize a single sun protection behavior compared with general sun safety messaging could potentially be a promising approach. The effectiveness of the videos in influencing attitudinal beliefs varied by behavior, with some gender and age moderation. There was an indirect effect on intention to use sunscreen.

CONCLUSIONS

This study advances our understanding of strategies for skin cancer prevention campaigns. Specifically, it suggests that focusing on a single sun protection behavior with targeted beliefs may be valuable as a first step in encouraging sun safety.

Obstacles to skin self-examination: are frontier adults inclined abstainers?

Individuals residing in U.S. frontier counties have limited access to dermatology care and higher melanoma mortality rates. Given these limitations, frontier residents rely disproportionately on skin self-examinations (SSE) for early detection of melanoma, though little is known about their SSE behaviors and barriers to conducting SSEs. The goal of the present study was to identify obstacles to SSE performance via a survey of adults (N = 107) living in a U.S. frontier county. Approximately 43% of participants were classified as inclined abstainers - individuals who intended to perform SSE, but failed to follow through. Compared to those who did follow through, inclined abstainers were more likely to be hindered by twelve barriers, including forgetting, letting other tasks get in the way of SSE, and struggling to identify a good time or routine for SSE performance. The barriers to action for these inclined abstainers are modifiable - for example, not remembering to do it - and well positioned for a behavioral intervention.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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.

Do ultraviolet photos increase sun safe behavior expectations via fear? A randomized controlled trial in a sample of U.S. adults

Ultraviolet (UV) photos reveal the world in a different light spectrum, including damage that is caused by UV light. In the context of skin cancer control, UV photos have the potential to communicate fear because they reveal underlying skin damage. U.S. adults (N = 2219) were assigned to a 5 (visual: UV skin damage, sun exposure, sunburn, photoaging, and mole removal) × 3 (replication: three examples of each visual condition) × 4 (efficacy: no efficacy, text only, visual, visual + text) randomized controlled trial. Compared to all other visual conditions combined, UV skin damage visuals generated greater fear which triggered increased sun safe behavior expectations. Compared with other visual conditions separately, only mole removal visuals produced equivalent fear as UV skin damage visuals. Visual efficacy conditions appeared to nullify rather than magnify the indirect path through fear. The results suggest one way UV images impact sun safe behavioral expectations is via fear and that researchers should continue to examine the position of fear in fear appeal theories.

Correlates of sun protection behaviors in racially and ethnically diverse U.S. adults

Although skin cancer incidence is highest among non-Hispanic Whites, minority populations are often diagnosed with more advanced stage disease and are more likely to experience poor outcomes. Fewer people of color do not practice primary prevention of skin cancer according to recommendations, but public health education and interventions to promote sun protection behaviors have consistently targeted non-Hispanic Whites. This study examines performance of sun protection behaviors in a multiethnic sample and whether demographic, lifestyle and psychosocial predictors of these behaviors differ by race and ethnicity. In this study, a probability-based sample of 1742 adults completed an online survey in 2015. Main outcomes of interest included sunscreen use, wearing a sleeved shirt, and seeking shade. We stratified the sample into racial/ethnic groups (White, Black, Hispanic, Asian) and investigated demographic, lifestyle and psychosocial correlates of these behaviors in each group. Differences in adjusted estimates from each behavior-specific model were tested across strata. Racial/ethnic groups were significantly different in regards to sunscreen use and wearing a sleeved shirt, but similarly engaged in seeking shade. Results from multivariate ordered logistic regression models for each behavior revealed important demographic, lifestyle and psychosocial predictors and the importance of some demographic correlates varied between racial/ethnic groups. This study provides insight into the practice and correlates of skin cancer prevention among a multiethnic sample. Our findings suggest that targeting public health education efforts and interventions to promote sun protection in minority populations may be a beneficial approach to addressing heightened skin cancer morbidity and mortality in these groups.

