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Background: Although skin cancer is the most common form of cancer in the United States, it is highly preventable by reducing exposure to ultraviolet radiation. This descriptive, correlational study describes the ultraviolet protection behaviors and beliefs of young adult dermatology patients.
Methods: Eighty-two dermatology patients aged 18-30 years were recruited from a suburban dermatology clinic in northern Utah. An investigator-developed questionnaire assessed ultraviolet protection stages of change, attitudes, and self-efficacy.
Results: Participants reported that on average they were in the preparation stage, had positive ultraviolet protection attitudes, and felt that it was neither easy nor difficult to use ultraviolet protection measures. Individuals who were older, more educated, had more sun-sensitive skin types, and spent less time outdoors on nonworkdays reported more responsible ultraviolet protection behaviors and beliefs.
Conclusions: The ultraviolet protection beliefs within this sample indicate generally favorable ultraviolet protection attitudes and adequate knowledge of ultraviolet exposure risks. Conversely, this sample reported inadequate and differential use of ultraviolet protection behaviors. Correlations involving demographic and clinical factors reveal that ultraviolet protection behaviors and beliefs are difficult to predict. Additional study findings support the need for continued efforts to promote ultraviolet protection among all young adults.
There is currently compelling epidemiological evidence for the causative role of natural ultraviolet (UV) radiation in the onset of melanoma (Armstrong & Kricker, 2001; Geller & Annas, 2003; Rivers, 2004; Siskind, Aitken, Green, & Martin, 2002), basal cell carcinoma (Almahroos & Kurban, 2004; Geller & Annas, 2003; Lacour, 2002), and squamous cell carcinoma (Almahroos & Kurban, 2004; Armstrong & Kricker, 2001; Ortonne, 2002). Similar associations have been demonstrated between each of the three main forms of skin cancer and artificial UV radiation sources, such as tanning beds (Centers for Disease Control and Prevention, 2004; Gallagher, Spinelli, & Lee, 2005; Karagas et al., 2002; Levine, Sorace, Spencer, & Siegel, 2005; Lim et al., 2004; Westerdahl, Ingvar, Masback, Jonsson, & Olsson, 2000). On the basis of this evidence, several national organizations currently recommend the use of the UV protection measures listed in Table 1 (American Cancer Society, 2007; Centers for Disease Control and Prevention, 2004). Historically, these UV protection recommendations have focused on children because childhood was considered to be a critical period for UV radiation exposure. More recently, however, data support that, for many individuals, UV exposure throughout the lifetime, not just in childhood, plays a critical role in the development of both melanoma and nonmelanoma skin cancer (Almahroos & Kurban, 2004; Diepgen & Mahler, 2002; Godar, Urbach, Gasparro, & van der Leun, 2003; Pfahlberg, Kolmel, Gefeller, & the Febim Study Group, 2001; Rivers, 2004; Siskind et al., 2002; Whiteman, Whiteman, & Green, 2001).
Because of recent efforts to strengthen UV protection education for adults in the United States, adults 35 years and older appear to be changing their UV protection behaviors for the better, whereas unprotected exposure to UV radiation in young adults has actually been increasing (Lim et al., 2004; American Academy of Dermatology, 2003). More specifically, between 1996 and 2003, the rate of sunscreen use (the most commonly used form of UV protection) decreased 15% for those younger than 25 years, bringing the rate of sunscreen use down to 34% (Lim et al., 2004; American Academy of Dermatology, 2003). In addition, tanning salon use in those younger than 25 years increased from 8% in 1996 to 26% in 2003 (Lim et al., 2004). Among 18- and 19-year-olds specifically, 47% reported using tanning beds three or more times in their lives (Demko, Borawski, Debanne, Cooper, & Stange, 2003), whereas female college students have reported 32% to 55% usage rates, with more than 80% of these individuals reporting their tanning salon use to be consistent (Lim et al., 2004).
