American College of Preventive Medicine practice policy statement: skin protection from ultraviolet light exposure. The American College of Preventive Medicine

Cosmeceutical Therapy: Engaging the Repercussions of UVR Photoaging on the Skin's Circadian Rhythm

Sunlight is an important factor in regulating the central circadian rhythm, including the modulation of our sleep/wake cycles. Sunlight had also been discovered to have a prominent influence on our skin's circadian rhythm. Overexposure or prolonged exposure to the sun can cause skin photodamage, such as the formation of irregular pigmentation, collagen degradation, DNA damage, and even skin cancer. Hence, this review will be looking into the detrimental effects of sunlight on our skin, not only at the aspect of photoaging but also at its impact on the skin's circadian rhythm. The growing market trend of natural-product-based cosmeceuticals as also caused us to question their potential to modulate the skin's circadian rhythm. Questions about how the skin's circadian rhythm could counteract photodamage and how best to maximize its biopotential will be discussed in this article. These discoveries regarding the skin's circadian rhythm have opened up a completely new level of understanding of our skin's molecular mechanism and may very well aid cosmeceutical companies, in the near future, to develop better products that not only suppress photoaging but remain effective and relevant throughout the day.

Skin Examination Practices Among Melanoma Survivors and Their Children

Many professional organizations recommend skin self-examination (SSE) as a tool for early detection of malignancy among melanoma survivors, a growing population that is at increased risk for new or recurrent melanoma. This study examined the frequency and correlates of SSE use among melanoma survivors. Additionally, we assessed skin exam use among children of survivors, who are at elevated lifetime risk for the disease. The California Cancer Registry was used to identify melanoma survivors, who were contacted, screened for eligibility, and invited to participate in a survey. The survey, administered by mail, web, or telephone, assessed a broad range of topics related to melanoma prevention in high-risk families. The present study focuses on skin examination practices of survivors and their children and potential correlates of these practices. Among a sample of 316 melanoma survivors, fewer than one in five participants performed monthly skin self-exams, a lower rate than that observed in previous studies. Although greater family history of melanoma, use of skin protection strategies, and the perceived severity of melanom were associated with more frequent use of skin self-exams, these relationships disappeared in adjusted analyses. Participants reported unexpectedly frequent use of skin examinations for their children despite the lack of professional guidelines for this practice. Interventions are needed to improve skin self-examination practices among melanoma survivors and to counsel parents about optimal melanoma prevention strategies for their children.

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.

Sun protection practices among children with a family history of melanoma: a pilot study

The goal of this pilot study was to assess sun protection practices and correlates among children with a family history of melanoma, a high risk and understudied group. Sixty-eight melanoma cases, recruited through the Los Angeles County cancer registry, completed a survey. Survivors provided data on 110 children (mean age = 8.11 years). Although most children used sunscreen (79 %), half experienced a recent sunburn. The mean sun protection level for the sample was similar to levels observed among average risk children. Efforts to reduce sunburn frequency and improve sun protection among these vulnerable children appear warranted.

Likelihood of dermatology patients to inquire about sun protection measures during a regular clinic visit

BACKGROUND

Health information-seeking behavior refers to ways individuals acquire health information. Few studies demonstrate its association with skin cancer.

OBJECTIVES

To determine the likelihood of patients to inquire about sun protection methods from dermatologists and whether such knowledge will affect their preventive behaviors.

METHODS

Over a 2-month period, 396 dermatology patients completed a survey assessing their sun awareness knowledge and inquiry about sun protection measures. Features associated with increased skin cancer risk were correlated with patients' inquiry about sun protection information and their future intentions to practice safe sun behavior.

RESULTS

One in seven patients (13.8%) inquired about sun protection measures. Patients with features known to be associated with increased skin cancer risk infrequently inquired about sun protection methods (4.5-23.8%). Post-physician counseling, patients with previous sun awareness education had a greater intention to use sunscreen routinely (41.4% vs 28.3%, p  =  .01), avoid the sun (31.2% vs 18.2%, p  =  .004), and wear sun-protective clothing (32.5% vs 23.2%., p  =  .05).

CONCLUSION

Patients' desire for medical information from physicians does not translate efficiently into seeking sun awareness information from dermatologists. Dermatologists should play a greater proactive role in skin cancer prevention through initiation of regular personalized discussions on sun awareness issues.

