J Behav Med (2009) 32:406–428 DOI 10.1007/s10865-009-9219-2
Skin cancer-related prevention and screening behaviors: a review of the literature Nadine A. Kasparian Æ Jordana K. McLoone Æ Bettina Meiser
Received: June 28, 2008 / Accepted: May 23, 2009 / Published online: June 12, 2009 Ó Springer Science+Business Media, LLC 2009
Abstract Primary prevention and early detection continue to be of paramount importance in addressing the public health threat of skin cancer. The aim of this systematic review was to provide a comprehensive overview of the prevalence and correlates of skin cancer-related health behaviors in the general population. To achieve this aim, 91 studies published in international peer-reviewed journals over the past three decades were reviewed and synthesized. Reported estimates of sunscreen use varied considerably across studies, ranging from 7 to 90%. According to selfreport, between 23 and 61% of individuals engage in skin self-examination at least once per year, and the documented prevalence of annual clinical skin examination ranges from 8 to 21%. Adherence to sun protection and screening recommendations is associated with a range of factors, including: female gender, sun-sensitive phenotype, greater perceived risk of skin cancer, greater perceived benefits of sun protection or screening, and doctor recommendation for screening. The literature suggests that a large proportion of the general population engage in suboptimal levels of sun protection, although there is substantial variability in findings. The strongest recommendation to emerge from this review is a call for the development and widespread use of N. A. Kasparian School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia N. A. Kasparian (&) J. K. McLoone B. Meiser Department of Medical Oncology, Prince of Wales Hospital, Dickinson Building Level 3, High St., Randwick, NSW 2031, Australia e-mail:
[email protected] J. K. McLoone B. Meiser Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
123
standardized measurement scales in future research, in addition to more studies with a population-based, multivariate design. It is also recommended that specific targeted interventions are developed to increase the prevalence of preventative and early intervention behaviors for the control of skin cancer. Keywords Skin cancer Melanoma Skin selfexamination Clinical skin examination Sun protection behaviors Health behavior prediction
Introduction Primary prevention and early detection continue to be of paramount importance in addressing the public health threat of both malignant melanoma and non-melanoma skin cancer. Skin cancer (including malignant melanoma, squamous cell carcinoma and basal cell carcinoma) is a common disease in all European-derived populations and has shown rapid increases in incidence over the last century (Jemal et al. 2001; Parkin et al. 2005). Incidence, however, varies by latitude and altitude, with regions closer to the equator and higher in altitude generally having higher rates of skin cancer (Tucker and Goldstein 2003). The major external cause of melanoma, as with all skin cancers, is sun exposure, but this is heavily modified by other personal risk factors such as the number and type of benign melanocytic naevi or moles (lesions of pigment forming skin cells), the character and intensity of skin pigmentation, and skin sensitivity to sunlight (Tucker and Goldstein 2003). Many of these factors have a strong genetic basis and epidemiological data suggest that different clinical patterns of melanoma are associated with different contributions of these predispositions and sun exposure (Whiteman et al.
J Behav Med (2009) 32:406–428
2003). Effective primary prevention and early detection are the keystones of skin cancer control at a population level, with the focus on behavioral strategies such as regular sun protection, sun avoidance during peak ultraviolet light hours, and the detection of skin cancers at an early, curable stage (Australian Cancer Network 2008; The Cancer Council Australia 2004). Sun protection behaviors include avoidance of direct sunlight exposure, particularly between the hours of 10 am and 2 pm; use of sun protective clothing, hats, and sunglasses when exposed to direct sunlight for periods greater than 15 min; and, as an adjunct to sun avoidance, use of broad spectrum sunscreens with a minimum sun protection factor (SPF) of 30. Regular skin surveillance by clinical skin examination (i.e. visual inspection of the whole body conducted by a dermatologist or other health care provider) and skin self-examination are believed to increase the chances of detecting thinner, more curable melanoma lesions (Masri et al. 1990; McPherson et al. 2006). There have been, however, no controlled trials evaluating the impact of clinical skin examination on melanoma mortality, and there is only one study supporting the link between skin self-examination and reduced melanoma mortality (Berwick et al. 1996). Due to this lack of mortality reduction data, some scientific groups do not recommend routine skin cancer surveillance at the population level (Australian Cancer Network 2008; Cancer Society of New Zealand 2007; The Cancer Council Australia 2007). The American Cancer Society, however, supports regular screening of individuals at average risk of developing skin cancer, either on its own or in conjunction with general health checks (Smith et al. 2005). Given that early detection is likely to reduce disease burden and the number of skin cancers diagnosed at advanced stages (MacKie et al. 1993; Masri et al. 1990), a strong case can be made for encouraging individuals in the general community to be aware of, and appropriately engaged in, both clinical and self-conducted skin examinations, particularly those at increased risk due to phenotypic, genetic or environmental factors. With the American Cancer Society (2007) estimating that approximately 80% of all skin cancers are preventable, research efforts directed at clarifying the correlates of sun protection behaviors, as well as early detection practices, are essential. While many studies have examined the prevalence and correlates of these health behaviors, the literature is lacking a clear and concise overview of the findings of this large body of research. The aim of the present systematic review was to provide a comprehensive overview of the available data on the prevalence and correlates of skin cancer-related health behaviors in the general population. To achieve this aim, 91 studies published in international peer-reviewed journals over the past three
407
decades were reviewed and synthesized. It is hoped that an understanding of the factors that contribute to engagement in sun protection and skin surveillance may be used to guide future research and intervention programs aimed at improving adherence to behavioral recommendations.
Literature search strategy and selection criteria Three strategies were employed to conduct the literature search (Cook et al. 1997; NHS Centre for Reviews and Dissemination 2001). First, the electronic databases from MEDLINE, Medline In-Process or other non-indexed citations, and PsycInfo were searched from January 1980 to May 2008 using the following keywords individually or in combination: skin cancer; melanoma; malignant melanoma; sun protection; sun exposure; sun behavior; prevention; skin cancer screening; skin self-examination; clinical skin examination; and total cutaneous examination. Second, the resulting list of publications was screened for non-research articles, duplicates and irrelevant references such as single case reports, letters, commentaries, conference abstracts, or those focused on clinical issues. Third, the reference lists of all publications identified were examined for potentially relevant articles not captured by the initial literature search. Inclusion and exclusion criteria were agreed upon by the authors prior to commencement of the review. The decision to review articles published from 1980 onwards was made in order to coincide with the introduction of national sun protection education programs and media campaigns, which were launched in countries such as Australia in the early 1980s (Marks 1999, 2004). Only studies published in English, involving participants from the general population, and reporting data on skin cancer-related prevention and screening behaviors or attitudes were considered eligible for inclusion in the review. Given the present focus on behavioral practices reported by those in the general community, papers that exclusively examined the beliefs and behaviors of individuals with a personal or family history of skin cancer were excluded. Studies which specifically focused on melanoma or those which focused on skin cancer more generally were included. Articles that appeared to describe overlapping patient populations were grouped together and where necessary in these cases, only the data from the largest study population was reported, or the most recent article in these groups.
Findings After deletion of duplicates, exclusion of articles according to our predefined criteria and manual searching of reference
123
408
lists, 91 articles that met the eligibility criteria were identified for review. For the purposes of organization and analysis, the relevant data were extracted and entered into a table that provided a summary of data on methodological characteristics, outcome variables and key findings for each study. In accordance with the evidence rating system developed by the National Health and Medical Research Council of Australia (2000), the majority of these articles provided Level IVa evidence; that is, evidence obtained from descriptive studies of individuals’ behaviors or attitudes. Throughout this paper, data on the correlates of each skin cancer-behavior are presented in a particular order, with the most robust associations presented first, followed by those which are less well-established, and then those which appear to be emerging from recent research. Due to space restrictions, only those studies reporting data on the correlates of sun protection behavior using multivariate (or regression) analysis are presented in Table 1. Throughout the text, examples of studies are cited to illustrate findings, rather than an exhaustive list of all studies identified.
Sun protection behaviors Since 1980, many countries have contributed to the available literature on individuals’ sun protection practices, with the majority of research carried out in Australia or the United States, as shown in Table 1. Sun protection behaviors have been studied in a wide range of samples including the general adult population (e.g. Hall et al. 2003), children (e.g. Hall et al. 2001), adolescents and young adults (e.g. McGee and Williams 1992; Sjoberg et al. 2004), parents (e.g. Glanz et al. 1999), beachgoers (e.g. Maddock et al. 2007), outdoor workers (e.g. Lewis et al. 2006), childcare workers (e.g. Glanz et al. 1999), university students (e.g. Savona et al. 2005), community skin cancer screening attendees (e.g. Berwick et al. 1992), health care professionals (e.g. Guile and Nicholson 2004), and patients with dermatological disorders other than skin cancer (Garbe and Buettner 2000). Sunscreen use Reported estimates of sunscreen use in the general population vary considerably, ranging from 7 to 90% (e.g. Banks et al. 1992; Wichstrom 1994). Given that Australia has the highest incidence of skin cancer in the world, it is not surprising to find that sunscreen usage rates in this country appear higher than in other countries (Pruim et al. 1999). Reported sunscreen use, however, is complicated by factors such as frequency and thoroughness of sunscreen application as well as re-application and also choice of
123
J Behav Med (2009) 32:406–428
sunscreen (i.e. use of sunscreens with a high versus a low sun protection factor) (Jones et al. 2000; Pincus et al. 1991). Studies that report on regular sunscreen use (with regular defined as ‘always’, ‘often’, or ‘most of the time’) during sun exposure over an extended period of time (usually defined as between 30 and 60 min), provide estimates of regular sunscreen use ranging from 7 to 72% (e.g. Dixon et al. 1999; Leary and Jones 1993). Research also shows that between 9 and 61% of study participants ‘seldom’ or ‘never’ use sunscreen whilst outdoors and in the sun (e.g. Douglass et al. 1997; Newman et al. 1996), and that 75% of adolescent males discontinue sunscreen use once tanned (Monfrecola et al. 2000). Use of protective clothing and avoidance of sun exposure Despite the wide variation in reported sun protection practices, overall the data suggest that the majority of individuals do not wear protective clothing or attempt to avoid sun exposure whilst outdoors. During summer months, 4–86% of participants report ‘often’ or ‘always’ wearing a hat when outside and in the sun (e.g. Cokkinides et al. 2001; Dixon et al. 1999); 4–70% report ‘often’ or ‘always’ wearing some form of protective clothing such as a long-sleeved shirt (e.g. Cokkinides et al. 2001; Dixon et al. 1999); 16–62% wear sunglasses (e.g. Robinson et al. 2000; Weinstock et al. 2000); and 15–59% report seeking shade or attempting to avoid direct sun exposure (e.g. Foot et al. 1993; Pruim et al. 1999). Use of a combination of sun protection methods Only a limited number of studies have examined combined use of sun protection measures. Data gleaned from these studies suggest that 1–9% of adults in the general population routinely use all four methods of sun protection in combination; that is, sunscreen, protective clothing, shade and timed sun avoidance (e.g. Martin 1995; Purdue 2002). Between 10 and 21% of study participants report using three methods of sun protection in combination (e.g. Cokkinides et al. 2001; Hall et al. 1997), 8–24% use two methods (Anderson et al. 1994; Hall et al. 1997; Purdue 2002), and 8–50% admit to never routinely practicing any form of sun protection (e.g. Clarke et al. 1997; Santmyire et al. 2001). Other studies have created simple algorithms for computing ‘adequate’ levels of sun protection, often based on country-specific sun protection guidelines. Of these, only 29–50% of participants have been classified as using adequate or appropriate levels of sun protection (e.g. Branstrom et al. 2004; Stepanski and Mayer 1998).