On the basis of these disturbing trends, a descriptive correlational trial was developed using self-report questionnaires to investigate the use of a novel approach to skin cancer prevention counseling by dermatology providers. In addition, data were collected to (a) describe the UV protection behaviors and beliefs of young adult dermatology patients and (b) examine potential correlations between these UV protection behaviors and beliefs and specific demographic and clinical factors. The results of these two aims are reported here.
From September to November 2006, 18- to 30-year-old participants were recruited from a suburban dermatology clinic in northern Utah. Participants were excluded if they were (a) seeking treatment of sunburn or (b) had an inability to read and understand English. Data were collected via self-report questionnaires that were completed by participants at the time of their scheduled dermatology appointment. Prior to the recruitment of participants, appropriate approval was obtained from the institutional review board.
Data were collected using an investigator-developed questionnaire that was based on an extensive review of the literature and input from experts in dermatology, skin cancer prevention research, and statistics. The questionnaire was also evaluated for readability and comprehension by a sample of young adults prior to data collection.
UV protection stages of change. Within this five-item measure, participants were asked to choose the statement that best applies to their use of five different UV protection practices (see Table 1). The response choices for these items were the following: (a) "I have never thought of using this method" (precontemplation), (b) "I'm thinking about using this method" (contemplation), (c) "I intend to start using this method" (preparation), (d) "I have started to use this method" (action), and (e) "I have been using this method for a long time" (maintenance). As indicated, each response corresponds to one of the five stages of change. In addition to analyzing each item individually, these five items were averaged into a single scale score (range = 1-5), with higher scores indicating more readiness to use UV protection behaviors. In prior research on skin cancer prevention, similar items have been demonstrated to be sensitive to expected differences between subgroups (Branstrom, Kristjansson, Ullen, & Brandberg, 2002; Kristjansson, Helgason, Mansson-Brahme, Widlund-Ivarson, & Ullen, 2003b; Kristjansson, Helgason, Rosdahl, Holm, & Ullen, 2001). The internal consistency of the items used in this study was supported by a Cronbach's alpha value of .71.
UV protection attitudes. The first of the four items assessing UV protection attitudes asks respondents if they think that the advantages of being tan outweigh the disadvantages, whereas the second item asks how much respondents like being tan. Response options for each question were on a 5-point Likert-scale. In prior research, similar items were found to be moderately reliable in test-retest analysis (kappa coefficients .50 and .56; Branstrom et al., 2002). The last two items were adapted from research by Kristjansson et al. (2001). These items ask respondents to rate on a 5-point Likert scale how healthy or harmful they think exposure to the sun or tanning beds is. During data analysis, these four items were evaluated individually and averaged into a single scale score (range = 1-5), with higher scores indicating more favorable UV protection attitudes. The Cronbach's alpha value obtained for these four items in the present sample was.69.
UV protection self-efficacy. To assess UV protection self-efficacy, respondents were asked to choose the statement that best describes how difficult or easy it is for them to use each method of protecting their skin from the sun and tanning beds (see Table 1). Respondents could choose one of five Likert-scale responses, ranging from very easy to very difficult. During data analysis, these five items were evaluated individually and averaged into a single scale score (range = 1-5), with higher scores indicating more difficulty using UV protection methods. In previous research, a similar measure of self-efficacy was able to distinguish between those who used UV protection behaviors and those who did not (de Vries, Lezwijn, Hol, & Honing, 2005). In the present sample, these items had an acceptable Cronbach's alpha value of .68.
Demographic and clinical variables. Demographic variables included age, gender, level of education, and marital status. Clinical variables included the primary reason for the participant's dermatology appointment, the date of data collection, and how long on average participants are outdoors during daylight hours on a typical workday and nonworkday. Participants were also asked if they have ever had skin cancer, if they have a family member who has had skin cancer, and/or if they know anyone who has had skin cancer (Jackson, Wilkinson, Hood, & Pill, 2000; Weinstock, Rossi, Redding, Maddock, & Cottrill, 2000). Finally, skin type was assessed using the six skin type categories described by Fitzpatrick (1988).