Compensation Behaviors and Skin Cancer Prevention

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A hierarchical clustering approach to identify repeated enrollments in web survey data

INTRODUCTION

Online surveys are a valuable tool for social science research, but the perceived anonymity provided by online administration may lead to problematic behaviors from study participants. Particularly, if a study offers incentives, some participants may attempt to enroll multiple times. We propose a method to identify clusters of non-independent enrollments in a web-based study, motivated by an analysis of survey data which tests the effectiveness of an online skin-cancer risk reduction program.

METHODS

To identify groups of enrollments, we used a hierarchical clustering algorithm based on the Euclidean distance matrix formed by participant responses to a series of Likert-type eligibility questions. We then systematically identified clusters that are unusual in terms of both size and similarity, by repeatedly simulating datasets from the empirical distribution of responses under the assumption of independent enrollments. By performing the clustering algorithm on the simulated datasets, we determined the distribution of cluster size and similarity under independence, which is then used to identify groups of outliers in the observed data. Next, we assessed 12 other quality indicators, including previously proposed and study-specific measures. We summarized the quality measures by cluster membership, and compared the cluster groupings to those found when using the quality indicators with latent class modeling.

RESULTS AND CONCLUSIONS

When we excluded the clustered enrollments and/or lower-quality latent classes from the analysis of study outcomes, the estimates of the intervention effect were larger. This demonstrates how including repeat or low quality participants can introduce bias into a web-based study. As much as is possible, web-based surveys should be designed to verify participant quality. Our method can be used to verify survey quality and identify problematic groups of enrollments when necessary.

Frequent Indoor Tanners' Beliefs About Indoor Tanning and Cessation

PURPOSE

Indoor tanning is associated with an increased risk of developing skin cancer. In the United States, nearly 1 in 5 white women aged 18 to 25 are indoor tanners. This study elicited beliefs about tanning indoors and quitting/cutting back on indoor tanning.

DESIGN

Semi-structured interviews.

PARTICIPANTS AND SETTING

Forty 18- to 25-year-old white females who engaged in frequent indoor tanning participated in either in-person or telephone interviews. Most were college students from southeastern Pennsylvania and Delaware.

METHOD

A semi-structured interview was used to elicit beliefs about indoor tanning and quitting or cutting back. Data analyses using NVivo and multiple coders identified key themes about going and quitting/cutting back on indoor tanning.

RESULTS

Key themes stated as reasons for indoor tanning included improving physical appearance, social acceptance, increased confidence, and happiness. The main themes identified as advantages of quitting/cutting back on indoor tanning were to decrease skin cancer risk and save money. Perceived disadvantages of quitting/cutting back included themes of concerns about being pale and a decline in self-confidence. The prospect of saving money and warm weather were seen as facilitating quitting/cutting back.

CONCLUSION

Findings suggest the necessity of addressing appearance concerns, psychological benefits associated with feeling more attractive, and short-term gains such as saving money. These findings provide a foundation for developing effective anti-indoor tanning communication.

Hierarchical modeling of melanocortin 1 receptor variants with skin cancer risk

The human MC1R gene is highly polymorphic among lightly pigmented populations, and several variants in the MC1R gene have been associated with increased risk of both melanoma and nonmelanoma skin cancers. The functional consequences of MC1R gene variants have been studied in vitro and in vivo in postulated causal pathways, such as G-protein-coupled signaling transduction, pigmentation, immune response, inflammatory response, cell proliferation, and extracellular matrix adhesion. In a case-control study nested within the Nurses' Health Study, we utilized hierarchical modeling approaches, incorporating quantitative information from these functional studies, to examine the association between particular MC1R alleles and the risk of skin cancers. Different prior matrices were constructed according to the phenotypic associations in controls, cell surface expression, and enzymatic kinetics. Our results showed the parameter variance estimates of each single nucleotide polymorphism (SNP) were smaller when using a hierarchical modeling approach compared to standard multivariable regression. Estimates of second-level parameters gave information about the relative importance of MC1R effects on different pathways, and odds ratio estimates changed depending on prior models (e.g., the change ranged from -21% to 7% for melanoma risk assessment). In addition, the estimates of prior model hyperparameters in the hierarchical modeling approach allow us to determine the relevance of individual pathways on the risk of each of the skin cancer types. In conclusion, hierarchical modeling provides a useful analytic approach in addition to the widely used conventional models in genetic association studies that can incorporate measures of allelic function.