Physician sun protection counseling: prevalence, correlates, and association with sun protection practices among US adolescents and their parents, 2004

OBJECTIVE

To assess the population prevalence and correlates of ever receiving physician advice to practice sun protection (i.e. sun protection counseling) and whether such counseling is associated with sun protection behaviors in adolescents and their parents.

METHOD

Analysis of a nationally representative cross-sectional telephone survey of ultraviolet radiation exposure behaviors among US adolescents ages 11 to 18 and their parents, conducted between August and November 2004.

RESULTS

Forty-four percent of US adolescents and their parents reported physician sun protection counseling. Counseling was more frequently reported by adolescents whose parents were also counseled, reported other sun protection information sources (skin cancer prevention media messages and school sun safety messages), had first degree relatives with skin cancer, and were white, non-Hispanic. Counseling was positively associated with regular sunscreen use, appropriate sunscreen application practices, and intermittent hat use, but not with other recommended behaviors. Sunscreen use rates were generally higher among adolescents reporting several sun protection information sources (counseling, media and school messages) than those with combinations of two or fewer of these sources.

CONCLUSIONS

The role of physicians, either independently or in concert with other information sources, should be explored in strategies promoting primary skin cancer prevention behaviors among adolescents and parents.

Familial cutaneous melanoma

Approximately 5-10 % of all cutaneous melanomas occur in families with hereditary melanoma predisposition. Worldwide, approximately 20-40% of kindreds with familial elanoma harbor germline mutations in the CDKN2A gene, located on chromosome 9p21, which encodes two different proteins, p16INK4 and p14ARF, both involved in regulation of cell cycle progression and induction of senescence. In different populations several recurring CDKN2A founder mutations have been described. The risk of melanoma in CDKN2A mutations carriers varies between populations and is higher in regions with high sun exposure and high incidence of melanoma in the general population. Some CDKN2A mutations have been associated not only with melanoma but also with increased risk of other malignancies--most notably pancreatic carcinoma. A much smaller number of families have germline mutations in the CDK4 gene on chromosome 12q14, encoding a cyclin dependent kinase which normally interacts with p16INK4A. The management of families with hereditary melanoma is discussed.

Ineffectiveness of sun awareness posters in dermatology clinics

BACKGROUND

Although sun awareness posters have been used in doctors' offices and clinics for decades to promote sun protective behaviour, there is no evidence of their usefulness.

OBJECTIVES

To investigate whether sun awareness posters lead to inquiry of skin cancer and sun protection measures.

METHOD

Patients considered at risk for skin cancer seen at a dermatology clinic were randomly asked to complete a questionnaire designed to assess the effectiveness of three different sun awareness posters placed in patient rooms. The posters were selected on the basis of their catchy slogan and eye-appealing images, and included those featuring parental interest, sex appeal and informative advice.

RESULTS

Only half of the patients noticed the posters (50.6%). The poster with sex appeal garnered the most attention (67.8%), followed by the informative poster (49.2%) and the parental interest poster (35.8%) (P < 0.001). Although patients who noticed the sun awareness poster inquired about cutaneous cancers and sun protection practices twice as often as those who did not notice the poster, only one-tenth of such inquiries were attributed to the poster ( approximately 5% of the target population). As reported in the questionnaire, the posters themselves were less effective than the advice of physicians in influencing patient attitudes towards sun protection measures.

CONCLUSION

Organizations that produce and disseminate posters should consider beyond focus groups when they design their posters and should consider field testing their products to ensure that they are reaching the targeted audience and are having the expected beneficial effect, otherwise their posters are simply decorative.

[Behaviors related to sunlight exposure versus protection in a random population sample from 15 Brazilian State capitals and the Federal District, 2002-2003]

This article examines region-specific relations between prevalence of protection against sunlight and socio-demographic and behavioral variables in Brazil. Data were derived from a cross-sectional population-based random sample. Information on sunlight exposure was available for a total of 16,999 individuals 15 years and older. Comparing the North and South of Brazil, crude differences between women and men in the use of "sunscreen" and "protective headwear" were +10.9% (95%CI: 7.1; 14.6) and -11.6% (95%CI: -17.0; -6.3) in the North and +21.3% (95%CI: 17.7; 24.9) and -16.0% (95%CI: -20.2; -12.5) in the South. Adjusted differences by selected variables confirmed that women use more sunscreen protection and less headwear protection as compared to men in both the North and South, but the difference was not homogeneous by region (interaction term p value < 0.05).