Invitation for participation through consecutive enrollment was extended to 109 potential participants based on their age and appointment status. Eighty-two (75%) of these eligible individuals consented to participate in this study. One individual was excluded because of a language barrier, and no one was excluded for seeking sunburn treatment. Independent samples t tests found no significant age differences between participants (n = 82) and those who declined participation (n = 27, p = .97), although chi-square analysis revealed that there were significantly more men who declined to participate in this study (p = .048).
As shown in Table 2, most of the sample reported that they were single (63%), women (66%), and had either one or more college degrees (44%) or had some college education (49%). Five participants had a personal history of skin cancer, and Skin Type III was the most prevalent (42%). The average amount of time participants reported spending outdoors during daylight hours was 1.6 hours on a workday and 2.8 hours on a nonworkday. Finally, the most commonly reported reasons for participants' appointments were either moles or spots to be checked (33%) or acne or rosacea (38%).
As shown in Table 3, descriptive statistics were used to profile each of the three outcome variables. Participants' reported readiness to use specific UV protection measures is further illustrated in Figure 1. As displayed, participants reported an overall mean stages of change scale score of 3.12 (SD = 1.05), which corresponds to the preparation stage. Individuals were in a more ready stage of change for avoiding tanning beds (M = 3.80, SD = 1.52) and wearing sunscreen (M = 3.62, SD = 1.42). Participants were least ready to avoid outdoor activities between 10 a.m. and 4 p.m. (M = 2.12, SD = 1.57).
The mean scale score for the attitude items was 3.57 (SD = 0.68), thus indicating positive attitudes toward UV protection. Participants reported that they somewhat liked being tan (M = 2.04, SD = 0.92), although they also reported that there are a few more disadvantages to being tan (M = 4.05, SD = 1.13). Furthermore, participants also reported that they think that exposure to the sun (M = 3.70, SD = 0.99) and tanning beds (M = 4.51, SD = 0.69) is rather harmful.
Regarding self-efficacy, the participants in this sample reported that overall it was neither easy nor difficult to protect their skin from UV rays (M = 2.59, SD = 0.76). Participants reported the most difficulty with avoiding activities between 10 a.m. and 4 p.m. (M = 3.83, SD = 1.12) and the greatest self-efficacy for avoiding tanning beds (M = 1.44, SD = 0.88).
Pearson correlations were run for each of the demographic and clinical variables and the outcome variable scale scores. As can be seen in Table 4, the outcome variable scale scores were not significantly associated with marital status, gender, contact with skin cancer, time spent outdoors on workdays, date of data collection, or the reason for participants' appointments.
From Table 4, it is also apparent, however, that respondents with more sun-sensitive skin types reported more favorable stages of change scale scores (r = -.31, p = .004), attitude scale scores (r = -.36, p = .001), and self-efficacy scale scores (r =.23, p = .040). Individuals who spent less daylight time outdoors on nonworkdays reported significantly more favorable UV protection attitudes (r = -.36, p = .001). Regarding age, older respondents reported more readiness to use UV protection behaviors (r = .28, p = .011) and less difficulty using UV protection measures (r = -.23, p = .038). Finally, participants with more education reported that they had less difficulty using UV protection methods (r = -.30, p = .007).
On average, the young adult dermatology patients in this sample reported that they felt that it was neither easy nor difficult to use UV protection measures. Participants also generally agreed that exposure to the sun and tanning beds is rather harmful. Furthermore, most participants reported that, although they somewhat liked being tan, they also felt that there are a few more disadvantages to being tan. These results indicate generally favorable UV protection attitudes and adequate knowledge about the risks associated with UV exposure. However, it is noteworthy that the social desirability of being tan is also apparent. The social acceptance, and even promotion, of a tan appearance not only undermines behavior change interventions but also places UV protection decades behind health behaviors such as smoking cessation and seatbelt use, as these favorable health behaviors are now generally encouraged by societal influences.