Banks et al. (1992)
Cody and Lee (1990)
USA
Method: Self-report questionnaire for behaviors in early summer, prior to acquiring a tan
Setting: Pediatric clinic
Design: Cross-sectional; convenience sample
Method: Randomized controlled trial of a video intervention Questionnaires at baseline, immediately and 10 weeks post-intervention
Setting: University
Australia Design: Prospective; convenience sample
Method: Questionnaire and diary for behaviors over preceding weekend
April–June 1989
Mean age (year)
220
15.2
20
2,029 15
N
Participants
July (year not 312 noted)
October 1986– March 1987
Cockburn et al. Australia Design: Cross-sectional; (1989) regional sample
Setting: 26 high schools across NSW
Data collection date
Authors (year) Country Design methods
55
42
51
% male
Sunscreen reapplication
Sunscreen use
Sun protection
Use of shade
Protective clothing
Sunscreen use
Sun protection behaviors
Behavior: Sunscreen use
Psychological: Greater perceived risk, perceived severity of skin cancer, perceived benefits and knowledge of sun protection, and fewer perceived barriers to sun protection
Clinical: Self-reported sun-sensitive skin type
Demographic: Female gender
Behavior: Total sun protection
Behavioral: Non-smoking status, greater number of sun protection opportunities
Social: Positive image of sun protection held by peers, greater perceived parental influence on sun protection
Psychological: Fewer perceived barriers to sun protection, greater perceived benefits, lower perceived risk (males only)
Clinical: Self-reported inability to tan
Demographic: Male gender, noncoastal residence
Behavior: Total sun protection
Correlates of sun protection behaviors
8% always reapplied sunscreen
After swimming for 30 min, Social: Having a close friend who regularly used sunscreen, having 38% of those who reported had parents insist on sunscreen use using sunscreen, never or rarely re-applied when younger
73% used sunscreen on half or Demographic: Female gender fewer of sun exposed days Psychological: Perceived a ‘safe’ sun exposure period as [30 min 9% always used sunscreen
33% never used sunscreen
Not reported
30% classified as using ‘‘adequate’’ sun protection
Prevalence of behaviors
Table 1 An overview of studies using multivariate analysis to examine the correlates of sun protection behavior among individuals in the general community
J Behav Med (2009) 32:406–428 409
123
123
Mermelstein and Riesenberg (1992)
USA
New Design: Cross-sectional; Zealand convenience sample
McGee and Williams (1992)
Method: One session, in-school intervention. Questionnaires at baseline and one week post-intervention
Setting: Grades 9 and 10 at ten high schools
Design: Prospective; convenience sample
Not reported
1,703 –
47
49
51
% male
Sunscreen use
Protective clothing
Hats
Sunscreen use
Sunscreen use
Protective clothing
14
14
Mean age (year)
Sun protection behaviors
Method: Questionnaire
345
972
N
Participants
Hat
February 1991
February– March 1990
Data collection date
Setting: Grade 10 at ten high schools in Auckland, Wellington and Christchurch
Method: Sun exposure and protection diary recorded over two consecutive weekends and questionnaire
Setting: Nine high schools in two urban cities and one rural town
Design: Cross-sectional; regional sample
Australia
Fritschi et al. (1992)
Design methods
Country
Authors (year)
Table 1 continued Correlates of sun protection behaviors
Behavior: Sunscreen use Demographic: Female gender, increased age 31% of females and 45% of males never used sunscreen Clinical: Sun-sensitive skin type 17% of those with sunPsychological: Greater intention to sensitive skin types used take precautions in the future, sunscreen at least most of higher perceived risk the time, compared with 7% of those with less sensitive skin
12% reported regular sunscreen use
52% reported often or always wearing protective clothing
54% reported often or always Behavior: Total sun protection using sunscreen when in the Psychological: Negative attitude sun last summer towards tanning, greater awareness 31% reported often or always of melanoma wearing a hat
46% wore shirts at all times outside
Shirts were worn for more than half the time outdoors
10% wore hats the entire time outside on both weekends
Sunscreen was used less than Behavior: Sunscreen use half the time spent in the Psychological: Greater knowledge of sun sun protection recommendations 13% used sunscreen the entire Clinical: Skin with a tendency to burn time outside on both Behavior: Hat use weekends Demographic: Male gender, rural Hats were worn less than half location the time spent in the sun
Prevalence of behaviors
410 J Behav Med (2009) 32:406–428
USA
Israel
Norway
Carmel et al. (1994)
Wichstrom (1994)
Method: Questionnaire
Setting: 56 Norwegian high schools
Design: Cross-sectional; national sample
Method: Information-based intervention. Questionnaires at baseline and 4 months post-intervention
Setting: Four Kibbutzim
Design: Prospective; convenience sample
Method: Questionnaire
Setting: University
Design: Cross-sectional; convenience sample
May 1992
April– November 1989
Not reported
–
17–23
15,169 17.3
509
266
45
44
50
35
% male
Demographic: Female gender
Behavior: Sunscreen use
Behavioral Less sun exposure
Psychological: Tan perceived as less valuable, skin cancer perceived as not preventable, greater value placed on personal health and appearance
Demographic: Female gender, increased age
Behavior: Total sun protection
Social: Knowing someone with skin cancer
Clinical: Greater skin sensitivity 35% of girls and 20% of boys Psychological: Positive physical reported using sunscreen self-concept (girls only), higher often or always perceived risk 75% of adolescents who Social: Friends’ use of sunscreen sunbathed on more than (moderated by low physical 5 days used sunscreen with self-concept in girls only) an SPF \6 Behavioral: Greater opportunity to sunbathe
Over 90% reported some sunscreen use with an average SPF of 4
Not reported Sun protection (.ie. hours of sun exposure, sunscreen use and protective clothing)
Sunscreen use
Behavior: Sunscreen use
Demographic: Female gender 44% reported seldom or never Clinical: Sun-sensitive skin using sunscreen Psychological: Internal health locus of control
Only 7% reported regular sunscreen use
3% wore a recommended shirt
Sunscreen use
Use of shade Protective clothing
Correlates of sun protection behaviors
45% used a ‘high’ level of sun Behavior: Total sun protection protection, 16% did not use Demographic: Currently married any form of sun protection Psychological: Fewer perceived 69% applied a sunscreen with barriers to sunscreen use SPF 15+ to at least one Behavioral: Conducted SSE more body part than five times, or not at all, in the 17% wore a wide-brimmed hat past 12 months 15% used shade
Prevalence of behaviors
Sun protection (general)
Hat use
–
Mean age (year)
Sun protection behaviors
Sunscreen use
670
N
Participants
Method: Direct observation, structured interview, and questionnaire
Data collection date
December– January (year not Setting: Beach-goers at six local noted) beaches
Australia Design: Cross sectional; convenience sample
Leary and Jones (1993)
Foot et al. (1993)
Authors (year) Country Design methods
Table 1 continued
J Behav Med (2009) 32:406–428 411
123
123
Newman et al. USA (1996)
Michielutte USA et al. (1996)
Hillhouse et al. USA (1996)
Method: Telephone survey
Setting: San Diego residents
Design: Cross-sectional; regional sample
Method: Structured interview
Setting: Six county public health departments and a primary care clinic serving a low income, rural population
Design: Cross-sectional; regional sample
Method: Questionnaire
Setting: University
Design: Cross-sectional; convenience sample
Method: Questionnaire
Setting: Cancer center in Southern California
April 1994
Not reported
June–August (year not noted)
Not reported
Design: Cross-sectional; convenience sample
Hourani and LaFleur (1995)
USA
Data collection date
Authors (year) Country Design methods
Table 1 continued
22.4
43
Mean age (year)
864
–
1,295 –
90
351
N
Participants
43
0
44
40
% male
Shirt use
Psychological: Greater skin cancer knowledge
Clinical: Fair skin, family history of skin cancer
Demographic: Female gender
Behavior: Sunscreen use during sunbathing
Behavioral: Regular physical examinations conducted by a GP
Psychological: Greater knowledge of skin cancer, fewer perceived barriers to sunscreen use
Demographic: Higher educational attainment, women aged 30–39 years were most likely to use sunscreen regularly (curvilinear relationship found, with the youngest and oldest women least likely to use sunscreen)
Behavior: Sunscreen use
41% reported never wearing a Behavior: Sunscreen use during recreation Demographic: Female gender, increased hat age 90% indicated wearing a shirt Clinical: Fair skin, previous skin cancer with sleeves at least diagnosis, family history of skin cancer sometimes while in the sun for recreation Psychological: Anti-tan attitudes, greater skin cancer knowledge
During recreation, 41% reported never using sunscreen on the face, and 49% reported never using sunscreen on the body
Sunscreen use during recreation
33% of women reported always using sunscreen when outdoors for an extended period of time in spring or summer
57% reported using sunscreen Behavior: Sunscreen use at least some of the time Demographic: Female gender when in the sun Psychological: Positive attitude towards sun protection and sunscreen use
61% reported never using sunscreen on the face or body when sunbathing
Hat use
Behavior: Sunscreen use
Correlates of sun protection behaviors
Demographic: Female gender 67% of those with a previous Clinical: Previous skin cancer diagnosis, a skin cancer diagnosis family history of skin cancer, a medium reported regular sunscreen to high sun sensitivity index score use
50% reported regular sunscreen use
Prevalence of behaviors
Sunscreen use while sunbathing
Sunscreen use
Sunscreen use
Sunscreen use
Sun protection behaviors
412 J Behav Med (2009) 32:406–428
USA
USA
Koh et al. (1997)
New Design: Cross-sectional; Zealand regional sample
Douglass et al. (1997)
Hall et al. (1997)
Australia
Clarke et al. (1997)
1992
Not reported
January 1996
September
Data collection date
Method: Structured telephone interview
July– September 1991 Setting: Random digit dialing of USA households
Design: Cross-sectional, national sample
Method: Structured interview
Setting: National Health Interview Survey
Design: Cross-sectional; national sample
Method: Questionnaire
Setting: Dunedin Multidisciplinary Health and Development study
Method: Random sampling of telephone directory. Structured interview
Setting: Coastal city
Design: Cross-sectional; convenience sample
Method: Verbally-administered survey
Setting: Grade 6 at two primary schools
Design: Cross-sectional; convenience sample
USA
Reynolds et al. (1996)
Design methods
Country
Authors (year)
Table 1 continued
21
19.4
11
Mean age (year)
2,459
42
10,048 –
909
355
509
N
Participants
45
48
51
47
51
% male
Sunscreen use
Sun avoidance
Protective clothing
Sunscreen use
Sunscreen use
Psychological: Not believing a tan increases personal attractiveness, intention to use sunscreen when swimming, perceived affordability of sunscreen
Demographic: Female gender
Behavior: Total sun protection
Correlates of sun protection behaviors
Clinical: Previous skin cancer diagnosis, sun-sensitive skin type
Demographic: Female gender, increased age, never married
Behavior: Total sun protection
Psychological: Greater perceived melanoma risk, greater knowledge of melanoma
Clinical: Sun-sensitive skin type, fewer sunburns now than at age 15
Demographic: Female gender
Behavior: Sunscreen use
Behavior: Sunscreen use Overall, only 25% of sunbathers routinely used a Demographic: Female gender, age sunscreen with SPF 15+ above 25 years, higher educational attainment 47% routinely applied sunscreen while sunbathing. Of these, only 55% used a sunscreen with SPF of 15+
Only 10% performed all three Psychological: Greater concern about sun protection behaviors skin cancer under these conditions Behavioral: Previous clinical skin examination
53% reported practicing at least one of the three sun protection methods if outside on a sunny day for more than 1 h