Awareness, knowledge and attitudes towards sun protection among skin cancer-treated patients in France

BACKGROUND

The incidence of skin cancer has risen over the past years, owing to increased exposure to ultraviolet radiation. Sun protection measures include avoiding exposure to the sun, using covering clothing and applying sunscreen. We evaluated the knowledge and compliance with advices about sun protection in a population of patients who had presented skin tumour(s).

SUBJECTS AND METHODS

A 30 question self-reporting questionnaire evaluating sun protective behaviour was distributed to 217 consecutive skin cancer-treated patients and completed by 198 of them.

RESULTS

72% of the responders had presented a melanoma, and 26% of them had presented only non-melanoma skin cancer. The present survey shows that patients who have had a skin cancer were aware of the cancer related risk of sunlight since 98% of the responders knew that ultraviolet radiations can include skin cancer. These patients did also take sun-protective measures because 73% of them had worn covering clothes when in the sun and 59% of them avoided outdoor activities during the midday hours.

CONCLUSION

These results suggest that, after diagnosis of a skin cancer, patients limited their sun exposure; and wear protective clothing. However, sun-protection measures did not seem to be completely adequate. An evaluation of the various barriers to sun safety might be a key to understanding the sub-optimal sun protection.

Skin cancer prevention in the primary care setting: assessment using a standardized patient

Our objective was to utilize the standardized patient technique in assessing the ability of primary care physicians to identify and counsel primary prevention for patients at high risk for skin cancer. A secondary goal was to test the feasibility of this technique as a measure of actual physician behaviors in the outpatient setting. We used a convenience sample of 15 primary care physicians. The standardized patient was an 18-year-old woman with skin phototype I. She presented to physicians as needing a general physical examination for a summer lifeguard job at a beach. She stated a family history of skin cancer. Physician performances were rated using a standard checklist completed by the standardized patient following each visit. We found that none of the physicians asked questions specifically related to skin phototype or sun exposure habits such as childhood sunburns. Only 13% asked about mole changes. For counseling, 67% of physicians recommended sunscreen use; only 7% discussed sunscreen types or procedures for effective use. Only 13% counseled other skin protective behaviors. No significant differences by physician gender were found in these areas; however, female physicians counseled more global health behaviors than male physicians (p < or = 0.01). Our pilot data suggest that little skin cancer primary prevention counseling is performed for high-risk patients. The standardized patient technique worked well in obtaining outcome data for physicians' preventive practices.

Do adolescent indoor tanners exhibit dependency?

BACKGROUND

Indoor tanning is a common adolescent risk behavior that has been hypothesized to be motivated and maintained by the mood-altering effects of ultraviolet light.

OBJECTIVE

Our purpose was to explore heretofore anecdotal reports that indoor tanning leads to dependency.

METHODS

A telephone interview was conducted among 1275 adolescents, ages 14 to 17 years. Self-reported difficulty in quitting indoor tanning was assessed among 267 adolescents (20.9% of total) who tanned indoors more than once in the previous year in relation to age of initiation, frequency of use, and positive or negative consequences of the practice.

RESULTS

Difficulty in quitting was more likely with younger age at initiation (age 13 years or younger vs ages 16 to 17; odds ratio = 4.3, 95% confidence interval 1.3-14.7) and higher frequency of use (P = .009), even after accounting for positive or negative consequences of indoor tanning and other demographic characteristics.

LIMITATIONS

This was a cross-sectional study design with a limited outcome measure.

CONCLUSION

Although preliminary, our findings for age at initiation and frequency of use in relation to difficulty in quitting indoor tanning are consistent with other potentially addictive behaviors taken up during adolescence.

Cutaneous melanoma

Episodic exposure of fair-skinned individuals to intense sunlight is thought to be responsible for the steadily increasing melanoma incidence worldwide over recent decades. Rarely, melanoma susceptibility is increased more than tenfold by heritable mutations in the cell cycle regulatory genes CDKN2A and CDK4. Effective treatment requires early diagnosis followed by surgical excision with adequately wide margins. Sentinel lymph node biopsy provides accurate staging, but no published results are yet available from clinical trials designed to assess the therapeutic efficacy of early complete regional node dissection in those with metastatic disease in a sentinel node. Magnetic resonance spectroscopy is one technique under investigation for non-invasive, in-situ assessment of sentinel nodes. Localised metastatic disease is best treated surgically. No postoperative adjuvant therapy is of proven value for improving overall survival, although numerous clinical trials of vaccines and cytokines are in progress. Medical therapies have contributed little to the control of established metastatic disease, but molecular pathways recently identified as being central to melanoma growth and apoptosis are under intense investigation for their potential as therapeutic targets.

