Content uploaded by Katie Dhingra
Author content
All content in this area was uploaded by Katie Dhingra on Feb 02, 2018
Content may be subject to copyright.
British Journal of Health Psychology (2018)
©2018 The British Psychological Society
www.wileyonlinelibrary.com
Appearance-based interventions to reduce UV
exposure: A systematic review
Sofia Persson
1
* , Yael Benn
1
, Katie Dhingra
2
,
David Clark-Carter
3
, Alison L. Owen
3
and Sarah Grogan
1
1
Manchester Metropolitan University, UK
2
Leeds Beckett University, UK
3
Staffordshire University, Stoke-on-Trent, UK
Purpose. As a majority of skin cancer cases are behaviourally preventable, it is crucial
to develop effective strategies to reduce UV exposure. Health-focused interventions
have not proved to be sufficiently effective, and it has been suggested that people might
be more susceptible to information about the negative effects of the sun on their
appearance.
Method. This systematic review of 30 separate papers, reporting 33 individual studies
published between 2005 and 2017, assesses the overall effectiveness of appearance
interventions on participants’ UV exposure and sun protection behaviour.
Results. Appearance-based interventions have positive effects on sun exposure and sun
protection, immediately after the intervention as well as up to 12 months afterwards. The
meta-analysis found a medium effect size on sun protection intentions for interventions
which combined UV photography and photoageing information: r
+
=.424; k=3,
N=319, CI =0.279–0.568, p=.023.
Conclusions. This review provides a current perspective on the effectiveness of
appearance-based interventions to reduce UV exposure, and also highlights methodo-
logical issues. It recommends that practitioners administer a UV photo intervention in
combination with photoageing information to reduce UV exposure. Furthermore, the
review specifically recommends that future research focuses on the use of theoretical
constructs to enhance photoageing information and is conducted with older participants
and in countries where people have less opportunity for sun exposure.
Statement of contribution
What is already known on this subject?
Appearance-focused interventions may in some cases be more effective than health-focused
interventions in reducing UV exposure, as the underlying motivations for tanning are associated
with appearance concerns.
Previous reviews and meta-analyses have indicated that appearance-focused interventions such as
photoageing and UV photo are associated with positive effects in reducing UV exposure and/or
increasing sun protection.
Previous reviews identified methodological issues with research on this topic, which included
limited a priori power calculations and a general lack of long-term follow-ups.
*Correspondence should be addressed to Sofia Persson, Department of Psychology, Manchester Metropolitan University, Brooks
Building, Bonsall Street, Manchester M15 6DP, UK (email: sofia.persson@stu.mmu.ac.uk).
DOI:10.1111/bjhp.12291
1
What does this study add?
This review concludes that photoageing information in combination with UV photo is associated
with a medium positive effect size on sun protection intentions. Photoageing can be manipulated
according to theoretical constructs (e.g., Theory of Alternative Behaviours), which may contribute
to its effectiveness.
Issues such as homogeneity of settings and participants and limited a priori power calculations in the
included studies have been identified.
This review specifically recommends that future research is conducted in locations with less overall
sun exposure, and with a more diverse participant range (e.g., more males and older participants).
Deaths from skin cancer are an increasing problem around the world; the World Health
Organization (WHO, 2018) reports that up to 2 million new cases occur globally each year.
In the United Kingdom, non-melanoma skin cancers are by far the most common type of
cancer with around 102,000 new cases diagnosed annually (Cancer Research UK, 2016).
There is an established link between ultraviolet (UV) radiation exposure and all types of
skin cancer; this includes intentional (e.g., indoor and outdoor tanning) and incidental
exposure (WHO, 2016). It is estimated that UV radiation causes 86% of malignant
melanoma cases in the United Kingdom (Cancer Research UK, 2016). Thus, skin cancer is
to a large degree behaviourally preventable, meaning that developing strategies to reduce
UV exposure could be effective in limiting new incidences (Jackson & Aiken, 2006).
Although the health-related costs of UV exposure and the benefits of sun protection are
relatively well known (Miles, Waller, Hiom, & Swanston, 2005), interventions that
highlight these consequences are not sufficiently effective (Mahler, Kulik, Gerrard, &
Gibbons, 2006). A possible reason for this is that tanning behaviour is primarily motivated
by a desire to improve appearance, and, as such, it is perhaps less responsive to health
warnings (McWhirter & Hoffman-Goetz, 2015). Research on both men and women
suggests that focusing on the appearance-related costs of UV exposure is effective in
reducing UV exposure (Grogan & Loosemore, 2015). A review by Dodd and Forshaw
(2010) found that appearance-based interventions were generally successful in improving
UV-protective behaviours (e.g., sun protection use), but only moderately successful in
altering behaviours relating to UV exposure. Another systematic review by McWhirter and
Hoffman-Goetz (2015) found that visual images, for example UV photography (i.e.,
showing participants current level of UV damage to their skin), were successful in
promoting sun protection and reducing UV exposure.