To protect or not to protect: examining reasons for sun protection among young women at risk for skin cancer

We aimed to further the understanding of the low rates of sun protection in young women at risk for skin cancer. Six-hundred-sixty-one daily diary entries were received via text message over 14 days from 56 young women at moderate to high risk of developing skin cancer. Women reported whether or not they used sun protection and also listed what their reasons were for using protection or not using sun protection each day. Multi-level modeling was used to examine the influence of study variables when predicting daily sun protection or lack of protection. The number of days in which sun protection was reported was positively associated with "habit" and "prevention" as reasons for protection and negatively associated with "not-needed" and "unprepared" as reasons for non-protection. Self-reported sun protection increased over the 14-day study period. Results of this study suggest the potential value of interventions aimed at motives for sun-protection behaviors.

Effect of interventions incorporating personalised cancer risk information on intentions and behaviour: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To provide a comprehensive review of the impact on intention to change health-related behaviours and health-related behaviours themselves, including screening uptake, of interventions incorporating information about cancer risk targeted at the general adult population.

DESIGN

A systematic review and random-effects meta-analysis.

DATA SOURCES

An electronic search of MEDLINE, EMBASE, CINAHL and PsycINFO from 1 January 2000 to 1 July 2017.

INCLUSION CRITERIA

Randomised controlled trials of interventions including provision of a personal estimate of future cancer risk based on two or more non-genetic variables to adults recruited from the general population that include at least one behavioural outcome.

RESULTS

We included 19 studies reporting 12 outcomes. There was significant heterogeneity in interventions and outcomes between studies. There is evidence that interventions incorporating personalised cancer risk information do not affect intention to attend or attendance at screening (relative risk 1.00 (0.97-1.03)). There is limited evidence that they increase smoking abstinence, sun protection, adult skin self-examination and breast examination, and decrease intention to tan. However, they do not increase smoking cessation, parental child skin examination or intention to protect skin. No studies assessed changes in diet, alcohol consumption or physical activity.

CONCLUSIONS

Interventions incorporating personalised cancer risk information do not affect uptake of screening, but there is limited evidence of effect on some health-related behaviours. Further research, ideally including objective measures of behaviour, is needed before cancer risk information is incorporated into routine practice for health promotion in the general population.

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.

Refinement of measures to assess psychosocial constructs associated with skin cancer risk and protective behaviors of young adults

The study's purpose was to select/refine measures assessing psychosocial constructs associated with skin cancer risk/protective behaviors. Cognitive interviewing was conducted with twenty participants locally, and a survey was conducted with 965 adults aged 18-25 years at moderate to high risk of developing skin cancer, recruited nationally online. Psychosocial measures assessed variables from the Integrative Model of Behavior Prediction. As a result of expert review and cognitive interviewing, items were removed, added, and/or made simpler, more personal, consistent, and less ambiguous. A factor analysis resulted in 14 scales and adequate model fit. Internal reliability and test-retest reliability was acceptable to good. Correlations among the psychosocial and behavioral variables were generally significant and in expected directions, demonstrating convergent validity. We have refined measures that assess important psychosocial constructs associated with skin cancer-related behaviors, that research participants can understand and complete successfully, and that are reliable and demonstrate evidence for validity.

