Compliance and data reliability in sun exposure studies with diaries and personal, electronic UV dosimeters

Associations between sun exposure, skin pH, and epidermal permeability in pregnancy: A longitudinal observational study

Little is known about how sun exposure may affect the maternal skin barrier during pregnancy when many hormonal and physiological changes occur. In this longitudinal observational study, 50 pregnant women were recruited at 18-24 weeks' gestation, 25 in summer-autumn, and 25 in winter-spring. At three time points in pregnancy at 18-24, 28-30, and 36-38 weeks' gestation, participants completed a validated sun exposure questionnaire and had skin permeability and surface pH measured on the volar forearm. We identified an association between increased sun exposure and increased skin permeability at 18-24 weeks' gestation (β = 0.85, p = 0.01). Lower transepidermal water loss (decreased skin permeability), mean = 12.1 (SD = 5.1) at 28-30 weeks' gestation was observed, compared to mean = 12.6 (SD = 4.0) at 18-24 weeks' and mean = 13.7 (SD = 8.5) at 36-38 weeks' gestation (n = 27, β = -1.83, p = 0.007). Higher skin pH readings, mean = 5.80 (SD = 0.58) were found at 28-30 weeks' gestation, compared to mean = 5.25 (SD = 0.62) at 18-24 weeks' and mean = 5.47 (SD = 0.57) at 36-38 weeks' gestation (n = 27, β = 0.40, p = 0.004). These gestational fluctuations remained after adjusting for Fitzpatrick skin type, season, and sun exposure. We observed gestational fluctuations in both skin permeability and skin pH, with 28-30 weeks' gestation being a significant point of difference compared to mid- and late-pregnancy periods.

Associations Between Multidimensional Sleep Health Parameters and Adolescents' Self-reported Light Exposure in the Free-living Environment

The objective of this study was to characterize the associations between light exposure in the free-living environment and multiple dimensions of sleep health of typically developing adolescents. Fifty-six (29 girls, 27 boys) typically developing adolescents (mean age = 13.59, SD = 0.89, range = 12-17 years) participated. For six consecutive nights, sleep was assessed in the home environment using actigraphy. During the same period, participants were asked to fill out a daily sleep log and a daily light exposure log, and to complete questionnaires regarding their alertness and subjective sleep satisfaction. Longer self-reported exposure to daylight in the morning was associated with longer objectively measured sleep duration. Longer self-reported exposures to electronic devices in the evening were associated with later objectively measured sleep onset and offset times, shorter sleep duration, and greater day-to-day sleep variability. Longer morning exposure to outdoor light was associated with a longer sleep duration. Self-reported light exposure was not associated with sleep satisfaction, alertness/sleepiness, or sleep efficiency. Among the covariates, circadian preference accounted for the highest percentage of variance. Adolescents' sleep health is associated with the self-reported duration of exposure to daylight in the morning and to electronic devices in the evening.

Ultraviolet exposure to the face in patients with xeroderma pigmentosum and healthy controls: applying a novel methodology to define photoprotection behaviour

BACKGROUND

In Xeroderma Pigmentosum (XP), the main means of preventing skin and eye cancers is extreme protection against ultraviolet radiation (UVR). Protection is most important for the face.

OBJECTIVES

We aimed to assess how well patients with XP adhere to medical advice to protect against UVR by objectively estimating the mean daily dose of UVR to the face.

METHODS

We objectively estimated the UVR dose to the face in 36 XP patients and 25 healthy individuals over 3 weeks in the summer. We used a new methodology which combined UVR dose measurements from a wrist-worn dosimeter with an activity diary record of face photoprotection behaviour for each 15 minute period spent outside. A protection factor was associated with each behaviour, and the data analysed using a negative binomial mixed-effects model.

RESULTS

The mean daily UVR dose (weighted for DNA damage capacity) to the face in the XP patients was 0.13 Standard Erythemal Doses (SED) (mean in healthy individuals = 0.51 SED). There was wide variation between patients (range <0.01 - 0.48 SED/day). Self-caring adult patients had a very similar UV dose to the face to cared-for patients (0.13 vs 0.12 SED/day) despite photoprotecting much more poorly when outside, because the self-caring adults were outside in daylight much less.

CONCLUSIONS

Photoprotection behaviour varies widely within the XP group indicating that non-adherence to photoprotection advice is a significant issue. Timing and duration of going outside are as important as photoprotective measures taken when outside, to determine the UVR exposure to the face. This new methodology will be of value in identifying the sources of UVR exposure in other conditions where facial UV exposure is a key outcome, particularly in patients with multiple non-melanoma skin cancers.