This study is modelled on the Williams, Grogan, Clark-Carter, and Buckley (2013a)
review and meta-analysis, which focused on the efficacy of appearance-based interven-
tions to reduce UV exposure. Williams, et al. (2013a) found an overall positive impact of
appearance-based interventions on reducing UV exposure, and the meta-analysis
indicated that UV photo (i.e., demonstrating actual UV damage to a participant’s face)
and/or photoageing information (i.e., providing participants with information about the
ageing effect of the sun) had a significant effect on sun protection intentions and future
indoor tanning behaviour. The authors identified a number of problems with the data set,
including limited long-term follow-ups, homogeneity of settings, and limited a priori
power analysis. This study aims to provide an updated review of the literature, which is
considered relevant as the last data search was executed over 5 years ago. This is
particularly important as research into appearance-focused interventions has developed
significantly since this time, for instance by including novel techniques such as facial
morphing (a type of intervention demonstrating potential future UV damage, by
2Sofia Persson et al.
morphing a current image of the person using a specialized software). This study also
includes a larger meta-analysis.
1. Do appearance-based interventions reduce UV exposure immediately after the
intervention and/or long-term?
2. What does new research (i.e., the studies not included in the Williams et al.,
2013a paper) add to current understanding of the efficacy of appearance-related
interventions to reduce UV exposure, and has the quality of research improved?
Method
Protocol and registration
A review protocol was not used; however, the review has been reported in accordance
with the PRISMA guidelines. See Appendix S1 for the PRISMA checklist.
Eligibility criteria
Eligibility criteria were identical to Williams, et al. (2013a). Studies included an
appearance-based intervention, either in isolation (i.e., assessing scores before and
after the intervention) or in comparison with another intervention (or control
condition), and were required to adopt a pre-test and post-test design, but not
necessarily randomized controlled trials (RCTs). Correlational studies were not
included. An appearance-based intervention was defined as an intervention that
highlighted negative effects of UV exposure on appearance, such as UV photography
or photoageing information. Furthermore, studies had to assess the effects of the
intervention on sun-seeking and/or sun-protective behaviours or intentions. Sun-
seeking behaviours were defined as behaviour that increased UV exposure and
included spending time in the sun or using indoor tanning booths; sun-protective
behaviours were defined as behaviour intended to decrease UV exposure, such as sun
lotion use or protective clothing. Finally, studies were required to administer a post-
test measure to assess the effectiveness of the intervention.
Information sources
The primary source of articles was Web of Knowledge (Science Citation Index Expanded,
Social Sciences Citation Index, Arts & Humanities Citation Index, Conference Proceed-
ings Citation Index –Science and Social Science, Emerging Sources Citation Index); in
addition to this, seven other electronic databases (CINAHL, ZETOC, PsycARTICLES,
PsycINFO, MEDLINE, OVID, and Proquest theses) were accessed to search for studies. To
ensure the searched databases provided a relevant literature base, it was confirmed that
the list of studies included in the Williams, et al. (2013a) paper was found. An ancestry
search, that is, identifying references that cited the identified papers, was also carried out
to identify any missing studies.
Search
This study used the same search terms as Williams, et al. (2013a), to ensure consistency:
‘(sun*OR UV) AND (appearance OR age spots OR photoaging OR damage OR wrinkles)
AND (skin cancer OR melanoma OR health) AND intervention*AND (sunscreen OR
protect*OR tan*OR expos*OR prevent*OR behav*)’, and included studies conducted 1
Appearance interventions to reduce UV exposure 3
January 2005–16 May 2017. The search was conducted by the first author. 2005 was used
as a starting point as research up until this point was sufficiently covered in previous
reviews.
Study selection and data collection process
Eligibility assessment was performed by the first author (see PRISMA flow chart in
Appendix) but agreed upon by all authors. A total of 170 records were identified through
database searches, and a total of 532 records were identified through the ancestry search,
yielding a total of 701 screened records. Following this, 655 records were excluded based
on irrelevancy and duplicity, leaving a total of 46 papers to be examined. In addition, six
studies were excluded because the intervention focused on health consequences of UV
exposure (Cheng, Guan, Cao, Liu, & Zhai, 2011; Dykstra, 2007; Hernandez et al., 2014;
Lazovich et al., 2013; Olson, Gaffney, Starr, & Dietrich, 2008 [included in the Williams,
et al. (2013a) review]; Thomas et al., 2011), three due to not examining relevant research
questions (Cox et al., 2009; Hillhouse, Turrisi, Stapleton, & Robinson, 2010; Walsh, Stock,
Peterson, & Gerrard, 2014), and seven for not containing an intervention (Cheetham &
Ogden, 2016; Hillhouse et al., 2016; Noar et al., 2015; Pagoto et al., 2009; Taylor,
Westbrook, & Chang, 2016; Welch, Chang, & Taylor, 2016; Williams et al., 2013). To
identify potential, prominent authors in this field were contacted (e.g., authors of the
Williams et al., 2013a) and asked whether they had any unpublished material.