Indoor tanning by adolescents: prevalence, practices and policies

Despite known acute and chronic health effects from the use of indoor tanning, including the potential for all forms of skin cancer, the practice is popular in the United States (US) and Europe. A review of the scientific literature that examines adolescents and indoor tanning use was undertaken, summarising what is known about prevalence and practices among adolescents, characteristics associated with adolescent use, and policies that regulate adolescent access to indoor tanning facilities. The prevalence of indoor tanning is consistently found to be higher among girls than boys and to increase with age in both Europe and the US. An examination of other demographic characteristics, skin cancer risk factors, knowledge, attitudes and social factors points to higher prevalence of the behaviour among adolescents with positive attitudes towards tans and whose friends or parents also tan indoors. Adolescent access to indoor tanning is rarely regulated in the US or Europe, and where regulations exist, business compliance is low. In addition, businesses actively market their product to adolescents as they organise to limit further regulations prohibiting adolescent access. Pricing, licensure, advertising restrictions and media campaigns, in combination with adolescent-targeted interventions, are possible strategies that could be tested for their effectiveness to reduce adolescent indoor tanning use. Harm reduction policies, such as eye protection, that reduce risk for adolescents who choose to tan indoors, are also important.

Maternal/female caregiver influences on adolescent indoor tanning

PURPOSE

To identify aspects of maternal/female caregiver (MFC) influences on adolescents' indoor tanning, including modeling, cognitions (MFC knowledge and attitudes about indoor tanning), and gatekeeping/monitoring (MFC permissiveness and concern) of indoor tanning.

METHODS

A telephone survey of adolescents aged 14-17 years and their female parent/caregiver in Minnesota and Massachusetts was conducted in 2000-2001 (n = 1284 matched pairs). Logistic regression was used to obtain odds ratios for relationships between measures of MFC influence and teens' indoor tanning practices, adjusting for demographic and sun sensitivity differences.

RESULTS

Separately, each of the five MFC influence variables was significantly associated with adolescents' indoor tanning practices. In a multivariate model, significant independent contributors were parents' behavior, parents' concern about their children's indoor tanning practices, and MFC permissiveness of teen indoor tanning. Using a combined summed scale of the 5 influence factors, there was a monotonically increasing likelihood of tanning with each incremental scale increase: (in comparison to none, 1 factor aOR = 4.1, 95% CI: 1.3, 12.8; any 2 factors aOR = 8.3, 95% CI: 2.8, 24.6; any 3 factors aOR = 14.3, 95% CI = 4.9, 41.8; any 4 factors aOR = 30.5, 95% CI: 10.3, 90.3; all 5 factors aOR = 66.0, 95% CI: 20.0, 217.6).

CONCLUSIONS

Mothers/female caregivers may be a powerful influence on their teenagers' indoor tanning use, and are an important target for future health promotion efforts to discourage youth indoor tanning.

Management of acute sunburn

Current literature documents the use of many pharmacologic agents in the management of acute sunburn. While numerous studies have been undertaken, there is no consensus on an algorithm for such treatment. We review the literature for an evidence-based approach to the management of sunburn. A MEDLINE search was conducted whereby all published articles related to sunburn or ultraviolet (UV)-induced erythema from 1966-2001 were evaluated. Studies and reviews were excluded if they were not conducted in human beings. The results of these studies are varying and often conflicting in terms of clinical effectiveness or feasibility. A total of 40 studies were reviewed. Fourteen out of the 40 studies addressed the actual treatment of sunburn (i.e. the application of a substance after the development of signs or symptoms). The majority concluded that either corticosteroids, NSAIDs, antioxidants, antihistamines or emollients were ineffective at decreasing recovery time. The remaining studies showed mild improvement with such treatments, but study designs or methods were flawed. Furthermore, regardless of the treatment modality, the damage to epidermal cells is the same. Given the lack of convincing data and consensus of opinion regarding sunburn management, the most effective and practical approach to acute sunburn is symptomatic treatment of UV light-induced symptoms, including erythema, pain and pruritus.

Skin cancer prevention and detection by nurses: attitudes, perceptions, and barriers

BACKGROUND

To examine attitudes and perceptions of nurses with respect to skin cancer prevention and detection; to identify barriers to skin cancer prevention and detection by nurses.