Review on Occupational Personal Solar UV Exposure Measurements

During leisure time, people can decide if they want to expose themselves to solar ultraviolet (UV) radiation and to what extent. While working, people do not have this choice. Outdoor workers are exposed to solar UV radiation (UVR) on a daily basis. This may pose a certain health risk, which can be estimated when the personal solar UVR exposure (PE) is known. During past decades, a variety of studies were conducted to measure PE of outdoor workers and our knowledge of the PE of outdoor workers has increased remarkably. As shown by this review, studies clearly indicate that PE of most outdoor workers exceeds the internationally proposed threshold limit value, which is comparable to 1.0 to 1.3 standard erythema dose (SED), respectively, to 1.1 to 1.5 UV Index received over one hour. Besides working in a high UVR environ, monotonic workflow (limited movement, nearly static posture) is a risk factor. In such cases, PE can be higher than ambient UVR. In this review, we provide also a list of milestones, depicting the progress and the most important findings in this field during the past 45 years. However, in many respects our knowledge is still rudimentary, for several reasons. Different measuring positions have been used so that measured PE is not comparable. Few studies were designed to enable the extension of measured PE to other locations or dates. Although the importance of a proper calibration of the measuring devices in respect to the changing solar spectrum was pointed out from the beginning, this is often not performed, which leads to high uncertainties in the presented PE levels. At the end of our review, we provide some key points, which can be used to evaluate the quality of a study respectively to support the design of future studies.

The Potential of Ultraviolet Radiation Meters in Secondary Schools as a Sun Protection Intervention Mechanism for Adolescents

The aim of this pilot study was to assess whether the installation of ultraviolet radiation (UVR) meters in secondary schools has the potential to improve adolescents’ sun protection-related knowledge, attitudes, and behaviours and reduce their exposure to UVR during school hours. Data were collected from students at two schools via online pre- and post-intervention surveys, measurement of sunscreen usage, polysulfone UVR exposure badges, and photographs of the schoolyards to assess hat and shade use. Several operational issues limited the quantity and quality of data that could be collected, and findings were mixed. While there were no significant changes in either self-reported or observed sun protection behaviours, there were significant improvements in UVR knowledge among students at the intervention school, and reactions to the meter were highly favourable. Students reported consulting the meter regularly and using it to make decisions about their sun protection behaviours. Overall, the study results offer some support for the use of UVR meters in areas frequented by adolescents and provide insights into the process issues that are likely to need to be addressed when attempting to trial sun protection interventions in schools.

Assessing recall of personal sun exposure by integrating UV dosimeter and self-reported data with a network flow framework

BACKGROUND

Melanoma survivors often do not engage in adequate sun protection, leading to sunburn and increasing their risk of future melanomas. Melanoma survivors do not accurately recall the extent of sun exposure they have received, thus, they may be unaware of their personal UV exposure, and this lack of awareness may contribute towards failure to change behavior. As a means of determining behavioral accuracy of recall of sun exposure, this study compared subjective self-reports of time outdoors to an objective wearable sensor. Analysis of the meaningful discrepancies between the self-report and sensor measures of time outdoors was made possible by using a network flow algorithm to align sun exposure events recorded by both measures. Aligning the two measures provides the opportunity to more accurately evaluate false positive and false negative self-reports of behavior and understand participant tendencies to over- and under-report behavior.

METHODS

39 melanoma survivors wore an ultraviolet light (UV) sensor on their chest while outdoors for 10 consecutive summer days and provided an end-of-day subjective self-report of their behavior while outdoors. A Network Flow Alignment framework was used to align self-report and objective UV sensor data to correct misalignment. The frequency and time of day of under- and over-reporting were identified.

FINDINGS

For the 269 days assessed, the proposed framework showed a significant increase in the Jaccard coefficient (i.e. a measure of similarity between self-report and UV sensor data) by 63.64% (p < .001), and significant reduction in false negative minutes by 34.43% (p < .001). Following alignment of the measures, under-reporting of sun exposure time occurred on 51% of the days analyzed and more participants tended to under-report than to over-report sun exposure time. Rates of under-reporting of sun exposure were highest for events that began from 12-1pm, and second-highest from 5-6pm.

CONCLUSION

These discrepancies may reflect lack of accurate recall of sun exposure during times of peak sun intensity (10am-2pm) that could ultimately increase the risk of developing melanoma. This research provides technical contributions to the field of wearable computing, activity recognition, and identifies actionable times to improve participants' perception of their sun exposure.