8% reported always using sunscreen, 34% used sunscreen most of the time, 49% used sunscreen sometimes, and 9% never used sunscreen
Behavior: Total sun protection 12% reported using sun protection every time they Clinical: Self-reported likelihood to went into the sun, 55% used burn was associated with greater sun protection most of the use of sun protection time, 25% used sun protection sometimes, and 8% rarely or never used sun protection
Sleeved shirts were worn 50% of the time while in the sun
Protective clothing
Sun protection (Defined broadly to include all methods)
6% of school children used sunscreen all of the time while in the sun
Prevalence of behaviors
Sunscreen use
Sun protection behaviors
J Behav Med (2009) 32:406–428 413
123
123
Design methods
Data collection date
Italy
Method: Telephone survey of guardians of a child aged 12 years or less
Setting: Random digit dialing to USA households, distributed in proportion to the population
Design: Cross-sectional; national sample
Method: Questionnaire
Setting: Ten high schools
Design: Cross-sectional; convenience sample
Method: Verbally-administered survey
July–August 1997
November 1996– February 1997
Germany, Design: Case control January Austria, Setting: Nine dermatology 1990–June Switzer1991 clinics treating skin disorders land other than skin cancer
Robinson et al. USA (2000)
Monfrecola et al. (2000)
Garbe and Buettner (2000)
Authors (year) Country
Table 1 continued
Mean age (year)
503 37.4
756 19.3
498 –
N
Participants
32
42
44
% male
Demographic: Female gender, younger age, indoor occupation
Behavior: Sunscreen use
Correlates of sun protection behaviors
30% of children used shade 27% wore a wide-brimmed hat 8% wore a long-sleeved shirt
Hat Protective clothing
Only 27% of parents used sunscreen themselves during the previous weekend
53% of parents reported that Behavior: Sunscreen use. (sunscreen applied to one’s child) their child always or usually used a sunscreen with an Demographic: Higher family income SPF of 15+ Clinical: Child has fair skin, previous 24% of children never used sunburns, family history of skin sunscreen cancer Children using sunscreen Behavioral: Greater overall sun spent an average of 22% exposure more time in the sun on the weekend than those who did not use sunscreen
Over 60% of students applied Behavior: Sunscreen use sunscreen to avoid sunburn Demographic: Female gender Once tanned, 75% of males Clinical: Sun-sensitive skin type did not continue to apply sunscreen
Clinical: At least one sunburn before 10% of sunscreen users used age 20 SPF [10, 42% of users Psychological: Positive attitude applied sunscreen only once toward the sun during sunbathing Behavioral: Increased sun exposure during recent holidays
41% never used sunscreen, 32% applied sunscreen occasionally, 27% used sunscreen regularly
Prevalence of behaviors
Use of shade
Sunscreen use
Sunscreen use
Sunscreen use
Sun protection behaviors
414 J Behav Med (2009) 32:406–428
Cokkinides USA et al. (2001)
Method: Structured telephone survey
Setting: American Cancer Society Sun Survey
Design: Cross-sectional; national sample
Method: Questionnaire
Setting: Adolescents aged 13– 17 years
Branstrom Sweden Design: Cross-sectional; et al. (2001) national sample
Method: Structured interview
Setting: Beach-goers at 21 of the largest Rhode Island beaches
July–October 1998
Spring and autumn of 1996
June–August 1995
Weinstock USA et al. (2000)
Design: Cross-sectional; convenience sample
Data collection date
Authors (year) Country Design methods
Table 1 continued
Mean age (year)
1,192 11–18
2,615 15
2,324 16–65
N
Participants
51
46
40
% male
10% reported practicing three or Social: Frequently receiving more sun protection information about sun protection behaviors routinely when from friends and family, receiving outdoors on a sunny summer advice about sun protection from day one’s health care provider 30% did not routinely practice any sun protection behaviors
Sun protection
Psychological: Greater perceived benefits of sun protection
4% wore a long-sleeved shirt
Sleeved shirt
Clinical: Greater sun sensitivity
Demographic: Female gender, younger age, parents with some college education
Behavior: Sunscreen use
4% wore a wide brimmed hat
32% routinely wore sunglasses
31% routinely used sunscreen
When outdoors on a sunny summer day,
Hat use
Sunglasses
Sunscreen use
Use of shade
Protective clothing
Sunscreen use
28% of males, 18% of females Behavior: Total sun protection reported using no form of sun Demographic: Female gender, protection while sunbathing younger age 33% males, 56% females used Clinical: Skin type I or II sunscreen while sunbathing Psychological: Negative attitude 20% males, 19% females wore toward sunbathing protective clothing Behavioral: Infrequent sunbathing 18% males, 14% females sought shade while outdoors
83% did not often avoid the sun during midday
Hat
Shirt
Sunglasses
Sun avoidance
Correlates of sun protection behaviors
45% used sunscreen often. Only Behavior: Total sun protection 24% regularly used a Demographic: Female gender, sunscreen with SPF 15+ on increased age all exposed body parts Clinical: Sun-sensitive skin type Articles worn ‘often’ while Behavioral: Non-users of tanning outdoors were: salons 62% often wore sunglasses Social: Personal knowledge of 41% often wore a shirt someone with skin cancer 14% often wore a widebrimmed hat
Prevalence of behaviors
Sunscreen use
Sun protection behaviors
J Behav Med (2009) 32:406–428 415
123
123
Purdue (2002) Canada
Behavior: Total sun protection
40% often used sunscreen 81% reported performing at least one protective behavior
Sunscreen use Sun protection
27% practiced only one type of behavior, 24% practiced two, 21% practiced three, and 9% practiced all four behaviors
44% often used shade
Variations: Males more likely to wear protective clothing; younger participants more likely to use sunscreen
Psychological: Greater concerns regarding sun protection, fewer perceived barriers to sun protection, no desire for a tan
Demographic: Female gender, increased age, higher educational When in the sun for [30 min: attainment
Timed sun avoidance 43% often or always avoided the peak UV exposure period
Behavior: Hat use Demographic: Male gender
Clinical: Fairer skin type
Demographic: Female gender
Behavior: Sunscreen use
Seeking shade
Prevalence not reported
Protective clothing
Hat use
Sunscreen use
47% often wore protective clothing
–
–
Sun protection
Protective clothing
15+
–
23% were very likely to wear Clinical: Recent doctor consultation protective clothing Behavioral: Non-smoker, frequent 40–50% unlikely to use any of seatbelt use the three sun protective Behavior: Use of shade behaviors assessed Demographic: Female gender, increased age, higher educational level, higher income
Protective clothing
Use of shade
30% indicated that they were Behavior: Sunscreen use very likely to use sunscreen Demographic: Female gender, when outdoors increased age, Caucasian ethnicity, 27% were very likely to use higher educational attainment, shade higher income
Correlates of sun protection behaviors
Sunscreen use
Prevalence of behaviors
Method: Structured telephone interview
1,027
2,589
–
% male
Sun protection behaviors
Use of shade
September 1996
Mean age (year)
32,440 –
N
Participants
Setting: Fair-skinned individuals who spent at least 30 min of leisure time in the sun
Design: Cross-sectional; national sample
Method: Questionnaire administered on high school completion, with 1 and 2 year follow-ups
Setting: Health in Translation Study
Schofield et al. Australia Design: Prospective; national (2001) sample
Method: Questionnaire
Setting: National Health Interview Survey
Australian summers 1993–97
1998
Santmyire USA et al. (2001)
Design: Cross-sectional; national sample
Data collection date
Authors (year) Country Design methods
Table 1 continued
416 J Behav Med (2009) 32:406–428
1999
USA
Israel
Geller et al. (2002)
Tamir et al. (2002)
Method: Questionnaire
Setting: Baseline assessment of intervention study
Branstrom Sweden Design: Cross-sectional; et al. (2004) national sample
Method: Structured telephone interview or questionnaire
May 2001
Mean age (year)
1,752
27
18+
10,079 14
N
Participants
February– 8,928 March 1994, 1996, Setting: National Health Survey 1998 of Jewish Adults
Design: Prospective; national sample
Method: Questionnaire
Setting: National Nurses Health Study
Design: Cross-sectional, national sample
Data collection date
Authors (year) Country Design methods
Table 1 continued
44
–
41
% male
Sun protection
Sunscreen use
Sun protection
Protective clothing
Hat use
37% practiced sun avoidance
Sun avoidance
Behavior: Total sun protection
Social: Peers who are not tanned
Psychological: Belief that it is not worth burning to get a tan, preference for natural/light colored skin
Clinical: Fair skin type
Demographic: Female gender, younger age
Behavior: Sunscreen use
Correlates of sun protection behaviors
Not reported
Proportion never using any sun protection decreased over time: 20% in 1994 to 13% in 1998
Psychological: Negative attitudes toward sun exposure, indifference toward having a tan, belief that sunbathing is risky, greater perceived control of sun protection (females only)
Clinical: Skin types I-III
Demographic: Female gender, increased age, higher educational attainment
Behavior: Total sun protection
Demographic Female gender, age 35–44 years, higher educational 25% used a hat use attainment, secularity, European 11% wore protective clothing origin Proportion always using some Clinical: Fair skin type form of sun protection increased over time: 34% in 1994 to 46% in 1998
In 1998, 37% used sunscreen
34% reported routine use of sunscreen during the past summer
Prevalence of behaviors
Sunscreen use
Sunscreen use
Sun protection behaviors
J Behav Med (2009) 32:406–428 417
123
Method: Structured telephone interview
Clinical: Sensitive skin type (all behaviors except use of sunglasses) 22% adolescents, 55% adults wore sunglasses Sunglasses
Demographic: Female gender (all behaviors except hat use), increased age 37% adolescents, 46% adults wore long-legged pants Long-legged pants
Behavior: Sun protection by adults
11% adolescents, 18% adults wore a long-sleeved shirt Long-sleeved shirt
Clinical: Sensitive skin which always burns (timed sun avoidance) 19% adolescents, 27% adults used shade
Hat use
Use of shade
Demographic: Male gender (increased hat use), age (older increased use of sunglasses, younger increased hat and sunscreen use) 37% adolescents, 33% adults used sunscreen
38% of adolescents, 48% of adults wore a hat
Behavior: Sun protection by adolescents Australia Design: Cross-sectional; national sample
November– January 2003–04 Setting: Random selection from residential telephone directories, selected in proportion to the population in each state
5,772 12–69
50
Sunscreen use
When outdoors on the weekend:
123
Dobbinson et al. (2008)
Mean age (year) N
Authors (year) Country Design methods
Table 1 continued
Data collection date
Participants
% male
Sun protection behaviors
Correlates of sun protection behaviors
J Behav Med (2009) 32:406–428
Prevalence of behaviors
418