METHODS

Descriptive survey of 457 nurses from the Texas State Board of Nurse Examiners in 1997.

RESULTS

Eighty-nine percent of the nurses reported that skin cancer was a serious problem, and 97% believed that many people were at risk. More than 89% stated that skin cancer prevention/detection would benefit patients, and 94% believed that such skills would benefit nurses. Eighty-four percent reported that it was in their scope of practice to teach skin cancer prevention to patients, and 61% stated that it was in their scope of practice to detect skin cancer in patients. Barriers to skin cancer prevention and detection included lack of national guidelines (69%), low priority among doctors (63%), and the belief that patients should take full responsibility for prevention (50%). Barriers to continuing education for skin cancer screening included lack of money (43%), not knowing how to obtain education (41%), time away from work (36%), and time away from home (26%).

CONCLUSIONS

These findings may suggest that nurses can play a role in skin cancer prevention and detection.

Barriers to sun safety in a Canadian outpatient population

BACKGROUND

It has long been recognized that compliance with recommended sun safety practices is suboptimal, yet few investigations have explored the barriers that people face in practicing good sun safety. In this context, barriers can exist at the following three levels: knowledge of sun safety, acquisition of sun safety information, and implementation of specific sun protective measures.

OBJECTIVE

The investigation reported herein sought to elucidate barriers to sun safety that individuals face. Ultimately, this study aimed to qualify the possible barriers that lead to a misalignment of current recommendations and sun safety practices.

METHODS

The study design was observational, and the instrument used for data collection was a self-administered questionnaire. Thirty-four outpatients of the RK Schachter Dermatology Centre of Sunnybrook and Women's College Health Sciences Centre (SWCHSC), Toronto, Ontario, as well as 27 outpatients of the Sport Care facility of SWCHSC were enrolled in the study. They represent the target population of those who are at greater risk of developing sun-related skin lesions. Data were analyzed using standard parametric and nonparametric techniques. Comparisons were made between the two outpatient groups and between other groups within the sample.

RESULTS

In general, level of sun safety knowledge was fairly high, though compliance to sun safety measures was suboptimal in both populations. There were no significant differences regarding level of knowledge between the 2 outpatient groups. Deficiencies in knowledge centered around risk factors for skin cancer. Frequently cited barriers to sun safety include inconvenience (34% of respondents), forgetting to use sun safety measures (49%), a desire to be tanned (33%), and protective clothing being too hot to wear (56%). High compliers were notable for their great likelihood of being counseled by a physician about sun safety ( P < 0.025) and their slightly higher mean knowledge scores.

CONCLUSIONS

These data support that knowledge alone does not predict compliance and that sun awareness campaigns should be evaluated based on their ability to affect behavior.

Skin cancer prevention: education and public health issues

OBJECTIVES

To examine current public health initiatives related to skin cancer prevention and early detection, and public education issues.

DATA SOURCES

Review articles, research reports, web sites, and government reports.

CONCLUSIONS

Skin cancer remains a major public health problem. Efforts to decrease the morbidity and mortality associated with skin cancer are gradually shifting toward primary prevention. Primary prevention efforts should not only be limited to using sunscreen, but should also focus on reductions in ultraviolet light exposure. Secondary prevention efforts include professional skin examinations and skin self-examination. Tertiary efforts focus on the prevention and detection of additional primary skin cancers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can influence the public to practice primary, secondary, and tertiary prevention strategies for skin cancer.

The adolescent traveler

Oh, to travel again with the carefree attitude of the adolescent! Yet most readers will think that this enormous list of precautions would merit never letting the adolescent out of the house. The traveler and his or her provider can be reassured that with appropriate (and confidential) forethought, the journeys that lie ahead can be joyful and healthy. The bottom line? The more information obtained before travel both for the traveler and his or her family, the less morbidity will be incurred. The primary care provider is in the perfect position to provide all of these services to the adolescent traveler.

Using nurse practitioners for skin cancer screening: a pilot study

BACKGROUND

Skin cancer screening has the potential to detect early precancerous lesions and may ultimately be important in reducing melanoma mortality. The purpose of this study was to evaluate the ability of trained nurse practitioners to accurately identify suspicious lesions in a clinical setting.

METHODS

We identified five nurse practitioners who had no previous experience in evaluating skin lesions. Each nurse practitioner participated in a training program for skin cancer detection consisting of a workshop, clinical apprenticeship, and didactic lectures.