What Do Adolescents See on Social Media? A Diary Study of Food Marketing Images on Social Media

Food marketing influences eating preferences and choices, especially among adolescents, contributing to the rise of overweight, obesity, and other chronic health disorders. Recent social media advancements have provided food marketers with platforms to reach out to many in more personal and authentic ways as compared to classical media advertising. Such personalized and borderless social media platforms allow marketers to easily use owned, paid, and earned (word-of –mouth) marketing strategies, including paid and non-paid influencers to reach younger target audiences. This study therefore aims to explore food messages adolescents (12–18 years old) encounter on social media, and assess these messages for their sources, the presence of core and non-core food, and the marketing strategies employed. To attain an in-depth understanding of the food messages that adolescents are continuously exposed to, we carried out a diary study with 21 Flemish adolescents who took screenshots of food images they encountered on their social media platforms for the duration of one week. A quantitative and qualitative content analysis of 611 images revealed that adolescents are mostly exposed to messages of non-core (67% of images) and branded (49% of images) food, often (49% of images) presented in association with a social context such as hanging around with friends, eating at restaurants and celebrating with food. Adolescents often encounter branded food images through peers and social media influencers, the majority of which are part of earned (49% of branded images) or paid (40% of branded images) media food marketing. This research provides an in-depth understanding of the social media messages that adolescents encounter on a daily basis and sheds light on food norms typically communicated on social media by marketers, peers, and influencers. Study findings highlight prominent social media food messages that should be tested for their persuasiveness, providing insights for future research that aims to assess the effects of social media food marketing on adolescents. Based on the study findings, we call for relevant policy actions that address current social media marketing strategies targeted at adolescents.

Reported light in the sleep environment: enhancement of the sleep diary

BACKGROUND

Light is the primary synchronizing cue for the circadian timing system, capable of exerting robust physiological effects, even with very dim and/or brief photic exposure. Mammals, including humans, are particularly susceptible to light at night. As such, measures of light in the sleeping environment are critical for evaluating sleep health. Sleep diaries provide inexpensive measures of sleep, but do not typically include light information.

METHODS

Four questions probing visual perception of light in the bedtime and waking environments were added to the Consensus Sleep Diary for Morning administration. As part of a lighting intervention study, 18 hospital Labor and Delivery Department personnel completed the sleep diary for 1 week in each of two experimental conditions while wearing Actiwatch devices equipped with photosensors. Diary responses were evaluated against photosensor values from the beginning and end of each rest interval (n=194 rest intervals), as well as against sleep measures, utilizing linear mixed models.

RESULTS

Responses to light questions were related to actual light measures at bedtime, controlling for shift type and experimental condition. In addition, subjective light information at bedtime and waking was related to both objective and subjective sleep parameters, with data generally indicating poorer sleep with light in the sleeping environment.

CONCLUSION

Questions addressing perception of light in the sleeping environment may provide a crude yet affordable metric of relative photic intensity. Further, as responses relate to sleep outcomes, subjective light information may yield valuable insights regarding mechanisms and outcomes of clinical significance in sleep and circadian research.

Adult UVR exposure changes with life stage - a 14-year follow-up study using personal electronic UVR dosimeters

Over a period spanning 14 years (1999-2001, 2006 and 2012), 31 volunteers participated in sun behaviour studies with the same protocol wearing a personal, electronic wrist-borne UVR dosimeter and completed sun exposure diaries resulting in a total of 15 946 measurements days (126 days per person per year). The participants individually maintained their UVR dose level and behaviour over the years. No statistically significant differences were seen from year to year in the "estimated annual UVR dose", the "mean UVR dose per day", the "mean percentage of ambient UVR", "days sunbathing to get a tan", "days with intermittent exposure" or in "sunburn episodes". The 20 participants still active in the labour market used sunscreen on more days in 2012 than in 1999 (p = 0.019) and with a significantly higher SPF (sun protecting factor (p < 0.001)) resulting in significantly fewer days with risk behaviour without sunscreen applied in 2012 than in 2006 (p < 0.001) and 1999 (p < 0.003). This was in contrast to the 11 participants who retired during the study period. The retired group received a non-significant 45% higher UV dose in 2012 than in 1999 (p = 0.054). In an additional study, nine 30-year-old indoor workers (high school students in the 1999 study) had changed their sun exposure pattern and had fewer days sunbathing (p = 0.008) and fewer risk behaviour days without sunscreen applied in 2012 than in 1999 (p = 0.002). Conclusion: The participants still active in the labour market maintained their sun exposure behaviour over a 14-year period. The retirees had a higher UVR dose and riskier exposure behaviour after retirement, while the high school students had changed to less risky sun behaviour on becoming indoor workers.