Ultraviolet radiation (UVR) exposure behaviors Numerous studies have demonstrated that a large proportion of young people and adults (i.e. between 42 and 76%) intentionally sunbathe outdoors for the primary purpose of acquiring a suntan, particularly females (e.g. Lucci et al. 2001; Michielutte et al. 1996). Of those over the age of 15 years, between 11 and 75% of females, and 6 and 44% of males, report ever using a tanning salon or solarium (e.g. Boldeman et al. 1997; Campbell and Birdsell 1994; Wichstrom 1994). In addition, a considerable percentage of sunbathers (i.e. between 36 and 84%) and sunbed users have reported skin burns as a result of such activities (e.g. Boldeman et al. 2001; Brandberg et al. 1998). Correlates of sun protection behavior Gender The single demographic characteristic most often associated with sun protection behavior, particularly sunscreen use, is gender. A large and growing body of evidence suggests striking gender differences in attitudes and behaviors related to sun protection. The literature overwhelmingly supports the notion that females are significantly more likely to use sunscreen, and most other forms of sun protection (with the exception of hats), compared to males (e.g. Branstrom et al. 2004; Geller et al. 2002). Females are also more likely than males to use sunscreen across a wider range of situations (Abroms et al. 2003; Scerri et al. 2002), to reapply sunscreen more frequently (Abroms et al. 2003; Devos et al. 2003), and to make greater use of shade as a means of sun protection (Campbell and Birdsell 1994; Hall et al. 1997; Purdue 2002). Only two studies have reported evidence contrary to this (Cockburn et al. 1989; Lower et al. 1998). Females, however, are also more likely to positively view, and frequently engage in, risky behaviors such as sunbathing (e.g. Boldeman et al. 2001; Sjoberg et al. 2004) and solarium use (e.g. Branstrom et al. 2004; Devos et al. 2003), even though males report spending greater amounts of time in the sun (e.g. Hoegh et al. 1999; Schofield et al. 2001), and greater frequency of sunburn (Hill et al. 1992; Melia and Bulman 1995). These behavioral differences, however, are more commonly observed in adolescence and young adulthood than in any other developmental period (Abroms et al. 2003; Koh et al. 1997; Robinson et al. 1997a). Compared to males, females generally tend to express more positive attitudes towards sun protection (e.g. Lamanna 2004; Purdue 2002), perceive fewer barriers to sun protection behavior (Cody and Lee 1990), and rate skin
J Behav Med (2009) 32:406–428
damage caused by sun exposure as more severe (Hillhouse et al. 1996). In comparison, males tend to report more pragmatic barriers to sun protection than females, including the inconvenience or expense associated with the use of sunscreen or protective clothing (e.g. Lowe et al. 1993; Shoveller et al. 1998), as well as simply forgetting to engage in sun protection (Purdue 2002). While gender differences in sun protection attitudes and behaviors are well established, less is known about the role of other demographic, psychological, and social factors that may explain these differences. Skin type In the strictest sense, skin type is an index of sun sensitivity which refers to both the potential for the skin to develop a tan and to burn (Garbe and Buettner 2000). Generally, skin type is measured according to Fitzpatrick’s classification, which is based on four categories. Skin types I and II are indicative of sun-sensitive skins (i.e. fair or pale skin that tends to burn but rarely tan in response to extended sun exposure). Skin types III and IV are darker, less sunsensitive, and generally tan in response to sun exposure. Despite the efficiency of this categorization system, however, previous investigators have assessed skin type using a variety of different methods including reliance on selfreport, limiting the comparability of findings across studies. Overall, individuals with sun-sensitive skin types (skin types I and II) appear most likely to engage in sun protection (e.g. Ermertcan et al. 2005; Geller et al. 2002; Tamir et al. 2002), and to report spending less time in the sun or at the beach (e.g. Branstrom et al. 2004; Schofield et al. 2001). Paradoxically, however, there is also evidence to suggest that individuals with sun-sensitive skin types report higher frequencies of sunbathing (e.g. Robinson et al. 1997b), sunbed use (e.g. Mermelstein and Riesenberg 1992; Robinson et al. 1997b) and, as one would expect, higher frequencies of sunburn compared to those with naturally darker skin pigmentation (e.g. Branstrom et al. 2004; Hall et al. 2003). Psychological factors The literature is comprised of many studies examining the association between sun protection behavior and psychological factors (e.g. Branstrom et al. 2001, 2004; Jackson and Aiken 2000), and these have produced several key findings. Across studies, psychological variables found to be associated with increased sun protection in the general population include: higher perceived risk of developing skin cancer (e.g. Douglass et al. 1997; Lamanna 2004); greater perceived benefits of sun protection (Cokkinides
419
et al. 2001; Glanz et al. 1999; e.g. Turrisi et al. 1999); lower perceived barriers to sun protection (e.g. Branstrom et al. 2004; Geller et al. 2002; Purdue 2002); greater intentions to use sun protection (Mermelstein and Riesenberg 1992; Reynolds et al. 1996); higher perceived value of health and appearance (Carmel et al. 1994); increased skin cancer-related anxiety (Keesling and Friedman 1987); greater knowledge of skin cancer and sun protection recommendations (e.g. Fritschi et al. 1992; Glanz et al. 1999; Pruim et al. 1999), and in some cases, greater perceived severity of skin cancer (Cody and Lee 1990). In terms of the perceived benefits of sun protection, numerous studies have found that a large proportion of individuals from the general population perceive protecting one’s skin from sun damage as an easy way to stay healthy and look younger. It is also commonly believed that unprotected sun exposure can increase one’s chances of developing skin cancer (Cokkinides et al. 2001; Jones et al. 2000). Sun protection methods, particularly the use of sunscreen and shade, are perceived as ‘very important’ by most individuals in samples derived from the general population (e.g. Stott 1999). The number of perceived benefits associated with sun exposure, however, often outweigh the perceived harms (Jones et al. 2000). Branstrom et al. (2001), for example, found that Swedish adolescents who perceived sunbathing as ‘harmful’ reported sunbathing just as often as those who believed sunbathing was ‘healthy’. A number of motivational barriers to sun protection have emerged in the literature. The most widely cited of these is the perceived physical attractiveness associated with having a tan (e.g. Mahler et al. 2003; Purdue 2002). Research findings suggest that the primary motivation for UVR exposure is often to achieve a tan, and the primary motive for tanning is most often appearance enhancement, particularly amongst females. Individuals typically report that they, as well as others, look more attractive with a tan (e.g. Dixon et al. 1999; Mahler et al. 2003), and believe that having a tan helps one to look or feel healthier (e.g. Cokkinides et al. 2001; Jones et al. 2000; Robinson et al. 2000). Sunbathing is also commonly associated with positive states such as enjoyment or relaxation (Cokkinides et al. 2001; Jones et al. 2000). It is important to note, however, that studies applying psychological variables to the task of predicting sun protection behavior have had varying levels of success and, at best, leave large amounts of the variance in health behavior unaccounted for (Clarke et al. 1997; Hill et al. 1984; Keesling and Friedman 1987). For example, Clarke et al. (1997) found that gender and skin type accounted for nine percent of the variance in sun protection behavior, while psychological variables such as perceived risk and
123
420
perceived severity only accounted for an additional five percent of the variance in reported behavior. Social factors There is also evidence to suggest that a number of social factors play a role in determining sun protection behavior, including: sun protection and tanning practices amongst peers (e.g. Cokkinides et al. 2001; Geller et al. 2002); perceived parental influences on sun protection (e.g. Cokkinides et al. 2001; Dixon et al. 1999); and advice about sun protection given by health care professionals (Cokkinides et al. 2001). Adolescents who believe their peers favor a tanned appearance are less likely to use adequate sun protection compared to those with friends who do not favor tanning (Lower et al. 1998), with females more likely to be influenced by their peer networks than males (Geller et al. 2002), particularly if they harbor negative views about their body (Wichstrom 1994). However, all of the studies cited above have sampled adolescents only, based on the premise that social factors are particularly critical for this developmental group.
J Behav Med (2009) 32:406–428
to be higher amongst those who report a family history of skin cancer compared to those who do not (Ermertcan et al. 2005; Hourani and LaFleur 1995; Newman et al. 1996; Robinson et al. 2000). Knowing a friend or acquaintance with skin cancer also appears to be positively correlated with sun protection use (Jones et al. 2000; Keesling and Friedman 1987; Weinstock et al. 2000). However, Hall et al. (2003) examined the sunburn experiences of over 28,000 American men and women and found that participants with a family history of melanoma reported a greater frequency of sunburn in the past 12 months compared to those without a family history. As a methodological point, however, it should be noted that none of the aforementioned studies confirmed reports of skin cancer within the family. Age
There are only limited data available to elucidate the relationship between personal history of skin cancer and sun protection behaviors amongst individuals in the general population. In a large Australian study assessing uptake and correlates of sun protection amongst 807 men and women, Pruim et al. (1999) found that recent non-melanoma skin cancer diagnosis had no association with uptake of sun protection beyond the use of shade. While several studies have reported similar results (Berwick et al. 1992; Robinson 1990), others have yielded conflicting data (e.g. Hall et al. 1997; Newman et al. 1996). Of the studies that did find a positive association between personal history of non-melanoma skin cancer and sun protection, Rosenman et al. (1995) found that a personal skin cancer diagnosis increased the likelihood of sun protection amongst farmers and their spouses, and a case-control study conducted in Israel found that individuals who had previously been treated for basal cell carcinoma were more likely to use sunscreen compared to controls (Harth et al. 1995).
The association between age and sun protection behavior is unclear. A number of studies have found a positive association between age and sun protection, particularly sunscreen use (e.g. Branstrom et al. 2004; Purdue 2002; Scerri et al. 2002); however, there is also evidence of a negative association between age and sun protection (e.g. Garbe and Buettner 2000; Pruim et al. 1999), as well as some studies which have found no association (e.g. Campbell and Birdsell 1994; Hourani and LaFleur 1995). The role of age as a correlate of sun protection behavior may be unclear, at least in part, due to the diverse range of age groups used in comparative analyses. For example, some studies have sampled adolescents of different ages, whilst others have compared children to adolescents, or adolescents to adults. Assessing this literature, it seems likely that the relationship between age and sun protection behavior is curvilinear. Supporting this, studies show that adolescents and young adults are less likely to use sun protection (e.g. Devos et al. 2003; Geller et al. 2002) and more likely to spend time in the sun (Devos et al. 2003; Newman et al. 1996), to sunbathe intentionally (e.g. Boldeman et al. 2001; Branstrom et al. 2001, 2004), to use sunbeds (e.g. Branstrom et al. 2004; Sjoberg et al. 2004), and to experience sunburn (e.g. Devos et al. 2003; Ermertcan et al. 2005; Hall et al. 2003), compared to both children and older adults.
Family history of skin cancer
Educational level and socioeconomic status
There are even fewer published data on the influence of family history of skin cancer on the use of sun protection amongst individuals in the general population. Of the studies that have examined this relationship, all but one (Berwick et al. 1992) have found sun protection behaviors
The evidence supports a positive association between sun protection behavior and educational attainment (e.g. Branstrom et al. 2004; Cokkinides et al. 2001; Koh et al. 1997; Michielutte et al. 1996). In contrast, there are conflicting reports for socioeconomic status or income level,
Personal history of skin cancer
123
J Behav Med (2009) 32:406–428
with some but not all studies reporting a positive association between socioeconomic status and sun protection (e.g. Ermertcan et al. 2005; Purdue 2002).