RESULTS

Evaluation of nurse practitioner competency involved three assessments. First, the nurse practitioner's ability to distinguish benign and malignant lesions was assessed using clinical color slides. The sensitivity of all five nurse practitioners to refer benign and malignant lesions for dermatologic follow-up based on the slides was 100%, whereas the specificity ranged from 53% to 100%. Second, each nurse practitioner evaluated approximately 25 different patients along with a single dermatologist. The nurse practitioner's ability to correctly refer patients with suspicious lesions for dermatologic follow-up was determined based on the dermatologist's assessment of need for referral. Results suggested a referral sensitivity and specificity ranging from 67% to 100% and 62% to 100%, respectively. In the final clinical assessment, 30 patients were independently examined by two dermatologists and four nurse practitioners. Using the consensus clinical diagnosis of the dermatologists as the gold standard, the nurse practitioner's sensitivity for detecting significant skin cancer lesions ranged from 50% to 100% and the detection specificity was 99% to 100%.

CONCLUSIONS

These preliminary results have important implications for skin cancer screening efforts and suggest that nurse practitioners can be trained to accurately identify and triage suspicious lesions.

Skin cancer screening and prevention in the primary care setting: national ambulatory medical care survey 1997

OBJECTIVE

To describe skin cancer prevention and screening activities in the primary care setting and to compare these findings to other cancer screening and prevention activities.

DESIGN

Descriptive study.

SETTING/PATIENTS

National Ambulatory Medical Care Survey 1997 data on office-based physician visits to family practitioners and internists.

MEASUREMENTS AND MAIN RESULTS

Data were obtained on 784 primary care visits to 109 family practitioners and 61 internists. We observed that the frequency of skin cancer prevention and screening activities in the primary care setting was much lower than other cancer screening and prevention activities. Skin examination was reported at only 15.8% of all visits (17.4% for family practitioners vs 13.6% for internists, P >.1). For other cancer screening, the frequencies were as follows: breast examination, 30.3%; Papanicolaou test, 25.3%; pelvic examination, 27.6%; and rectal examination, 17.9%. Skin cancer prevention in the form of education and counseling was reported at 2.3% of these visits (2.9% for family practitioners vs 1.5% for internists, P >.1), while education on breast self-examination, diet and nutrition, tobacco use, and exercise was 13.0%, 25.3%, 5.7%, and 17.9%, respectively.

CONCLUSIONS

The results of this study indicate that the proportion of primary care visits in which skin cancer screening and prevention occurs is low. Strategies to increase skin cancer prevention and screening by family practitioners and internists need to be considered.

Predicting children's sunscreen use: application of the theories of reasoned action and planned behavior

BACKGROUND

Skin cancer remains the most common form of cancer in the United States despite the fact that most cases can be prevented by limiting sun exposure. Childhood and adolescence are periods of life during which prolonged sun exposure is particularly common. Accordingly, promoting sun-protective behaviors during these formative years can be of critical importance in preventing skin cancer. The present study applied the theories of reasoned action and planned behavior to the understanding of children's sunscreen use. Based on these theories, it was hypothesized that attitudes, subjective norms, and perceived behavioral control would be related to intentions to use sunscreen, which, in turn, would be related to actual sunscreen use.

METHODS

Questionnaires measuring sun-related attitudes, beliefs, perceived control, and intentions were administered to 199 fourth graders (ages 9 to 13, mean = 10.3) attending public schools in Florida. Self-report measures of sun-related behavior were administered to the same subjects 1 month later.

RESULTS

Results of correlational analyses were consistent with study hypotheses. Higher rates of sunscreen use at follow-up were predicted by stronger intentions to use sunscreen assessed 1 month previously. In addition, stronger intentions to use sunscreen were found to be related to more favorable attitudes toward sunscreen use, stronger beliefs that peers and parents favored sunscreen use, and greater perceptions of personal control in using sunscreen. Path and multiple regression analyses identified direct and indirect relationships among study variables that partially confirmed those predicted by the theories and provided support for the use of an expanded model that included perceived behavioral control.

CONCLUSIONS

The present study confirmed hypotheses derived from the theories of reasoned action and planned behavior regarding the relation of attitudes, subjective norms, and perceived behavioral control to sunscreen use among fourth graders. In addition to their theoretical significance, these findings suggest ways to intervene at the individual, classroom, and family levels to promote greater sunscreen use in this age group.