Skin cancer-related prevention and screening behaviors - Springer Link

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

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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.

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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

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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

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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

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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


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

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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)


Method: Questionnaire

345

972

N

Participants

Hat

February 1991

February– March 1990


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


410 J Behav Med (2009) 32:406–428

USA

Israel

Norway

Carmel et al. (1994)

Wichstrom (1994)


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


Setting: University


May 1992

April– November 1989

Not reported

–

17–23

15,169 17.3

509

266

45

44

50

35

% male



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


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


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


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


Sun protection (general)

Hat use

–

Mean age (year)


Sunscreen use

670

N

Participants

Method: Direct observation, structured interview, and questionnaire


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)


Table 1 continued

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123

Newman et al. USA (1996)

Michielutte USA et al. (1996)

Hillhouse et al. USA (1996)

Method: Telephone survey

Setting: San Diego residents


Method: Structured interview

Setting: Six county public health departments and a primary care clinic serving a low income, rural population



Setting: University



Setting: Cancer center in Southern California

April 1994

Not reported

June–August (year not noted)

Not reported


Hourani and LaFleur (1995)

USA



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


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)


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



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


Sunscreen use while sunbathing

Sunscreen use

Sunscreen use

Sunscreen use


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


Method: Structured telephone interview

July– September 1991 Setting: Random digit dialing of USA households

Design: Cross-sectional, national sample


Setting: National Health Interview Survey



Setting: Dunedin Multidisciplinary Health and Development study

Method: Random sampling of telephone directory. Structured interview

Setting: Coastal city


Method: Verbally-administered survey

Setting: Grade 6 at two primary schools


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




Clinical: Previous skin cancer diagnosis, sun-sensitive skin type

Demographic: Female gender, increased age, never married


Psychological: Greater perceived melanoma risk, greater knowledge of melanoma

Clinical: Sun-sensitive skin type, fewer sunburns now than at age 15



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


Sunscreen use


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123

Design methods


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



Setting: Ten high schools


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



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


Use of shade

Sunscreen use

Sunscreen use

Sunscreen use


414 J Behav Med (2009) 32:406–428

Cokkinides USA et al. (2001)

Method: Structured telephone survey

Setting: American Cancer Society Sun Survey



Setting: Adolescents aged 13– 17 years

Branstrom Sweden Design: Cross-sectional; et al. (2001) national sample


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)




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


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


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


Sunscreen use


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Purdue (2002) Canada


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



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


Sunscreen use



1,027

2,589

–

% male


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


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


Setting: National Health Interview Survey

Australian summers 1993–97

1998

Santmyire USA et al. (2001)




Table 1 continued

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1999

USA

Israel

Geller et al. (2002)

Tamir et al. (2002)


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


Setting: National Nurses Health Study

Design: Cross-sectional, national sample



Table 1 continued

44

–

41

% male

Sun protection

Sunscreen use

Sun protection

Protective clothing

Hat use

37% practiced sun avoidance

Sun avoidance


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



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


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


Sunscreen use

Sunscreen use


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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:

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Mean age (year) N


Table 1 continued


Participants

% male



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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

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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

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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

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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.

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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

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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

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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

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(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

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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).

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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

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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).

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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

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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.

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