Children sustain high levels of skin DNA photodamage, with a modest increase of serum 25-hydroxyvitamin D3 , after a summer holiday in Northern Europe

BACKGROUND

Childhood solar ultraviolet radiation (UVR) exposure increases the risk of skin cancer in adulthood, which is associated with mutations caused by UVR-induced cyclobutane pyrimidine dimers (CPD). Solar UVR is also the main source of vitamin D, essential for healthy bone development in children.

OBJECTIVES

To assess the impact of a 12-day Baltic Sea (54° N) beach holiday on serum 25-hydroxyvitamin D₃ [25(OH)D₃ ] and CPD in 32 healthy Polish children (skin types I-IV).

METHODS

Blood and urine were collected before and after the holiday and assessed for 25(OH)D₃ and excreted CPD, respectively, and personal UVR exposure was measured. Diaries were used to record sunbathing, sunburn and sunscreen use. Before- and after-holiday skin redness and pigmentation were measured by reflectance spectroscopy.

RESULTS

The average ± SD daily exposure UVR dose was 2·4 ± 1·5 standard erythema doses (SEDs), which is borderline erythemal. The mean concentration of 25(OH)D₃ increased (× 1·24 ± 0·19) from 64·7 ± 13·3 to 79·3 ± 18·7 nmol L^-1 (P < 0·001). Mean CPD increased 12·6 ± 10·0-fold from 26·9 ± 17·9 to 248·9 ± 113·4 fmol μmol^-1 creatinine (P < 0·001). Increased 25(OH)D₃ was accompanied by a very much greater increase in DNA damage associated with carcinogenic potential. Overall, skin type had no significant effects on behavioural, clinical or analytical outcomes, but skin types I/II had more CPD (unadjusted P = 0·0496) than skin types III/IV at the end of the holiday.

CONCLUSIONS

Careful consideration must be given to the health outcomes of childhood solar exposure, and a much better understanding of the risk-benefit relationships of such exposure is required. Rigorous photoprotection is necessary for children, even in Northern Europe.

Review on Nonoccupational Personal Solar UV Exposure Measurements

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

Sun sensitivity and sun protective behaviors during sun exposure among indoor office workers in the American Midwest

BACKGROUND/PURPOSE

Sun sensitivity, a confounder between sun exposure and sun protection, is often overlooked. We examined how sun exposure and sun protection behaviors among indoor workers varied by sun sensitivity.

METHODS

Sun exposure and sun protection diaries over a 45-day period from Midwestern United States indoor workers were examined. We categorized sun sensitivity (fair and non-fair complexion) using tanning inability and sunburn tendency. Total exposure (sunrise to sunset) and peak exposure (10 am and 4 pm) lasting at least 60 minutes were examined. Percentages of time using sun protection were reported. We determined associations between fair complexion, mean sun exposure, and mean sun protection times with logistic regression.

RESULTS

Fair individuals spent less time in the sun than non-fair individuals, but a greater proportion of time using sun protection behaviors, including sunscreen with SPF 30+ (odds ratio (OR) = 1.36; 95% confidence interval (95% CI) = 0.98, 1.87)), or wearing long-sleeved shirts (OR = 2.89; 95% CI = 1.24, 6.73).

CONCLUSION

Fair individuals spent less time in the sun and practiced more sun protective behaviors than non-fair individuals. This complex association between sun sensitivity, sun protection and sun exposure has not consistently been addressed in studies of skin cancer.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Reliability and consistency of a validated sun exposure questionnaire in a population-based Danish sample

An important feature of questionnaire validation is reliability. To be able to measure a given concept by questionnaire validly, the reliability needs to be high.

The objectives of this study were to examine reliability of attitude and knowledge and behavioral consistency of sunburn in a developed questionnaire for monitoring and evaluating population sun-related behavior.

Sun related behavior, attitude and knowledge was measured weekly by a questionnaire in the summer of 2013 among 664 Danes. Reliability was tested in a test-retest design. Consistency of behavioral information was tested similarly in a questionnaire adapted to measure behavior throughout the summer.

The response rates for questionnaire 1, 2 and 3 were high and the drop out was not dependent on demographic characteristic. There was at least 73% agreement between sunburns in the measurement week and the entire summer, and a possible sunburn underestimation in questionnaires summarizing the entire summer. The participants underestimated their outdoor exposure in the evaluation covering the entire summer as compared to the measurement week. The reliability of scales measuring attitude and knowledge was high for majority of scales, while consistency in protection behavior was low.