Skin self-examination In the general population, many individuals appear to have misconceptions about the early clinical signs of melanoma, or overestimate the danger of benign pigmented skin lesions (e.g. Baade et al. 2005; Branstrom et al. 2002). Skin self-examination is typically defined as the careful and deliberate examination of all areas of one’s skin, including those areas rarely exposed to the sun, for changes in spots or moles. Not all studies, however, have assessed skin selfexamination using this definition, with many studies neglecting to assess the thoroughness of self-screening. Studies examining the frequency of skin self-examination show that between 23 and 61% of individuals in the general population report engaging in skin self-examination at least annually (Aitken et al. 2004; Douglass et al. 1998; Friedman et al. 1993; Girgis et al. 1991; Robinson et al. 1998; Weinstock et al. 1999). In the United States, Oliveria et al. (1999) interviewed 549 Caucasian adults and identified only 24% as having ever engaged in self- or partner-conducted skin examination. The rate of reported skin selfexamination is higher, however, amongst dermatology clinic patients, with almost 60% of the dermatological patients surveyed by Robinson et al. (2002) engaging in this screening practice on a monthly basis. Comparing men and women, a large Australian study found that 51% of women versus 43% of men had ever conducted skin selfexamination (Hill et al. 1991). Overall, most studies have found that females are more likely to engage in skin self-examination than males (Balanda et al. 1994; Douglass et al. 1998; Girgis et al. 1991; Robinson et al. 1998; Weinstock et al. 1999); however, one research group reported no gender differences for this screening behavior (Cody and Lee 1990). Aside from gender, increased awareness or knowledge of melanoma has been found to be associated with individuals having ever performed skin self-examination (Miller et al. 1996; Oliveria et al. 1999). Variables associated annual skin self-examination have been more widely investigated and include: greater perceived risk of developing skin cancer (Douglass et al. 1998; Girgis et al. 1991; Robinson et al. 1998), doctor recommendation (Aitken et al. 2004; Robinson et al. 1998; Weinstock et al. 1999), greater perceived benefits of early skin cancer detection (Girgis et al. 1991), partner assistance with skin examination (Weinstock et al. 2004), availability of a mirror (Weinstock et al. 2004), concern about skin cancer (Aitken et al. 2004; Weinstock
421
et al. 1999), personal history of skin cancer (Aitken et al. 2004; Girgis et al. 1991), and increased awareness or knowledge of melanoma (Balanda et al. 1994; Cody and Lee 1990; Douglass et al. 1998; Friedman et al. 1993; Robinson et al. 1998; Weinstock et al. 1999). Associations between skin self-examination and other demographic variables are equivocal. Studies have identified associations between self-screening and increased age (Miller et al. 1996; e.g. Robinson et al. 1998), being married (Balanda et al. 1994), higher education level (e.g. Aitken et al. 2004; Robinson et al. 1998), being employed (Girgis et al. 1991), and having health insurance (Girgis et al. 1991). However, Weinstock et al. (1999) found no association between skin self-examination and age, income, marital status, education level or sun sensitivity. Conversely, other studies have found that the likelihood of engagement in skin self-examination decreases with age (Aitken et al. 2004; Oliveria et al. 1999) and higher education level (Oliveria et al. 1999). Common reasons for infrequent engagement in skin self-examination include: forgetfulness (29%); a failure to see the personal relevance of skin self-examination (22%); and a lack of suspicious lesions during previous self-performed screening (15%) (Weinstock et al. 1999). The majority (75%) of adults sampled by Weinstock et al. (1999) had never been advised by a health professional about the importance of selfscreening.
Clinical skin examination The annual prevalence of self-reported clinical skin examination in the general population ranges from 8 to 21% (Aitken et al. 2006; Janda et al. 2004b; LeBlanc et al. 2008; Rodriguez et al. 2007; Saraiya et al. 2004), while the percentage of study participants reporting having ever engaged in clinical skin examination ranges from 9 to 45% (e.g. Carriere et al. 2007; Geller et al. 2003; LeBlanc et al. 2008; Tamir et al. 2002). In Australia, there is some evidence for an increasing prevalence of screening for skin cancer by whole-body skin examination (Janda et al. 2004a), although comparison with earlier studies is problematic due to variations in item wording. A recent survey of 792 adults attending a free skin cancer screening in the United States found that screening attendees gave the following reasons for uptake of clinical skin examination: belief that they had a suspicious skin lesion (41%); prompting by an advertisement for screening in the media (31%); a personal or family history of skin cancer (20 and 21%, respectively); and encouragement from family or friends to participate in screening (19%) (Call et al. 2004). Common reasons for non-attendance include: forgetfulness (28%), lack of time
123
422
(18%), a perceived lack of suspicious lesions (15%), and not considering clinical skin examination as personally relevant or important (15%) (Bergenmar et al. 1997). Most published studies assessing frequency of clinical skin examination have sampled attendees of skin cancer screening clinics and as such, all study participants have recently had at least one physician-conducted skin examination. Correlates of clinical skin examination, as indicated by clinic attendees, include: female gender (Bergenmar et al. 1997; de Rooij et al. 1997; Koh et al. 1991; McGee et al. 1994; Melia et al. 2000), higher education level (Koh et al. 1991), increased age (Melia et al. 2000), a previous diagnosis of skin cancer (Schwartz et al. 2002), greater number of objective risk factors for skin cancer (Koh et al. 1991; McGee et al. 1994), and higher perceived risk of skin cancer (Bergenmar et al. 1997). Several studies have also shown that previous engagement in skin cancer screening is positively associated with recent screening uptake, providing evidence against the notion that prior skin examination without lesion detection may result in a false sense of security about one’s chances of developing skin cancer (Brandberg et al. 1993; Rampen et al. 1993). Patient characteristics associated with early melanoma detection include: female gender, at least one atypical nevus (or mole), more than 20 clinically benign nevi, and a personal history of melanoma (Schwartz et al. 2002). Further, Temoshok et al. (1985) found that lower levels of knowledge about melanoma and lower understanding of its treatment were correlated with both tumor thickness and level of invasion on melanoma detection. Studies which have assessed uptake of clinical skin examination in the general population have reported similar results, with higher education level (Saraiya et al. 2004), increased age (Saraiya et al. 2004), previous diagnosis of skin cancer (Mullen et al. 1996), and previous uptake of skin cancer screening (Brandberg et al. 1996; Evans et al. 1985) identified as correlates of clinic-based skin cancer screening attendance. Saraiya et al. (2004) have also identified family history of melanoma and greater use of sun protection as correlates of screening uptake in the general population. Further, the literature suggests that men over 50 years of age are more likely to present with thicker melanomas (Hanrahan et al. 1998), and have a higher risk of developing invasive melanoma and of dying due to melanoma (Jemal et al. 2000).
Discussion For the past three decades, numerous studies across various disciplines have sought to identify and understand the factors associated with sun exposure, sun protection and skin cancer screening behaviors. This review of original
123
J Behav Med (2009) 32:406–428
studies on individuals’ attitudes, beliefs and behaviors in regards to sun protection and skin surveillance published between January 1980 and May 2008 identified 91 relevant articles from research groups located worldwide. As shown in Table 1, the data indicate that a large proportion of individuals in the general population do not practice sun protection when outdoors and in the sun. Further, uptake of skin cancer surveillance practices such as skin self-examination and clinical skin examination are low. Most evident, however, is the substantial variation in the prevalence of the examined behaviors, as reported by different studies. Thus, what is resoundingly clear from this review is that even 91 studies may not be sufficient to produce a pool of results from which strong statements can be made about the prevalence, and potential correlates, of sun protection and skin cancer screening behavior. The observed variability in findings across studies may reflect environmental and cultural differences between study samples, as well as differences in reported behavioral practices over time (Tamir et al. 2002), and methodological variability in regards to the measurement of skin cancerrelated behaviors. For example, as shown in Table 1, sunscreen usage rates reported by studies undertaken in Australia, which has the highest incidence of skin cancer in the world, are particularly high (Pruim et al. 1999) compared to countries such as Germany, Switzerland, Malta, Turkey and the United Kingdom, where skin cancer rates are lower (e.g. Bourke et al. 1995; Branstrom et al. 2001; Ermertcan et al. 2005; Garbe and Buettner 2000; Jones et al. 2000), and public health campaigns about skin cancer and sun protection have been more limited. The wide range of reported rates of sun protection and skin surveillance behaviors across different studies may also reflect the lack of standardized measurement scales in this field of research. As such, the validity of comparisons between studies utilizing different methodologies may be limited. Moreover, if estimates of these health behaviors are sensitive to assessment format, then presumably there will be different estimates of the ‘true’ prevalence of sun protection and skin surveillance. Further, the wide variation in prevalence estimates for sun protection and screening behaviors introduces some uncertainty into the results of analyses of correlates. This underscores the importance of developing for future research, standardized, validated and reliable measures of sun exposure, solarium use, sun protection and skin surveillance. Only recently have steps in this direction been taken, with the formation in 2005 of a collaborative research group in the USA aimed at developing a consensus-based set of core measures to assess sun exposure and sun protection habits. Based on a combination of expert review and cognitive interviewing, this collaborative process has yielded standardized survey items appropriate for use in studies involving adults, adolescents or children (Glanz et al. 2008).
J Behav Med (2009) 32:406–428
However, these survey items have only recently been published and future population-based studies with a prospective, multivariate design are necessary to evaluate the utility of these measures across the diverse settings of sun protection research. Future collaboration between experts is similarly needed to develop core measures of skin surveillance, including the frequency and thoroughness of both skin self-examination and clinical skin examination practices. So long as there are vast differences in the way these behaviors are assessed between studies, we will continue to struggle to draw clear and valid comparisons across the literature. Further methodological work in this area stands to increase the potential for generalization and comparability between studies, as well as clarify the ‘true’ prevalence of these behaviors and their correlates. To this end, it is encouraging to find that over time, researchers have moved away from the recruitment of convenience samples and toward greater use of population-based designs, as shown in Table 1. Collaborative efforts focused on the refinement of research methodologies in this field will undoubtedly aid the development of effective interventions for the improvement of skin-cancer related prevention and screening behaviors. Based on the findings of this review, several variables have been shown to facilitate uptake of sun protection as well as skin surveillance, including: female gender, sunsensitive skin type, greater perceived risk of developing skin cancer, greater perceived benefits of sun protection or early skin cancer detection, doctor recommendation for screening, higher educational level and knowledge of skin cancer, and in some studies, a personal or family history of skin cancer. In contrast, key variables associated with lower levels of engagement in sun protection include: male gender, greater perceived attractiveness of a tanned body, and higher perceived barriers to sun protection or skin cancer screening. The literature has also produced a number of mixed findings, which are important to consider. The association between age and sun protection behavior is a key example. While there are data to support a positive, as well as a negative, association between age and sun protection behavior, there is also evidence for a curvilinear relationship, which can be accounted for in developmental terms. From this perspective, sun protection practices among children are likely to be high given the protective role played by parents, child care workers and school teachers in regards to sun-related behavior. In adolescence however, when risktaking behaviors are known to increase and social norms and body image perceptions emerge as important determinants of behavior (Moore and Rosenthal 1992; Radius et al. 1980), the use of sun protection practices is likely to decrease. As young adults begin to mature and to place greater value on their health and well-being, sun protection practices may
423
increase, providing an account for the curvilinear association found in the literature. More work is needed, however, to provide greater insight into the strength of this association, and the underpinning psychological and social processes. Examining the role of psychological variables in determining sun protection behavior, Branstrom et al. (2001) found that Swedish adolescents who perceived sunbathing as ‘harmful’ reported sunbathing just as often as those who believed sunbathing was ‘healthy’. This finding is intriguing because it signals the potential for cognitive dissonance; the unpleasant internal state that arises when individuals notice inconsistency between their attitudes and their behaviors (Baron and Byrne 1997; Festinger 1962). The concept of cognitive dissonance may also provide an account for the paradoxical findings reported in the sun protection literature for females, and individuals with sun-sensitive skin types. The evidence suggests that, among young people, sun protection behaviors are likely to be influenced by a number of competing or conflicting beliefs, such as the desire to prevent skin cancer versus the desire to achieve a tan. It is possible that these competing goals are reconciled to some extent, particularly among young females and those with fair skin, through inadequate sunscreen use; that is, use of sunscreens with a low sun protection factor, or failure to reapply sunscreen during extended sun exposure (e.g. Robinson et al. 1997b). In doing so, young people may believe they are complying with sun safety messages, while still achieving the desired sun tan. It is also possible that such findings reflect a perceived lack of personal relevancy among adolescents in regards to the risks associated with extended sun exposure. Indeed, perceptions of the negative consequences of sun exposure may be considered too far into the distant future for young people to warrant immediate behavioral change (Branstrom et al. 2001; Livingston et al. 2001). Clearly, the role of such cognitive or decisional balance processes warrants further empirical investigation, with the view to informing the development of updated public health campaigns targeting youth. On the whole, risk perceptions, attitudes, and beliefs as well as behavioral intentions and knowledge, have been the keystones of many psychological investigations in this field. Conceptually, findings in this field are consistent with, and partially support, the Health Belief Model (Janz and Becker 1984; Rosenstock 1974). From this theoretical perspective, the efficacy of public health messages about skin cancer prevention may be enhanced by highlighting the benefits of sun protection and early skin cancer detection (perceived benefits), while recognizing the powerful competing attitudes and beliefs that may interfere with uptake (perceived barriers), and emphasizing that no one is immune to skin cancer (perceived susceptibility), which in the case of malignant melanoma, may be fatal (perceived severity).