Within this sample, the average participant only reported that they were in the preparation stage, meaning that they "intended to start" using the five UV protection methods listed in Table 1. This inadequate use of UV protection behaviors is consistent with previous research on UV exposure among young adults (Lim et al., 2004; American Academy of Dermatology, 2003) and with research documenting that within the young adult population there is a lack of consideration given to UV protection (Bernhardt, 2001) and an underestimation of personal risk for skin cancer (Bergenmar & Brandberg, 2001). In addition to the inadequacy of current UV protection behaviors among young adults, the discrepancy between the reported UV protection attitudes and behaviors among this age group presents a formidable challenge to skin cancer prevention efforts. This is in part because of the need to develop interventions that do more than simply improve UV protection attitudes but also develop ways to change behavior.
The results of this study also clearly illustrate the differential use of UV protection behaviors by young adults. Specifically, the young adults in this sample were most ready to avoid tanning beds and least ready to avoid outdoor activities between 10 a.m. and 4 p.m. Similarly, participants also reported the greatest self-efficacy for avoiding tanning beds and the most difficulty with avoiding activities between 10 a.m. and 4 p.m. Similar findings have been reported in two separate studies involving Swedish adolescents (Kristjansson et al., 2003b) and adults (Kristjansson et al., 2001). These results demonstrate the challenge inherent to having multiple UV protection recommendations (see Table 1). By design, these recommendations are broad in both magnitude and scope to provide the best possible UV protection. Consequently, individuals may feel that these recommendations are unrealistic and/or too difficult to implement and therefore independently decide how much UV protection is sufficient for their personal circumstances.
In addition, the fact that participants in this sample expressed the least readiness and self-efficacy for avoiding outdoor activities between 10 a.m. and 4 p.m. indicates that the accessibility of sunlight also presents a challenge for skin cancer prevention. Solar UV radiation is generally readily available and, in many instances, unavoidable. Because of this, it is reasonable to assume that for most individuals if no action is taken, some amount of unprotected UV exposure will occur. Thus, unlike many other health behavior change topics, UV protection requires an individual to focus not just on refraining from harmful activities but also on taking proactive steps to avoid unnecessary UV exposure.
When examining the correlations between UV protection behaviors and beliefs and the demographic and clinical factors collected in this study, the findings support that individuals who are older, more educated, have more sun-sensitive skin types, and spend less time outdoors on nonworkdays have more responsible UV protection behaviors and beliefs. In the prior UV protection literature, similar relationships have been supported for both age (Branstrom, Ullen, & Brandberg, 2004; Saraiya, Hall, & Uhler, 2002; Weinstock, Rossi, Redding, & Maddock, 2002) and skin type (Cottrell, McClamroch, & Bernard, 2005; de Vries et al., 2005; Demko et al., 2003; Kristjansson et al., 2001; Mahler, Kulik, Gibbons, Gerrard, & Harrell, 2003; Weinstock et al., 2000, 2002). The relationship between education and UV protection behaviors found in this study helps to clarify the inconsistent findings of previous studies. More specifically, the findings of two previous studies involving adult and adolescent participants were similar to the findings in this study: Higher education and greater cognitive ability are associated with reduced tanning bed use and increased use of recommended UV protection measures (Branstrom et al., 2004; Demko et al., 2003). Conversely, one national survey found that adults with a college degree had higher rates of sunburn when compared with those without a high school degree (Brown, Quain, Troxel, & Gelfand, 2006).