To our knowledge, this is the first study to report reliability for a completely validated questionnaire on sun-related behavior in a national random population based sample. Further, we show that attitude and knowledge questions confirmed their validity with good reliability, while consistency of protection behavior in general and in a week's measurement was low.

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Objectively validated questionnaires tested for reliability/behavioral consistency.

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Strong reliability of the knowledge and attitude items was shown.

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Knowledge about behavioral consistency between questionnaire measurement periods

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A recommendable design for short term evaluation of skin cancer prevention campaigns

Duration of Casual Sunlight Exposure Necessary for Adequate Vitamin D Status in Indian Men

OBJECTIVES

To investigate the duration of casual sunlight ultraviolet-B (UVB) exposure required to maintain optimal Vitamin D status (25-hydroxyvitamin-D [25(OH)D]) >50 nmol/L in urban Indian men, using polysulfone (PSU) dosimeters and a sunlight exposure questionnaire.

METHODS

In healthy men (aged 40-60 years) from Pune (18.52° N, 73.86° E), India, serum 25(OH)D was measured using enzyme-linked immunosorbent assay. Sunlight exposure was assessed using PSU dosimeter and by questionnaire.

RESULTS

Of 160 men (48.3 ± 5.6 years), 26.8% were deficient and 40.6% had insufficient Vitamin D concentrations. A hyperbolic function for the relationship between PSU measured sunlight exposure in standard erythema dose (SED) and serum 25(OH)D concentrations (r = 0.87, P < 0.01) revealed that daily exposure of 1 SED was sufficient to maintain serum 25(OH)D concentrations over 50 nmol/L. The curve plateaued around 5 SED (80 nmol/L) and extrapolation of the curve (>5 SED) did not increase 25(OH)D concentrations above 90 nmol/L. Receiver operating curve analysis confirmed that 1 SED-UV exposure was sufficient to maintain 25(OH)D concentrations over 50 nmol/L. Based on the questionnaire data, >1 h of midday casual sunlight exposure was required to maintain serum 25(OH)D concentrations above 50 nmol/L. Duration of sunlight exposure assessed by questionnaire and PSU dosimeter showed a significant correlation (r = 0.517, P < 0.01).

CONCLUSION

In urban Indian men, >1 h of casual midday sunlight exposure daily was required to maintain serum 25(OH)D concentrations above 50 nmol/L, and >2 h of casual sunlight exposure was needed to maintain 25(OH)D concentrations above 75 nmol/L. Excess sunlight did not increase 25(OH)D linearly. The sunlight exposure questionnaire was validated for use in clinical studies and surveys.

Skin autofluorescence reflects individual seasonal UV exposure, skin photodamage and skin cancer development in organ transplant recipients

IMPORTANCE

Ultraviolet radiation (UVR)-induced skin cancers varies among organ transplant recipients (OTRs). To improve individual risk assessment of skin cancer, objectively quantified skin photodamage is needed.

OBJECTIVES

We measured personal UVR-exposure dose in OTRs and assessed the relation between individual UVR exposure, skin cancer and objectively measured photodamage in terms of skin autofluorescence, pigmentation, and black light-evaluated solar lentigines.

MATERIALS AND METHODS

Danish OTRs with (n=15) and without a history of skin cancer (n=15) kept sun diaries from May to September and wore personal dosimeters recording time-stamped UVR doses in standard erythema doses (SED). Photodamage was quantified as skin autofluorescence with excitation at 370nm (F370) and 430nm (F430), skin pigmentation (pigment protection factor, PPF), and black light-evaluated solar lentigines.

RESULTS

OTRs with skin cancer received a higher UVR dose than OTRs without skin cancer (median 116 SED vs. 67 SED, p=0.07) and UVR exposure doses were correlated with increased PPF (p=0.052) and F370 on the shoulder (F370_shoulder) (p=0.04). We found that skin cancer was associated with F370_shoulder (OR 10.53, CI 3.3-31,938; p=0.018) and time since transplantation (OR 1.34, CI 0.95-1.91, p=0.097). A cut-off at 7.2 arbitrary units, 89% of OTRs with skin cancer had F370_shoulder values above 7.2 arbitrary units and F370_shoulder was additionally related to patient age (p=0.09) and black light-evaluated solar lentigines (p=0.04).

CONCLUSION

F370 autofluorescence indicates objectively measured photodamage and may be used for individual risk assessment of skin cancer development in OTRs.