123
424
Such an approach is consistent with the major findings of this review. These data also suggest doctor-patient communication as a powerful vehicle for the communication of skin cancer-related messages. The existing literature can also be used to provide an evidence base for the development of strategies targeted at those individuals least likely to engage in sun protection and screening behaviors; in particular men, adolescents, those with a lower objective or perceived risk of developing skin cancer, and those with lower levels of knowledge about skin cancer. Although characteristics such as gender and absence of phenotypic or genetic risk factors are not amenable to intervention, the identification of these factors can assist in ensuring that subsequent intervention strategies are effectively targeted. It appears crucial that preventive programs in this area are based on behavioral data specific to gender. In regards to sun protection, for example, programs or campaigns specifically tailored to men might place greater emphasis on the importance of practical aspects of sun protection such as simple strategies to limit the role of forgetfulness as a barrier to sunscreen use. Sun protection and screening behaviors may also be maximized by enlisting the support of partners to influence or encourage men’s participation in health behaviors, particularly given the evidence that greater partner involvement is correlated with greater uptake of cancer screening (e.g. Meiser et al. 2007). In contrast, interventions targeting adolescents, particularly young women, may benefit from the inclusion of peer discussion and the cognitive reframing of perceptions with regard to sun-tanned skin as an attractive ideal. It is hoped that the use of such strategies, at least as a starting point, may work towards engendering healthy beliefs about physical attractiveness in the community, such that young people may ‘‘love the skin they’re in’’ without the need to tan. From a public health perspective, there is also growing concern that individuals may change their sun protection attitudes and behaviors based on recent scientific and subsequent media reports about the beneficial effects of sun exposure for Vitamin D production (e.g. Scully et al. 2008). While prevention of Vitamin D deficiency was not identified as a possible motivation for sun exposure in the present review, recent studies have started to explore this issue (Youl et al. 2009), demonstrating both uncertainty and concern about Vitamin D and sun exposure in the general population. Preliminary evidence also suggests that this concern may lead to negative attitudes towards sun protection, and in turn, reduced sun protection practices (Youl et al. 2009). It is possible that the tailoring of some public health messages regarding sun exposure and Vitamin D may be causing confusion among the general population, highlighting a need to bolster health messages regarding sun exposure and the
123
J Behav Med (2009) 32:406–428
importance of sun protection practices (Youl et al. 2009). Again, it may also be imperative for health professionals to take an active educative role in regards to this complex issue. In summary, the field of behavioral research has developed greatly over the past 30 years and has amassed a considerable amount of high level evidence-based knowledge regarding the demographic, clinical, psychological and social correlates of sun protection and skin surveillance behaviors. In recent years, several skin cancer-related reviews have been conducted, including reviews of the literature on tanning behaviors (Autier 2007; Reynolds 2007), sun protection interventions (e.g. Sheer 1999), and the evidence as it relates to children and adolescents (Boe and Tillotson 2006; Hart and DeMarco 2008; Stanton et al. 2004). To our knowledge, however, this is the first systematic review to assemble the data on sun protection as well as skin surveillance from a period of over 25 years, with particular focus on identifying the prevalence and correlates of these health behaviors. This review has served to synthesize and evaluate the data reported by 91 original studies; however, the body of literature as it currently stands, is often inconsistent and demonstrates a remarkably wide variation in the prevalence of reported behaviors. Explanation of this variation is severely hindered by the lack of methodological consistency across studies. Moreover, studies that have applied psychological variables to the task of predicting sun protection behavior have had varying levels of success and, at best, leave large amounts of the variance in health behavior unaccounted for. Thus, the strongest recommendation to emerge from this review is a call for the development and widespread use of standardized measures in future sun protection and skin cancer screening research, in addition to more studies with a population-based, multivariate design. It is also recommended that specific targeted interventions are developed to increase the prevalence of preventative and early intervention behaviors for the control of skin cancer. Financial support Nadine Kasparian is supported by a Post-Doctoral Clinical Research Fellowship from the National Health and Medical Research Council of Australia (NH&MRC ID 510399). Bettina Meiser is supported by a Career Development Award from the National Health and Medical Research Council of Australia (NH&MRC ID 350989). This project was also supported by The Cancer Council NSW Strategic Research Partnership Grant (ID SRP06-X5), and a Cancer Institute NSW Program Grant for Excellence in Translational Research.
References Abroms, L., Jorgensen, C. M., Southwell, B. G., Geller, A. C., & Emmons, K. M. (2003). Gender differences in young adults’ beliefs about sunscreen use. Health Education & Behavior, 30, 29–43.
J Behav Med (2009) 32:406–428 Aitken, J. F., Janda, M., Lowe, J. B., Elwood, M., Ring, I. T., Youl, P. H., et al. (2004). Prevalence of whole-body skin self-examination in a population at high risk for skin cancer (Australia). Cancer Causes and Control, 15, 453–463. Aitken, J. F., Youl, P. H., Janda, M., Lowe, J. B., Ring, I. T., & Elwood, M. (2006). Increase in skin cancer screening during a community-based randomized intervention trial. International Journal of Cancer, 118, 1010–1016. American Cancer Society. (2007). Facts and figures 2007. Atlanta: American Cancer Society. Anderson, P. J., Lowe, J. B., Stanton, W. R., & Balanda, K. P. (1994). Skin cancer prevention: A link between primary prevention and early detection? Australian Journal of Public Health, 18, 417–420. Australian Cancer Network. (2008). Clinical practice guidelines for the management of melanoma in Australia and New Zealand. Canberra: National Health and Medical Research Council (NHMRC). Autier, P. (2007). Sunscreen use and increased duration of intentional sun exposure: Still a burning issue. International Journal of Cancer, 121, 1–5. Baade, P. D., Balanda, K. P., Stanton, W. R., Lowe, J. B., & Del Mar, C. B. (2005). Community perceptions of suspicious pigmented skin lesions: Are they accurate when compared to general practitioners? Cancer Detection and Prevention, 29, 267–275. Balanda, K. P., Lowe, J. B., Stanton, W. R., & Gillespie, A. M. (1994). Enhancing the early detection of melanoma within current guidelines. Australian Journal of Public Health, 18, 420–423. Banks, B. A., Silverman, R. A., Schwartz, R. H., & Tunnessen, W. W., Jr. (1992). Attitudes of teenagers toward sun exposure and sunscreen use. Pediatrics, 89, 40–42. Baron, R., & Byrne, D. (1997). Social psychology. Boston: Allyn and Bacon. Bergenmar, M., Tornberg, S., & Brandberg, Y. (1997). Factors related to non-attendance in a population based melanoma screening program. Psycho-Oncology, 6, 218–226. Berwick, M., Fine, J. A., & Bolognia, J. L. (1992). Sun exposure and sunscreen use following a community skin cancer screening. Preventive Medicine, 21, 302–310. Berwick, M., Begg, C. B., Fine, J., Roush, G. C., & Barnhill, R. L. (1996). Screening for cutaneous melanoma by skin self-examination. Journal of the National Cancer Institute, 88, 17–23. Boe, K., & Tillotson, E. (2006). Encouraging sun safety for children and adolescents. Journal School Nursing, 22, 136–141. Boldeman, C., Jansson, B., Nilsson, B., & Ullen, H. (1997). Sunbed use in Swedish urban adolescents related to behavioral characteristics. Preventive Medicine, 26, 114–119. Boldeman, C., Branstrom, R., Dal, H., Kristjansson, S., Rodvall, Y., Jansson, B., et al. (2001). Tanning habits and sunburn in a Swedish population age 13–50 years. European Journal of Cancer, 37, 2441–2448. Bourke, J. F., Healsmith, M. F., & Graham-Brown, R. A. (1995). Melanoma awareness and sun exposure in Leicester. British Journal of Dermatology, 132, 251–256. Brandberg, Y., Bolund, C., Michelson, H., Mansson-Brahme, E., Ringborg, U., & Sjoden, P. (1993). Participation in public screening for melanoma. European Journal of Cancer, 29, 860–863. Brandberg, Y., Bolund, C., Michelson, H., Mansson-Brahme, E., Ringborg, U., & Sjoden, P. O. (1996). Perceived susceptibility to and knowledge of malignant melanoma: Screening participants vs the general population. Preventive Medicine, 25, 170–177. Brandberg, Y., Ullen, H., Sjoberg, L., & Holm, L. E. (1998). Sunbathing and sunbed use related to self-image in a randomized sample of Swedish adolescents. European Journal of Cancer Prevention, 7, 321–329. Branstrom, R., Brandberg, Y., Holm, L., Sjoberg, L., & Ullen, H. (2001). Beliefs, knowledge and attitudes as predictors of