Additionally, ProQuest theses was searched for unpublished material. An extraction
table was designed based on the main elements reported in the Williams, et al. (2013a)
study. Data were extracted by the first author, with 10% checked blind (i.e., indepen-
dently extracted by another member of the team and then compared to the data extraction
conducted by the first author) by the sixth author during April–May 2017. Due to the high
level of agreement (88%), the remainder of the data were checked non-blind by the same
author, with agreement of 94%. Any disagreements were resolved by discussion. All
papers were further checked and agreed upon by the second author. The final review
includes 30 separate articles (33 independent studies, as some articles reported more than
one study); 18 of these papers (20 individual studies) were not included in the Williams,
et al. (2013a) article. Information extracted from the studies included participant
characteristics, study location and settings; intervention characteristics, outcome
measures, and which, if any, theoretical constructs were utilized to inform the
intervention; and methodological issues.
A formal tool was not utilized to assess methodological bias, but the first author
assessed risk of bias in each study by examining the methodology (i.e., study design,
proposed analyses, type of intervention, comparison groups), randomization process,
quality of the outcome measures (e.g., Cronbach’s alpha), and research funding. No
studies were deemed to be biased, aside from the Bae, Bae, Wang, and Gilchrest
(2017) paper, as it was neither controlled nor randomized and did not compare the
intervention with a control condition. However, this risk of bias did not adversely
impact the meta-analysis, as it was excluded due to lack of sufficient details for effect
size calculation, and was therefore only commented on in the systematic review. In
addition, small-study bias and publication bias were assessed utilizing Egger’s
regression (Egger, Davey-Smith, Schneider, and Minder, 1997) and trim and fill
analyses (Duval & Tweedie, 2000). This was reviewed and agreed upon by the
second and last authors. In sum, the main outcomes of interest included sun-seeking
4Sofia Persson et al.
behaviours and intentions (i.e., indoor and outdoor tanning), and sun-protective
behaviours and intentions (i.e., use of protective clothing or suntan lotion).
Meta-analytical strategy
The meta-analysis employed a random effects model. All but one of the studies included in
the review were also included in the meta-analysis. Bae et al. (2017) was not included
as the main author declined a request for additional data to facilitate effect size
calculations. Three studies (Mahler, Kulik, Gerrard, & Gibbons, 2007, 2013; Mahler et al.,
2006) included separate UV photo and photoageing information components (with the
same participants) and hence were added as two separate studies under the two relevant
interventions. Studies were categorized according to the type of appearance intervention,
creating four separate data sets: interventions with UV photo, photoageing information,
UV photo in combination with photoageing information, and interventions that could not
be classified as either, for instance facial morphing or group discussions. Due to the
heterogeneous nature of the final category, it was not possible to further distinguish
between these interventions. The process of categorization into types of interventions
enabled the inclusion of the same participants in separate analyses. In addition, studies
described in Gibbons, Gerrard, Lane, Mahler, & Kulik (2005) were originally analysed as
one by that paper’s authors, resulting in a total of 34 independent studies included in the
meta-analysis. For each of these studies, correlation coefficient rwas calculated to assess
the relationship between the appearance-based intervention and the outcome variable,
which was classified as sun protection or UV exposure. Following Cohen’s (1992)
recommendations, r=.10 was taken to represent a ‘small’ effect size, r=.30 a ‘medium’
effect size, and r=.50 a ‘large’ effect size. Long-term (i.e., any follow-up longer than
immediately following the intervention, ranging from 1 week to 6 months) effects of the
interventions are commented on in the systematic paper review as there were not enough
studies with similar levels of follow-ups to include this as a moderator analysis.