An investigation of the predictors of photoprotection and UVR dose to the face in patients with XP: a protocol using observational mixed methods

INTRODUCTION

Xeroderma pigmentosum (XP) is a rare genetic condition caused by defective nucleotide excision repair and characterised by skin cancer, ocular and neurological involvement. Stringent ultraviolet protection is the only way to prevent skin cancer. Despite the risks, some patients' photoprotection is poor, with a potentially devastating impact on their prognosis. The aim of this research is to identify disease-specific and psychosocial predictors of photoprotection behaviour and ultraviolet radiation (UVR) dose to the face.

METHODS AND ANALYSIS

Mixed methods research based on 45 UK patients will involve qualitative interviews to identify individuals' experience of XP and the influences on their photoprotection behaviours and a cross-sectional quantitative survey to assess biopsychosocial correlates of these behaviours at baseline. This will be followed by objective measurement of UVR exposure for 21 days by wrist-worn dosimeter and daily recording of photoprotection behaviours and psychological variables for up to 50 days in the summer months. This novel methodology will enable UVR dose reaching the face to be calculated and analysed as a clinically relevant endpoint. A range of qualitative and quantitative analytical approaches will be used, reflecting the mixed methods (eg, cross-sectional qualitative interviews, n-of-1 studies). Framework analysis will be used to analyse the qualitative interviews; mixed-effects longitudinal models will be used to examine the association of clinical and psychosocial factors with the average daily UVR dose; dynamic logistic regression models will be used to investigate participant-specific psychosocial factors associated with photoprotection behaviours.

ETHICS AND DISSEMINATION

This research has been approved by Camden and King's Cross Research Ethics Committee 15/LO/1395. The findings will be published in peer-reviewed journals and presented at national and international scientific conferences.

Comparing Handheld Meters and Electronic Dosimeters for Measuring Ultraviolet Levels under Shade and in the Sun

This study aimed to compare the validity, reliability and practicality of alternative portable methods for measuring erythemal UVR levels in passive recreation areas in public parks. UVR levels were measured for point in time comparisons between Solarmeter 6.5 handheld meters and time-stamped electronic dosimeters in a large central park in Melbourne, Australia. Observations were made at 20 locations in the park by two research assistants under two conditions: (1) matched shade (2) contrasting shade-no shade. Comparisons were also made with scientific instruments on the UVR monitoring station rooftop and by remotely selecting UV records and forecasts on cloud-free dates of park observations. There was good agreement between the portable UVR instruments in the park setting as confirmed via Bland Altman plots, while the dosimeter appeared less sensitive to change in shade conditions. The rooftop measurements showed that the Solarmeter 6.5 UVR readings were comparable to those of the adjacent rooftop instruments. The practicalities of using the dosimeters and Solarmeters for behavioral studies are discussed. These findings provide a basis for use of the Solarmeter 6.5 to measure changes in UVR levels due to different environmental conditions with relative accuracy for intervention studies in outdoor settings.

Measuring sun exposure in epidemiological studies: Matching the method to the research question

Sun exposure has risks and benefits for health. Testing these associations requires tools for measuring sun exposure that are feasible and relevant to the time-course of the health outcome. Recent sun exposure, e.g. the last week, is best captured by dosimeters and sun diaries. These can also be used for medium-term sun exposure e.g. over several weeks, but incur a high participant burden. Self-reported data on "typical time outdoors" for working and non-working days, is less detailed and not influenced by day-to-day variation. Over a longer period, e.g. the lifetime, or for particular life stages, proxies of sun exposure, such as latitude of residence or ambient ultraviolet (UV) radiation levels (from satellites or ground-level monitoring) can be used, with additional detail provided by lifetime sun exposure calendars that include locations of residence, usual time outdoors, and detail of sunburn episodes. Objective measures of lifetime sun exposure include microtopography of sun-exposed skin (e.g. using silicone casts) or conjunctival UV autofluorescence. Potential modifiers of the association between sun exposure and the health outcome, such as clothing coverage and skin colour, may also need to be measured. We provide a systematic approach to selecting sun exposure measures for use in epidemiological health research.

Black light visualized solar lentigines on the shoulders and upper back are associated with objectively measured UVR exposure and cutaneous malignant melanoma