425 sunbathing habits and use of sun protection among Swedish adolescents. European Journal of Cancer Prevention, 10, 337–345. Branstrom, R., Hedblad, M. A., Krakau, I., & Ullen, H. (2002). Laypersons’ perceptual discrimination of pigmented skin lesions. Journal of the American Academy of Dermatology, 46, 667–673. Branstrom, R., Ullen, H., & Brandberg, Y. (2004). Attitudes, subjective norms and perception of behavioural control as predictors of sun-related behaviour in Swedish adults. Preventive Medicine, 39, 992–999. Call, T. R., Boucher, K. M., Whiting, B. L., Hart, M., Newman, K., Kinney, A. Y., et al. (2004). Motivating factors for attendance of skin cancer screenings. Journal of the American Academy of Dermatology, 51, 642–644. Campbell, H. S., & Birdsell, J. M. (1994). Knowledge, beliefs, and sun protection behaviors of Alberta adults. Preventive Medicine, 23, 160–166. Cancer Society of New Zealand. (2007). Position statement on skin cancer and early detection. Available at http://www.cancernz. org.nz/uploads/CSNZ_PS_Skin.pdf. Carmel, S., Shani, E., & Rosenberg, L. (1994). The role of age and an expanded Health Belief Model in predicting skin cancer protective behavior. Health Education Research, 9, 433–447. Carriere, P., Baade, P., Newman, B., Aitken, J., & Janda, M. (2007). Cancer screening in Queensland men. Medical Journal of Australia, 186, 404–407. Clarke, V., Williams, T., & Arthey, S. (1997). Skin type and optimistic bias in relation to the sun protection and suntanning behaviors of young adults. Journal of Behavioral Medicine, 20, 207–222. Cockburn, J., Hennrikus, D., Scott, R., & Sanson-Fisher, R. (1989). Adolescent use of sun-protection measures. Medical Journal of Australia, 151, 136–140. Cody, R., & Lee, C. (1990). Behaviors, beliefs, and intentions in skin cancer prevention. Journal of Behavioral Medicine, 13, 373–389. Cokkinides, V. E., Johnston-Davis, K., Weinstock, M., O’Connell, M. C., Kalsbeek, W., Thun, M. J., et al. (2001). Sun exposure and sun-protection behaviors and attitudes among U.S. youth, 11 to 18 years of age. Preventive Medicine, 33, 141–151. Cook, D. J., Mulrow, C. D., & Haynes, R. B. (1997). Systematic reviews: Synthesis of best evidence for clinical decisions. Annals of Internal Medicine, 126, 376–380. de Rooij, M. J., Rampen, F. H., Schouten, L. J., & Neumann, H. A. (1997). Factors influencing participation among melanoma screening attenders. Acta Dermato Venereologica, 77, 467–470. Devos, S. A., Baeyens, K., & Van Hecke, L. (2003). Sunscreen use and skin protection behavior on the Belgian beach. International Journal of Dermatology, 42, 352–356. Dixon, H., Borland, R., & Hill, D. (1999). Sun protection and sunburn in primary school children: The influence of age, gender, and coloring. Preventive Medicine, 28, 119–130. Dobbinson, S., Wakefield, M., Hill, D., Girgis, A., Aitken, J. F., Beckmann, K., et al. (2008). Prevalence and determinants of Australian adolescents’ and adults’ weekend sun protection and sunburn, summer 2003–2004. Journal of the American Academy of Dermatology, 59, 602–614. Douglass, H. M., McGee, R., & Williams, S. (1997). Sun behaviour and perceptions of risk for melanoma among 21-year-old New Zealanders. Australian and New Zealand Journal of Public Health, 21, 329–334. Douglass, H. M., McGee, R., & Williams, S. (1998). Are young adults checking their skin for melanoma? Australian and New Zealand Journal of Public Health, 22, 562–567. Ermertcan, A. T., Ozturkcan, S., Dinc, G., Yurtman, D., Pala, T., & Sahin, M. T. (2005). Sunscreen use and sun protection practices
123
426 in students and personnel of Celal Bayar University. Photodermatology, Photoimmunology and Photomedicine, 21, 191–197. Evans, A. M., Love, R. R., Meyerowitz, B. E., Leventhal, H., & Nerenz, D. R. (1985). Factors associated with active participation in a cancer prevention clinic. Preventive Medicine, 14, 358–371. Festinger, L. (1962). A theory of cognitive dissonance. Oxford: Stanford University Press. Foot, G., Girgis, A., Boyle, C., & Sanson-Fisher, R. (1993). Solar protection behaviours: A study of beachgoers. Australian Journal of Public Health, 17, 209–214. Friedman, L., Bruce, S., Webb, J., Weinberg, A., & Cooper, H. (1993). Skin self-examination in a population at increased risk for skin cancer. American Journal of Preventive Medicine, 9, 359–364. Fritschi, L., Green, A., & Solomon, P. (1992). Sun exposure in Australian adolescents. Journal of the American Academy of Dermatology, 27, 25–28. Garbe, C., & Buettner, P. G. (2000). Predictors of the use of sunscreen in dermatological patients in Central Europe. Preventive Medicine, 31, 134–139. Geller, A. C., Colditz, G., Oliveria, S., Emmons, K., Jorgensen, C., Aweh, G. N., et al. (2002). Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 US children and adolescents. Pediatrics, 109, 1009–1014. Geller, A. C., Zhang, Z., Sober, A. J., Halpern, A. C., Weinstock, M. A., Daniels, S., et al. (2003). The first 15 years of the American Academy of Dermatology skin cancer screening programs: 1985–1999. Journal of the American Academy of Dermatology, 48, 34–41. Girgis, A., Campbell, E., Redman, S., & Sanson-Fisher, R. (1991). Screening for melanoma: A community survey of prevalence and predictors. Medical Journal of Australia, 154, 338–343. Glanz, K., Lew, R., Song, V., & Cook, V. (1999). Factors associated with skin cancer prevention practices in a multiethnic population. Health Education and Behavior, 26, 344–359. Glanz, K., Yaroch, A., Dancel, M., Saraiya, M., Crane, L., Buller, D., et al. (2008). Measures of sun exposure and sun protection practices for behavioral and epidemiologic research. Archives of Dermatology, 144, 217–222. Guile, K., & Nicholson, S. (2004). Does knowledge influence melanoma-prone behavior? Awareness, exposure, and sun protection among five social groups. Oncology Nursing Forum, 31, 641–646. Hall, H. I., May, D. S., Lew, R. A., Koh, H. K., & Nadel, M. (1997). Sun protection behaviors of the U.S. white population. Preventive Medicine, 26, 401–407. Hall, H. I., McDavid, K., Jorgensen, C. M., & Kraft, J. M. (2001). Factors associated with sunburn in white children aged 6 months to 11 years. American Journal of Preventive Medicine, 20, 9–14. Hall, H., Saraiya, M., Thompson, T., Hartman, A., Glanz, K., & Rimer, B. (2003). Correlates of sunburn experiences among U.S. adults: Results of the 2000. National Health Interview Survey. Public Health Reports, 118, 540–549. Hanrahan, P. F., Hersey, P., & D’Este, C. A. (1998). Factors involved in presentation of older people with thick melanoma. Medical Journal of Australia, 169, 410–414. Hart, K., & DeMarco, R. (2008). Primary prevention of skin cancer in children and adolescents: A review of the literature. Journal of Pediatric Oncology Nursing, 25, 67–78. Harth, Y., Ulman, Y., Peled, I., & Friedman-Birnbaum, R. (1995). Sun protection and sunscreen use after surgical treatment of basal cell carcinoma. Photodermatology, Photoimmunology and Photomedicine, 11, 140–142. Hill, D., Rassaby, J., & Gardner, G. (1984). Determinants of intentions to take precautions against skin cancer. Community Health Studies, 8, 33–44.
123
J Behav Med (2009) 32:406–428 Hill, D., White, V., Borland, R., & Cockburn, J. (1991). Cancerrelated beliefs and behaviours in Australia. Australian Journal of Public Health, 15, 14–23. Hill, D., White, V., Marks, R., Theobald, T., Borland, R., & Roy, C. (1992). Melanoma prevention: Behavioral and nonbehavioral factors in sunburn among an Australian urban population. Preventive Medicine, 21, 654–669. Hillhouse, J. J., Stair, A. W., I. I. I., & Adler, C. M. (1996). Predictors of sunbathing and sunscreen use in college undergraduates. Journal of Behavioral Medicine, 19, 543–561. Hoegh, H., Davis, B., & Manthe, A. (1999). Sun avoidance practices among non-hispanic white Californians. Health Education and Behavior, 26, 360–368. Hourani, L., & LaFleur, B. (1995). Predictors of gender differences in sun-screen use and screening outcome among skin cancer screening participants. Journal of Behavioral Medicine, 18, 461–477. Jackson, K., & Aiken, L. (2000). A psychosocial model of sun protection and sunbathing in young women: The impact of health beliefs, attitudes, norms, and self-efficacy for sun protection. Health Psychology, 19, 469–478. Janda, M., Elwood, M., Ring, I. T., Firman, D. W., Lowe, J. B., Youl, P. H., et al. (2004a). Prevalence of skin screening by general practitioners in regional Queensland. Medical Journal of Australia, 180, 10–15. Janda, M., Youl, P. H., Lowe, J. B., Elwood, M., Ring, I. T., & Aitken, J. F. (2004b). Attitudes and intentions in relation to skin checks for early signs of skin cancer. Preventive Medicine, 39, 11–18. Janz, N., & Becker, M. (1984). The Health Belief Model: A decade later. Health Education Quarterly, 11, 1–47. Jemal, A., Devesa, S. S., Fears, T. R., & Hartge, P. (2000). Cancer surveillance series: changing patterns of cutaneous malignant melanoma mortality rates among whites in the United States. Journal of the National Cancer Institute, 92, 811–818. Jemal, A., Devesa, S. S., Hartge, P., & Tucker, M. A. (2001). Recent trends in cutaneous melanoma incidence among whites in the United States. Journal of the National Cancer Institute, 93, 678–683. Jones, F., Harris, P., & Chrispin, C. (2000). Catching the sun: An investigation of sun-exposure and skin protective behaviour. Psychology Health & Medicine, 5, 131–141. Keesling, B., & Friedman, H. (1987). Psychosocial factors in sunbathing and sunscreen use. Health Psychology, 6, 477–493. Koh, H. K., Geller, A. C., Miller, D. R., Caruso, A., Gage, I., & Lew, R. A. (1991). Who is being screened for melanoma/skin cancer? Characteristics of persons screened in Massachusetts. Journal of the American Academy of Dermatology, 24, 271–277. Koh, H., Bak, S., Geller, A., Mangione, T., Hingson, R., Levenson, S., et al. (1997). Sunbathing habits and sunscreen use among white adults: Results of a national survey. American Journal of Public Health, 87, 1214–1217. Lamanna, L. (2004). College students’ knowledge and attitudes about cancer and perceived risks of developing skin cancer. Dermatology Nursing, 16, 161–176. Leary, M., & Jones, J. (1993). The social psychology of tanning and sunscreen use: Self-presentational motives as a predictor of health risk. Journal of Applied Social Psychology, 23, 1390– 1406. LeBlanc, W. G., Vidal, L., Kirsner, R. S., Lee, D. J., Caban-Martinez, A. J., McCollister, K. E., et al. (2008). Reported skin cancer screening of US adult workers. Journal of the American Academy of Dermatology, 59, 55–63. Lewis, E., Mayer, J., & Slymen, D. (2006). Postal workers’ occupational and leisure-time sun safety behaviours (United States). Cancer Causes and Control, 17, 181–186.