College Students' Perceptions of Worry and Parent Beliefs: Associations with Behaviors to Prevent Sun Exposure

More research is needed to understand how attitudes impact behaviors that afford sun protection. The current study examined the impact of students' perceptions of parental beliefs about sun exposure and its influence on their practiced sun protection behaviors and worry about sun exposure. Participants were college students (N = 462) at a large Midwestern university. They completed a survey to examine their perceptions of risks and messages about sun exposure and sun exposure behaviors. Results indicated that gender and students' perceptions of parental beliefs about sun exposure were related to sun protection behaviors and their own worry over sun exposure. Specifically, males showed lower levels of sun protection behaviors, with the exception of wearing a hat with a brim, and lower levels of worry about sun exposure compared to females. Roughly a third of our sample had a family history of skin cancer, and this variable was related to worry about sun exposure and parental beliefs. Prevention messages and interventions to reduce sun risk for college students should address risks of sun exposure as well as educating young adults about the importance of wearing sunscreen, protective clothing, and hats to improve sun protection.

Parent and Child Characteristics Associated with Child Sunburn and Sun Protection Among U.S. Hispanics

BACKGROUND/OBJECTIVES

Skin cancer incidence has been increasing in U.S. Hispanics over several decades and the postdiagnosis outcomes are worse for Hispanics than for non-Hispanic whites. Parents are influential in children's health preventive behaviors, but little is known about parental factors associated with children's skin cancer-related behaviors in the U.S. Hispanic population. The present study examined parental and child correlates of skin cancer-related behaviors (sunburns, sunbathing, sun-protective clothing use, and sunscreen use) of children of Hispanic parents.

METHODS

This survey study included a population-based sample of 360 U.S. Hispanic parents (44.8% male) who had a child 14 years of age or younger. Measures included parental reports of parent and child demographic characteristics, parent skin cancer knowledge and linguistic acculturation, and parent and child skin cancer-related behaviors.

RESULTS

Approximately 28% of children and 31.9% of parents experienced at least one sunburn in the past year and approximately 29% of children and 36.7% of parents were reported to sunbathe. Moderate use of sun-protective clothing and sunscreen was reported for parents and their children. Child sun-protective clothing use and sunscreen use, sunburns, and sunbathing were associated with the corresponding behaviors of their parents.

CONCLUSIONS

Future research should consider the role of acculturation and perceived risk in the sun protection behaviors of U.S. Hispanic children, particularly in those who report a fair skin type. Hispanic parents should be included in interventions targeting their children's skin cancer-related behaviors, and it is suggested that such interventions could also encourage parents to improve their own behaviors.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

An online skin cancer risk-reduction intervention for young adults: Mechanisms of effects

OBJECTIVE

The study's purpose was to investigate moderator, implementation, and mediator variables related to the efficacy of UV4.me, an Internet intervention that decreased ultraviolet radiation (UV) exposure and increased skin protection behaviors among young adults.

METHOD

A total of 965 18-25 year olds at risk for skin cancer were recruited nationally online. Participants were randomized to an experimental website (UV4.me), a control website, or assessment only. Participant characteristics (moderators), engagement with and perceptions of interventions (implementation measures), and exposure and protection attitudinal variables (mediators) were assessed. Linear regression and mediation analyses were conducted.

RESULTS

Intervention effects on skin protection were greater for participants with a family history of skin cancer (p = .01). Intervention effects on UV exposure were greater among recent indoor tanners (p = .04). Improvements in skin protection (but not UV exposure) were associated with perceiving the interventions as satisfying or helpful (ps < .01). The experimental group had better outcomes if they completed more modules (ps < .01) or set more behavioral goals (ps < .01). Knowledge and exposure decisional balance mediated intervention effects for UV exposure (ps < .05), and protection decisional balance, self-efficacy, and intentions mediated intervention effects for protection (ps < .05).