Previous studies on the association of solar lentigines with ultraviolet radiation (UVR) exposure have been based on retrospective questionnaires about UVR exposure. We aimed to investigate the association between solar lentigines and UVR exposure in healthy individuals using objective measurements, and to investigate the association between solar lentigines and cutaneous malignant melanoma (CMM). Forty-eight patients with CMM and 48 controls that matched the patients individually by age, sex, constitutive skin type and occupation participated. Solar lentigines on the shoulders and upper back were counted and graded into 3 categories using black light photographs to show sun damage. Current UVR exposure in healthy controls was assessed by personal electronic UVR dosimeters that measured time-related UVR and by corresponding exposure diaries during a summer season. Sunburn history was assessed by interviews. Among controls, the number of solar lentigines was positively associated with daily hours spent outdoors between noon and 3 pm on holidays (P = 0.027), days at the beach (P = 0.048) and reported number of life sunburns (P < 0.001). Compared with matched controls CMM patients had a higher number of solar lentigines (P = 0.044). There was a positive association between CMM and higher solar lentigines grade; Category III versus Category I (P = 0.002) and Category II versus Category I (P = 0.014). Our findings indicate that solar lentigines in healthy individuals are associated with number of life sunburns, as well as time spent outdoors around noon on holidays and beach trips during a summer season, most likely reflecting past UVR exposure, and that solar lentigines are a risk factor for CMM.

Sun exposure patterns of urban, suburban, and rural children: a dosimetry and diary study of 150 children

City children had a more intermittent sun exposure pattern, while rural children had a higher UVR exposure on school/kindergarten days. This may explain the higher skin cancer incidences in urban populations.

Feasibility of a GP delivered skin cancer prevention intervention in Australia

Background

Despite years of public education, sun-related behaviours are difficult to change and a recent survey showed low levels of sun protection. In this study we evaluated the feasibility and acceptability of an opportunistic skin cancer prevention intervention in general practice.

Methods

We used a controlled pre-and-post intervention design. Participants (n = 100) were recruited sequentially from patients attending two general practices in Sydney, Australia, from November to December 2010. Participants in the intervention practice (n = 50) received general practitioner delivered sun protection advice after completing a skin cancer risk assessment tool, and a sun protection pamphlet, in addition to routine care, at a single attendance. The skin cancer risk assessment tool provided three levels of risk. The general practitioner (GP) reinforced the level of risk and discussed sun protection. Participants in the control practice (n = 50) received routine care. We measured feasibility by patients’ and GPs’ participation in the intervention and time taken, and acceptability by intervention participants and GPs ratings of the intervention. We measured reported sun-related knowledge, attitudes and behaviour between the two groups at 1 and 13 months.

Results

The intervention was found to be feasible within existing primary care team arrangements. Participation at baseline was 81% (108/134), and repeated participation was 88% (88/100) at 1 month and 70% (70/100) at 13 months. Participants and practitioners found the intervention acceptable. At 1 month, sun-related knowledge had increased in both patient groups, with a greater increase in the intervention group (adjusted mean difference 0.48, p = 0.034). There were no differences between groups in sun-related knowledge, attitudes and behaviour at 13 months.

Conclusions

A brief opportunistic skin cancer prevention intervention in general practice is feasible and acceptable. Further research in this setting with a more intensive intervention would be justified.

Sun exposure and protection behavior of Danish farm children: parental influence on their children

Healthy sun habits acquired in childhood could reduce skin cancer incidence. We examined the sun exposure and protection behavior of an expected high-exposure group of children, and the association to their parents. Open, prospective cohort study. One hundred and thirty nine participants (40 families) kept daily sun behavior diaries (sun exposure, sunscreen use, sunburns) over a 4-month summer period (15,985 diary days). The Pigment Protection Factor (PPF), an objective measure of sun exposure, was measured at two body sites, before and after summer. All participants presented data from the same 115 days. Risk behavior (sun exposure of upper body) took place on 9.5 days (boys) and 15.6 days (girls). Sunburn and sunscreen use were infrequent. Boys' sun exposure resulted in an increased photo protection over the study period of 1.7 SED (upper arm) and 0.8 SED (shoulder) to elicit erythema. Corresponding values for girls were as follows: 0.9 SED (upper arm) and 0.5 SED (shoulder). Boys' sunscreen use correlated to their mothers' (r = 0.523, P = 0.02). Girls' number of risk days (r = 0.552, P = 0.005) and sun exposure (upper arm: r = 0.621, P < 0.001) correlated to their mothers'. The children's sun exposure was substantial. Only mothers influenced children's sun behavior and exposure. This may be of relevance in future sun protection campaigns.

Validation of a light questionnaire with real-life photopic illuminance measurements: the Harvard Light Exposure Assessment questionnaire

BACKGROUND

Shift work, which necessitates light exposure at night, is now considered a probable carcinogen. To study the effects of light on chronic diseases like cancer, methods to measure light exposure in large observational studies are needed. We aimed to investigate the validity of self-reported current light exposure.

METHODS

We developed a self-administered semiquantitative light questionnaire, the Harvard Light Exposure Assessment (H-LEA) questionnaire, and compared photopic scores derived from this questionnaire with actual photopic and circadian measures obtained from a real-life 7-day light meter application among 132 women (85 rotating night shift workers and 47 day workers) participating in the Nurses' Health Study II.