J Behav Med (2009) 32:406–428 Livingston, P., White, V., Ugoni, A., & Borland, R. (2001). Knowledge, attitudes, and self-care practices related to sun protection among secondary students in Australia. Health Education Research, 16, 269–278. Lowe, J. B., Balanda, K. P., Gillespie, A. M., Del Mar, C. B., & Gentle, A. F. (1993). Sun-related attitudes and beliefs among Queensland school children: The role of gender and age. Australian Journal of Public Health, 17, 202–208. Lower, T., Girgis, A., & Sanson-Fisher, R. (1998). The prevalence and predictors of solar protection use among adolescents. Preventive Medicine, 27, 391–399. Lucci, A., Watts Citro, H., & Wilson, L. (2001). Assessment of knowledge of melanoma risk factors, prevention, and detection principles in Texas teenagers. Journal of Surgical Research, 97, 179–183. MacKie, R. M., McHenry, P., & Hole, D. (1993). Accelerated detection with prospective surveillance for cutaneous malignant melanoma in high-risk groups. Lancet, 341, 1618–1620. Maddock, J. E., O’Riordan, D. L., Lunde, K. B., & Steffen, A. (2007). Sun protection practices of beachgoers using a reliable observational measure. Annals of Behavioral Medicine, 34, 100–103. Mahler, H. I., Kulik, J. A., Gibbons, F. X., Gerrard, M., & Harrell, J. (2003). Effects of appearance-based interventions on sun protection intentions and self-reported behaviors. Health Psychology, 22, 199–209. Marks, R. (1999). Two decades of the public health approach to skin cancer control in Australia: Why, how and where are we now? Australasian Journal of Dermatology, 40, 1–5. Marks, R. (2004). Campaigning for melanoma prevention: A model for a health education program. European Academy of Dermatology and Venereology, 18, 44–47. Martin, R. H. (1995). Relationship between risk factors, knowledge and preventive behaviour relevant to skin cancer in general practice patients in South Australia. British Journal of General Practice, 45, 365–367. Masri, G. D., Clark, W. H., Jr., Guerry, D., I. V., Halpern, A., Thompson, C. J., & Elder, D. E. (1990). Screening and surveillance of patients at high risk for malignant melanoma result in detection of earlier disease. Journal of the American Academy of Dermatology, 22, 1042–1048. McGee, R., & Williams, S. (1992). Adolescence and sun protection. New Zealand Medical Journal, 105, 401–403. McGee, R., Elwood, M., Williams, S., & Lowry, F. (1994). Who comes to skin checks? New Zealand Medical Journal, 107, 58–60. McPherson, M., Elwood, M., English, D. R., Baade, P. D., Youl, P. H., & Aitken, J. F. (2006). Presentation and detection of invasive melanoma in a high-risk population. Journal of the American Academy of Dermatology, 54, 783–792. Meiser, B., Cowan, R., Costello, A., Giles, G., Lindeman, G., & Gaff, C. (2007). Prostate cancer screening uptake amongst men with a family history of prostate cancer. Urology, 70, 738–742. Melia, J., & Bulman, A. (1995). Sunburn and tanning in a British population. Journal of Public Health Medicine, 17, 223–229. Melia, J., Harland, C., Moss, S., Eiser, J. R., & Pendry, L. (2000). Feasibility of targeted early detection for melanoma: A population-based screening study. British Journal of Cancer, 82, 1605–1609. Mermelstein, R., & Riesenberg, L. (1992). Changing knowledge and attitudes about skin cancer risk factors in adolescents. Health Psychology, 11, 371–376. Michielutte, R., Dignan, M. B., Sharp, P. C., Boxley, J., & Wells, H. B. (1996). Skin cancer prevention and early detection practices in a sample of rural women. Preventive Medicine, 25, 673–683. Miller, D. R., Geller, A. C., Wyatt, S. W., Halpern, A., Howell, J. B., Cockerell, C., et al. (1996). Melanoma awareness and
427 self-examination practices: Results of a United States survey. Journal of the American Academy of Dermatology, 34, 962–970. Monfrecola, G., Fabbrocini, G., Posteraro, G., & Pini, D. (2000). What do young people think about the dangers of sunbathing, skin cancer and sunbeds? A questionnaire survey among Italians. Photodermatology, Photoimmunology and Photomedicine, 16, 15–18. Moore, S. M., & Rosenthal, D. A. (1992). Australian adolescents’ perceptions of health-related risks. Journal of Adolescent Research, 7, 177–191. Mullen, P. B., Gardiner, J. C., Rosenman, K., Zhu, Z., & Swanson, G. M. (1996). Skin cancer prevention and detection practices in a Michigan farm population following an educational intervention. Journal of Rural Health, 12, 311–320. National Health & Medical Research Council (NHMRC) National Breast Cancer Centre Psychosocial Working Group. (2000). Psychosocial clinical practice guidelines: Providing information, support, and counselling for women with breast cancer. Canberra: Commonwealth of Australia. Newman, W. G., Agro, A. D., Woodruff, S. I., & Mayer, J. A. (1996). A survey of recreational sun exposure of residents of San Diego, California. American Journal of Preventive Medicine, 12, 186– 194. NHS Centre for Reviews and Dissemination. (2001). Undertaking systematic reviews of research on effectiveness: CRD’s guidance for those carrying out or commissioning reviews. York: University of York. Oliveria, S. A., Christos, P. J., Halpern, A. C., Fine, J. A., Barnhill, R. L., & Berwick, M. (1999). Evaluation of factors associated with skin self-examination. Cancer Epidemiology, Biomarkers and Prevention, 8, 971–978. Parkin, D., Bray, F., Ferlay, J., & Pisani, P. (2005). Global cancer statistics, 2002. CA: A Cancer Journal for Clinicians, 55, 74–108. Pincus, M. W., Rollings, P. K., Craft, A. B., & Green, A. (1991). Sunscreen use on Queensland beaches. Australasian Journal of Dermatology, 32, 21–25. Pruim, B., Wright, L., & Green, A. (1999). Do people who apply sunscreens, re-apply them? Australasian Journal of Dermatology, 40, 79–82. Purdue, M. P. (2002). Predictors of sun protection in Canadian adults. Canadian Journal of Public Health, 93, 470–474. Radius, S. M., Dillman, T. E., Becker, M. H., Rosenstock, I. M., & Horvath, W. J. (1980). Adolescent perspectives of health and illness. Adolescence, 15, 375–384. Rampen, F. H., Berretty, P. J., Van Huystee, B. E., Kiemeney, L. A., & Nijs, C. H. (1993). Lack of selective attendance of participants at skin cancer/melanoma screening clinics. Journal of the American Academy of Dermatology, 29, 423–427. Reynolds, D. (2007). Literature review of theory-based empirical studies examining adolescent tanning practices. Dermatology Nursing, 19, 440–443. Reynolds, K. D., Blaum, J. M., Jester, P. M., Weiss, H., Soong, S. J., & Diclemente, R. J. (1996). Predictors of sun exposure in adolescents in a southeastern U.S. population. Journal of Adolescent Health, 19, 409–415. Robinson, J. K. (1990). Behavior modification obtained by sun protection education coupled with removal of a skin cancer. Archives of Dermatology, 126, 477–481. Robinson, J., Rademaker, A., Sylvester, J., & Cook, B. (1997a). Knowledge, attitudes, and behaviors of midwest adolescents. Preventive Medicine, 26, 364–372. Robinson, J. K., Rademaker, A. W., Sylvester, J. A., & Cook, B. (1997b). Summer sun exposure: Knowledge, attitudes, and behaviors of Midwest adolescents. Preventive Medicine, 26, 364–372.
123
428 Robinson, J., Rigel, D., & Amonette, R. (1998). What promotes skin self-examination? Journal of the American Academy of Dermatology, 39, 752–757. Robinson, J. K., Rigel, D. S., & Amonette, R. A. (2000). Summertime sun protection used by adults for their children. Journal of the American Academy of Dermatology, 42, 746–753. Robinson, J., Fisher, S., & Turrisi, R. (2002). Predictors of skin selfexamination performance. Cancer, 95, 135–146. Rodriguez, G. L., Ma, F., Federman, D. G., Rouhani, P., Chimento, S., Multach, M., et al. (2007). Predictors of skin cancer screening practice and attitudes in primary care. Journal of the American Academy of Dermatology, 57, 775–781. Rosenman, K. D., Gardiner, J., Swanson, G. M., Mullan, P., & Zhu, Z. (1995). Use of skin-cancer prevention strategies among farmers and their spouses. American Journal of Preventive Medicine, 11, 342–347. Rosenstock, I. (1974). The Health Belief Model and preventive health behaviour. In M. Becker (Ed.), The Health Belief Model and personal health behaviour (pp. 27–59). Thorofare: Charles B Slack. Santmyire, B. R., Feldman, S. R., & Fleischer, A. B., Jr. (2001). Lifestyle high-risk behaviors and demographics may predict the level of participation in sun-protection behaviors and skin cancer primary prevention in the United States: Results of the 1998 National Health Interview Survey. Cancer, 92, 1315–1324. Saraiya, M., Hall, H. I., Thompson, T., Hartman, A., Glanz, K., Rimer, B., et al. (2004). Skin cancer screening among U.S. adults from, 1992, 1998, and 2000 National Health Interview Surveys. Preventive Medicine, 39, 308–314. Savona, M. R., Jacobsen, M. D., James, R., & Owen, M. D. (2005). Ultraviolet radiation and the risks of cutaneous malignant melanoma and non-melanoma skin cancer: Perceptions and behaviours of Danish and American adolescents. European Journal of Cancer Prevention, 14, 57–62. Scerri, L., Aquilina, S., Amato, G. A., & Dalmas, M. (2002). Sun awareness and sun protection practices in Malta. Journal of European Academy Dermatology and Venereology, 16, 47–52. Schofield, P. E., Freeman, J. L., Dixon, H. G., Borland, R., & Hill, D. J. (2001). Trends in sun protection behaviour among Australian young adults. Australian and New Zealand Journal of Public Health, 25, 62–65. Schwartz, J. L., Wang, T. S., Hamilton, T. A., Lowe, L., Sondak, V. K., & Johnson, T. M. (2002). Thin primary cutaneous melanomas: Associated detection patterns, lesion characteristics, and patient characteristics. Cancer, 95, 1562–1568. Scully, M., Wakefield, M., & Dixon, H. (2008). Trends in news coverage about skin cancer prevention, 1993–2006: Increasingly mixed messages for the public. Australian and New Zealand Journal of Public Health, 32, 461–466. Sheer, B. (1999). Issues in summer safety: A call for sun protection. Pediatric Nursing, 25, 319–324. Shoveller, J. A., Lovato, C. Y., Peters, L., & Rivers, J. K. (1998). Canadian National Survey on sun exposure & protective behaviours: Adults at leisure. Cancer Prevention & Control, 2, 111–116. Sjoberg, L., Holm, L. -E., Ullen, H., & Brandberg, Y. (2004). Tanning and risk perception in adolescents. Health, Risk &Society, 6, 81–94.
123
J Behav Med (2009) 32:406–428 Smith, R., Cokkinides, V., & Eyre, H. (2005). American Cancer Society guidelines for the early detection of cancer. CA: A Cancer Journal for Clinicians, 55, 31–44. Stanton, W., Janda, M., Baade, P., & Anderson, P. (2004). Primary prevention of skin cancer: A review of sun protection in Australia and internationally. Health Promotion International, 19, 369–378. Stepanski, B. M., & Mayer, J. A. (1998). Solar protection behaviors among outdoor workers. Journal of Occupational and Environmental Medicine, 40, 43–48. Stott, M. A. (1999). Tanning and sunburn: Knowledge, attitudes and behaviour of people in Great Britain. Journal of Public Health Medicine, 21, 377–384. Tamir, D., Tamir, J., Dayan, I., Josef, H., Orenstein, A., & Shafir, R. (2002). Positive changes in sun-related behavior in Israel (1994– 1998). Preventive Medicine, 35, 369–375. Temoshok, L., Heller, B. W., Sagebiel, R. W., Blois, M. S., Sweet, D. M., DiClemente, R. J., et al. (1985). The relationship of psychosocial factors to prognostic indicators in cutaneous malignant melanoma. Journal of Psychosomatic Research, 29, 139–153. The Cancer Council Australia. (2004). Position statement: Screening and early detection of skin cancer. Australia: The Cancer Council Australia. The Cancer Council Australia. (2007). National Cancer Prevention Policy 2007–09. New South Wales: The Cancer Council Australia. Tucker, M., & Goldstein, A. (2003). Melanoma etiology: Where are we? Oncogene, 22, 3042–3052. Turrisi, R., Hillhouse, J., Gebert, C., & Grimes, J. (1999). Examination of cognitive variables relevant to sunscreen use. Journal of Behavioral Medicine, 22, 493–509. Weinstock, M., Martin, R., Risica, P., Berwick, M., Lasater, T., Rakowski, W., et al. (1999). Thorough skin examination for the early detection of melanoma. American Journal of Preventive Medicine, 17, 169–175. Weinstock, M. A., Rossi, J. S., Redding, C. A., Maddock, J. E., & Cottrill, S. D. (2000). Sun protection behaviors and stages of change for the primary prevention of skin cancers among beachgoers in southeastern New England. Annals of Behavioral Medicine, 22, 286–293. Weinstock, M. A., Risica, P. M., Martin, R. A., Rakowski, W., Smith, K. J., Berwick, M., et al. (2004). Reliability of assessment and circumstances of performance of thorough skin self-examination for the early detection of melanoma in the Check-It-Out Project. Preventive Medicine, 38, 761–765. Whiteman, D., Watt, P., Purdie, D., Hughes, M., Hayward, N., & Green, A. (2003). Melanocytic nevi, solar keratoses, and divergent pathways to cutaneous melanoma. Journal of the National Cancer Institute, 95, 806–812. Wichstrom, L. (1994). Predictors of Norwegian adolescents’ sunbathing and use of sunscreen. Health Psychology, 13, 412–420. Youl, P. H., Janda, M., & Kimlin, M. (2009). Vitamin D and sun protection: The impact of mixed public health messages in Australia. International Journal of Cancer, 124, 1963–1970.