An interpretation of the findings regarding time outdoors on workdays and nonworkdays is difficult because of the lack of standardization in measures used to assess this variable. This being said, it is interesting to note that only the sun exposure individuals have more control over, time outdoors on nonworkdays, was correlated with UV protection beliefs. This finding suggests that UV exposure among young adults is amenable to change. Finally, although there was no significant correlation between gender and UV protection behaviors and beliefs in this study, the inconsistent findings of previous studies support the need for continued research on the relationship between this variable and UV protection behaviors. More specifically, a preponderance of evidence suggests that females are more likely than males to sunbathe and use tanning beds (Branstrom et al., 2004; Demko et al., 2003; Knight, Kirincich, Farmer, & Hood, 2002; Kristjansson, Branstrom, Ullen, & Helgason, 2003a; Lazovich & Forster, 2005) and use UV protection behaviors (Branstrom et al., 2004; Cottrell et al., 2005; de Vries et al., 2005; Weinstock et al., 2000, 2002). These data suggest that UV exposure behaviors among women are more intentional, although further research is needed to elucidate the motivation for sunbathing and UV protection behaviors among both women and men.
Perhaps the most alarming finding in this study is the lack of a relationship between the outcome variables and having a personal history of skin cancer or a personal knowledge of someone with skin cancer.
In the previous research on this topic, having a personal history of skin cancer had no effect on the desire for a suntan or the use of UV protection measures (Jackson et al., 2000; Weinstock et al., 2000). Yet, having a family history of skin cancer or a personal knowledge of someone with skin cancer has been associated with both higher (Weinstock et al., 2000, 2002) and lower rates of using UV protection behaviors (Jackson et al., 2000; Knight et al., 2002; Manne et al., 2004). One significant difference in the design of these studies and the data reported here is that most of these studies examined health behaviors in a wider age range of adults. One potential explanation for these unexpected findings is the fact that skin cancer can take years, even decades, to appear. This lack of immediate consequences can make it particularly difficult for individuals to change their UV exposure behaviors. Furthermore, the most immediate indicator of UV exposure, tan skin, is often considered to be desirable.
Finally, there are several findings from this study that have clear implications for the provision of skin cancer prevention messages by dermatology providers. First, the high participation rate suggests that young adult dermatology patients want to learn more about skin cancer prevention from their healthcare provider. Second, the fact that none of the outcome variables were associated with the reason for participants' appointments indicates that the provision of UV protection counseling should not be dependent on the reason patients present to a dermatology clinic. In other words, UV protection counseling should be provided to all young adult patients, as opposed to targeting only those patients who present to have moles checked. Furthermore, the inconsistent relationship between many demographic and clinical factors and the outcome variables in this and previous studies indicates that UV protection behaviors and beliefs cannot be easily predicted, and thus, it is important to provide skin cancer prevention counseling to all patients.
This study is limited by the use of self-report measures that may have been influenced by social desirability and recall biases. Furthermore, as this study was a pilot, designed primarily for feasibility, the size of the study sample is relatively small. However, the external validity of the findings is strengthened by the high participation rate (75%) and the fact that the data were collected during regularly scheduled appointments in an office setting without extensive exclusionary criteria. On the basis of these study characteristics, the findings of this study can be generalized to patient populations with similar demographic and clinical characteristics.
In summary, the data collected regarding UV protection beliefs reveal that, although tanning is perceived to be socially desirable, this sample expressed generally favorable UV protection attitudes and adequate knowledge of UV exposure risks. These findings contrast the inadequate and differential use of UV protection behaviors reported by participants. The availability of sunlight and the complexities inherent to having multiple UV protection guidelines appear to be partially responsible for these findings. Furthermore, the correlations involving demographic and clinical factors reveal that UV protection behaviors and beliefs are difficult to predict. Although these challenges make the development of skin cancer prevention interventions difficult, the findings of this study support that continued effort should be made to promote UV protection among all young adults.
The authors wish to thank Nancy Press, PhD, and Susan Butterworth, PhD, for their contributions to the development of this study.