RESULTS

After adjustment for age, body mass index (BMI), collection day, and night work status, the overall partial Spearman correlation between self-report of light exposure and actual photopic light measurements was 0.72 (P < 0.001; Kendall τ = 0.57) and 0.73 (P < 0.0001; Kendall τ = 0.58) when correlating circadian light measurements. There were only minimal differences in accuracy of self-report of light exposure and photopic or "circadian" light measurement between day (r = 0.77 and 0.78, respectively) and rotating night shift workers (r = 0.68 and 0.69, respectively).

CONCLUSIONS

The results of this study provide evidence of the criterion validity of self-reported light exposure using the H-LEA questionnaire.

IMPACT

This questionnaire is a practical method of assessing light exposure in large-scale epidemiologic studies.

Agreement between diary records of time spent outdoors and personal ultraviolet radiation dose measurements

Little is known about the validity of self-recorded sun exposure and time spent outdoors for epidemiological research. The aims of the current study were to assess how well participants' self-recorded time outdoors compared to objective measurements of personal UVR doses. We enrolled 124 volunteers aged 40 and above who were identified from targeted subgroups of US radiologic technologists. Each volunteer was instructed to wear a polysulfone (PS) dosimeter to measure UVR on their left shoulder and to complete a daily activity diary, listing all activities undertaken in each 30 min interval between 9:00 A.M. and 5:00 P.M. during a 7 day period. In a linear regression model, self-recorded daily time spent outdoors was associated with an increase of 8.2% (95% CI: 7.3-9.2%) in the personal UVR exposure with every hour spent outdoors. The amount of self-recorded total daily time spent outdoors was better correlated with the personal daily UVR dose for activities conducted near noon time compared to activities conducted in the morning or late afternoon, and for activities often performed in the sun (e.g. gardening or recreation activities) compared to other outdoor activities (e.g. driving) in which the participant is usually shaded from the sun. Our results demonstrated a significant correlation between diary records of time spent outdoors with objective personal UVR dose measurements.

Sunlight exposure assessment: can we accurately assess vitamin D exposure from sunlight questionnaires?

The purpose of this review is to summarize the peer-reviewed literature in relation to sunlight exposure assessment and the validity of using sunlight exposure questionnaires to quantify vitamin D status. There is greater variability in personal ultraviolet (UV) light exposure as the result of personal behavior than as the result of ambient UV light exposure. Although statistically significant, the correlation coefficients for the relation between personal report of sun exposure and ambient UV light measured by dosimetry (assessment of radiation dose) are relatively low. Moreover, the few studies to assess the relation between sunlight measures and serum 25-hydroxyvitamin D show low correlations. These low correlations may not be surprising given that personal factors like melanin content in skin and age also influence cutaneous synthesis of vitamin D. In summary, sunlight exposure questionnaires currently provide imprecise estimates of vitamin D status. Research should be directed to develop more objective, nonintrusive, and economical measures of sunlight exposure to quantify personal vitamin D status.

Solar UVR Exposure, Concurrent Activities and Sun-Protective Practices Among Primary Schoolchildren

Comprehensive measures of ultraviolet radiation (UVR) exposure, concurrent activities and sun-protective practices are needed to develop and evaluate skin cancer prevention and sun protection interventions. The UVR exposures of 345 primary schoolchildren at 23 schools around New Zealand were measured using electronic UVR monitors for 1-week periods over 12 weeks in 2004 and 2005. In addition, ambient UVR levels on a horizontal surface were measured on-site at each school. Children completed activity diaries during the period UVR measurements were made and provided information on their indoor and outdoor status and clothing and sun protection worn. Mean total daily UVR exposure (7:00-20:00 h NZST + 1) at the body location where the UVR monitors were worn was 0.9 SED (standard erythemal dose, 1 SED = 100 J m(-2)). This was 4.9% of the ambient UVR on a horizontal surface. Mean time spent outdoors was 2.3 h day(-1). Differences in children's UVR exposure could be explained in part by activity, where outdoor passive pursuits were associated with higher UVR exposure rates than outdoor active and outdoor travel pursuits. Compared with older children, the activities of younger children, although labeled the same, resulted in different UVR exposures, either as a result of reporting differences or a real difference in UVR exposure patterns. UVR exposure rates were generally higher on weekdays compared with the weekend, confirming the important role of school sun protection and skin cancer prevention programs. High UVR exposure activities included physical education, athletics and lunch break.