CONCLUSIONS

The experimental intervention was more efficacious for certain high risk groups. The more individuals liked and engaged with the interventions (e.g., by setting goals), the better their outcomes. Mediation results inform theory about change mechanisms and differed by behavioral outcome. (PsycINFO Database Record

Relationship factors and couples' engagement in sun protection

Individuals may be more motivated to adopt health practices if they consider the benefits of these behaviors for their close relationships. The goal of this study was to examine couple concordance with sun protection and use the interdependence and communal coping theory to evaluate the role of relationship factors in sun protection. One hundred and eighty-four married couples aged 50 years and older completed measures of objective skin cancer risk, perceived risk, sun protection benefits, relationship-centered motivations for sun protection, discussions about sun protection, and sun protection. A mediational model was evaluated. Results indicated a high level of couple concordance. Partners who adopted a relationship-centered motivation for sun protection were more likely to discuss sun protection with one another, and partners who discussed sun protection together were more likely to engage in sun protection. One partner's attitude about personal risk and sun protection benefits was associated with the other partner's sun protection. Wives had higher relationship-centered motivation and discussed sun protection more with their husbands. Behavioral interventions may benefit from encouraging couples to discuss sun protection and encouraging married individuals to consider the benefits of sun protection for their relationship and for their spouse's health.

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

INTRODUCTION

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

STUDY DESIGN

RCT conducted in 2014, with data analyzed in 2015.

SETTING/PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Visual Exemplification and Skin Cancer: The Utility of Exemplars in Promoting Skin Self-Exams and Atypical Nevi Identification

The present article reports an experiment investigating untested propositions of exemplification theory in the context of messages promoting early melanoma detection. The study tested visual exemplar presentation types, incorporating visual persuasion principles into the study of exemplification theory and strategic message design. Compared to a control condition, representative visual exemplification was more effective at increasing message effectiveness by eliciting a surprise response, which is consistent with predictions of exemplification theory. Furthermore, participant perception of congruency between the images and text interacted with the type of visual exemplification to explain variation in message effectiveness. Different messaging strategies influenced decision making as well, with the presentation of visual exemplars resulting in people judging the atypicality of moles more conservatively. Overall, results suggest that certain visual messaging strategies may result in unintended effects of presenting people information about skin cancer. Implications for practice are discussed.

Sociocultural experiences, body image, and indoor tanning among young adult women

The purpose of this survey study was to evaluate a model of body image influences on indoor tanning behavior. Participants were 823 young adult women recruited from a probability-based web panel in the United States. Consistent with our hypothesized model, tanning-related sociocultural experiences were indirectly associated with lifetime indoor tanning use and intentions to tan as mediated through tan surveillance and tan dissatisfaction. Findings suggest the need for targeting body image constructs as mechanisms of behavior change in indoor tanning behavioral interventions.

Inflammatory Bowel Disease and Skin Cancer: An Assessment of Patient Risk Factors, Knowledge, and Skin Practices

Objective. Patients with inflammatory bowel disease (IBD) are at increased risk from skin cancer. Aims include assessing IBD patients' risk factors and knowledge of skin cancer and current skin protection practices to identify gaps in patient education regarding skin cancer prevention in IBD. Methods. IBD patients ≥ 18 years were recruited to complete an online survey. Results. 164 patients (mean age 43.5 years, 63% female) with IBD (67% Crohn's disease, 31% ulcerative colitis, and 2% indeterminate colitis) were included. 12% (n = 19) of patients had a personal history and 34% (n = 55) had a family history of skin cancer. Females scored better on skin protection (16.94/32 versus 14.53/32, P ≤ 0.03) and awareness (35.16/40 versus 32.98/40, P ≤ 0.03). Patients over 40 years old scored better on prevention (17.45/28 versus 15.35/28, P = 0.03). Patients with skin cancer scored better on prevention (20.56/28 versus 15.75/28, P ≤ 0.001) and skin protection (21.47/32 versus 15.33/32, P ≤ 0.001). 61% of patients recognized the link between skin cancer and IBD. Conclusions. The majority of IBD patients are aware of the link between skin cancer and IBD; however, skin protection practices are suboptimal. This emphasizes the role of healthcare professionals in providing further education for skin cancer prevention in the IBD population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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