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Cottrell, R., McClamroch, L., & Bernard, A. L. (2005). Melanoma knowledge and sun protection attitudes and behaviors among college students by gender and skin type. American Journal of Health Education, 36(5), 274-278. [Context Link]
de Vries, H., Lezwijn, J., Hol, M., & Honing, C. (2005). Skin cancer prevention: Behaviour and motives of Dutch adolescents. European Journal of Cancer Prevention, 14(1), 39-50. [Context Link]
Demko, C. A., Borawski, E. A., Debanne, S. M., Cooper, K. D., & Stange, K. C. (2003). Use of indoor tanning facilities by White adolescents in the United States. Archives of Pediatrics & Adolescent Medicine, 157, 854-860. [Context Link]
Diepgen, T. L., & Mahler, V. (2002). The epidemiology of skin cancer. British Journal of Dermatology, 146(Suppl. 61), 1-6. [Context Link]
Fitzpatrick, T. B. (1988). The validity and practicality of sun-reactive Skin Types I through VI. Archives of Dermatology, 124(6), 869-871. [Context Link]
Gallagher, R. P., Spinelli, J. J., & Lee, T. K. (2005). Tanning beds, sunlamps, and risk of cutaneous malignant melanoma. Cancer Epidemiology, Biomarkers & Prevention, 14(3), 562-566. [Context Link]
Geller, A. C., & Annas, G. D. (2003). Epidemiology of melanoma and nonmelanoma skin cancer. Seminars in Oncology Nursing, 19(1), 2-11. [Context Link]
Godar, D. E., Urbach, F., Gasparro, F. P., & van der Leun, J. C. (2003). UV doses of young adults. Photochemistry and Photobiology, 77(4), 453-457. [Context Link]
Jackson, A., Wilkinson, C., Hood, K., & Pill, R. (2000). Does experience predict knowledge and behavior with respect to cutaneous melanoma, moles, and sun exposure? Possible outcome measures. Behavioral Medicine, 26(2), 74-79. [Context Link]
Karagas, M. R., Stannard, V. A., Mott, L. A., Slattery, M. J., Spencer, S. K., & Weinstock, M. A. (2002). Use of tanning devices and risk of basal cell and squamous cell skin cancers. Journal of the National Cancer Institute, 94(3), 224-226. [Context Link]
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Lazovich, D., & Forster, J. (2005). Indoor tanning by adolescents: Prevalence, practices and policies. European Journal of Cancer, 41(1), 20-27. [Context Link]
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The Dermatology Nurses' Association has launched a new official journal called the Journal of Dermatology Nurses' Association (JDNA). DNA members (Medical Assistants, LPNs, RNs, NPs, Pas, and other office staff) are encouraged to provide content by writing columns or manuscripts.
If you do not feel you are ready for writing we also need many more reviewers at different levels to review columns, case studies, and manuscripts on administration/leadership, evidence-based practice, research, clinical, and educational pieces.
All of the editorial board members are willing to mentor you as you learn how to write columns or manuscripts, or turn a presentation into a paper or to review content. Please visit the JDNA Editorial Manager site at http://jdna.edmgr.com/ for more information or to submit a manuscript.
JDNA is interested in receiving columns, case studies, and manuscripts on the following suggested topics-but we welcome all topics related to dermatologic care and will consider all submissions:
* Dermatologic issues in pediatrics
* Dermatologic issues in elderly or other special populations
* Cutaneous manifestations of chronic diseases (e.g. diabetes)
* Evidence based projects (even if it is only lessons learned by doing it)
* Dermatologic issues related to head and neck
* Dermatologic issues related to oral mucus
* Completed Nursing research
* New therapies
* New Drugs
* New Products
* Dermatologic emergencies
* Patient safety issues
* Quality of Life for individuals with chronic dermatologic disorders
* Patient education sheets
* Patient perspectives
* Patient Advocacy
* Literature and media reviews
* Concept Papers
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