Where studies contained two (or more) conditions, the appearance-focused condition
was defined as the one with the strongest focus on appearance, and the control condition
contained, where possible, active element (e.g., another intervention, as compared to a
passive control being waitlist only). Where studies contained more than one appearance-
focused intervention, these were compared separately to a control condition, creating
separate effect sizes. Where studies lacked relevant statistics, authors were contacted to
provide additional information that could facilitate the effect size calculations. All authors
except one (Bae et al., 2017) responded with the requested information (Christensen,
Champion, & Wagner, 2014; Cornelis, Cauberghe, & De Pelsmacker, 2014; Gibbons,
et al., 2005; Hevey et al., 2010; Mahler, Beckerley, & Vogel, 2010; Mahler, Kulik, Gerrard,
& Gibbons, 2010; Morris, Cooper, Goldenberg, Arndt, & Gibbons, 2014; Sontag & Noar,
2017; Stapleton, Turrisi, Hillhouse, Robinson, & Abar, 2010). These authors were also
asked about any unpublished material they might have. As the majority of the studies
included a follow-up immediately after the interventi on, where possible, this point in time
was used to calculate effect sizes to ensure homogeneity of the data. For studies that did
not have an immediate follow-up (N=7), or did not report sufficient data for this point,
effect sizes were calculated for the nearest available time following the intervention.
The meta-analysis assessed the effectiveness of the intervention on four specific
outcome variables: sun-protective intentions, sun-protective behaviour, UV exposure
intentions, and UV exposure. In addition, effectiveness was also assessed as a weighted
mean for multiple outcome variables, henceforth referred to as a combined outcome
Appearance interventions to reduce UV exposure 5
variable. If multiple outcomes were measured for one of the categories above, for
example, both sun exposure and sun lotion were measured to examine sun-protective
behaviour, an overall effect size was calculated as the weighted mean of these measures.
Random effect sizes were computed using SPSS version 22 and the macros developed by
Wilson (2005). Effect sizes were weighted by sample, with a 95% confidence interval, and
an estimate of heterogeneity. Publication bias and small-study bias were also assessed
(Duval & Tweedie, 2000; Egger et al., 1997).
Results
Descriptive features of the studies
Participants and settings
Across all samples, there were 7,348 participants, with sample sizes ranging from 50 to
965 participants. Twelve studies specifically targeted females, whereas four studies
targeted males. The remainder had a mixed-gender participant group. Twelve studies
based their sample size on power calculations. The majority of the studies included
participants aged between 16 and 35 years. Participants were predominately White.
Seven studies targeted a risk group such as indoor tanners or highway workers. A majority
(75.8%) of the interventions were implemented in a research facility or University setting,
with the remainder (24.2%) being administered online or in a community setting (e.g., a
public beach).
Appearance-based interventions
The most common type of intervention (N=17) was UV photography, either in isolation or
combined with information about photoageing. Three of the UV photo studies (Mahler et al.,
2006, 2007, 2013) administered two separate interventions on UV photo and photoageing.
The second most common type of intervention (N=7) was photoageing information. The
remainder of the studies utilized alternative types of interventions, such as discussing and
challenging the tanned ideal, manipulating media images, or implementing facial morphing.
Twenty-one of the studies based their interventions fully or in part on theory. See Table S1 for
full details of the theoretical basis and critical points for each of the studies.
Measures employed
All studies administered post-intervention measures to assess the effect of an
appearance-based intervention on UV exposure intentions and/or behaviours. All but
one (Bae et al., 2017) of the studies compared this to a control condition (passive
control in six of the studies). All of the papers utilized some form of self-report
measure to assess intervention efficacy. An alternative method to assess behavioural
efficacy of the intervention examines skin colour. It involves the use of a skin
reflectance spectrophotometer which, when based on hue lightness and saturation
on various skin sites, can indicate level of UV exposure (Mahler et al., 2006). This
technique was utilized by four studies.
Descriptive results from systematic review
Table 1 provides a summary of the overall pattern of findings. Table S2 provides a detailed
description of the individual studies, including intervention design and findings. Overall, a
majority (N=29) of the studies reported that an appearance-focused intervention had a
6Sofia Persson et al.
Table 1. General summary of results
Sample Settings Interventions Outcomes measured Follow-up Findings Theoretical basis
N=7,348
(M=222.67,
Median =148,
SD =189.96)
75.8% Research
facility or
University
17 =UV photo
(with or without
photoageing
information)
12 =Sun-protective
intentions
and behaviours
12 =Immediately
only
Positive
findings =29
studies
27 =theoretical basis
72.9% women 15.2% online 7 =photoageing
information
10 =UV exposure
and intentions
21 =between
1 week
and 12 months
Positive findings
confined to specific
participant
group/condition =4
6=no theoretical
basis
12–75 years
age range
9% Other 9 =neither
UV photo or
photoageing info
11 =combination
of both
No difference =4
12 =utilized power
calculations
Appearance interventions to reduce UV exposure 7
positive effect on reducing UV exposure and/or increasing sun protection. Interestingly,
four of the studies that reported positive findings only found this effect when examining a
particular participant group or combination of conditions; Cornelis et al. (2014) found
that an appearance intervention decreased intentions to tan when the argument against
tanning was two-sided, but not when it was one-sided; Stapleton et al. (2010) found that
their intervention decreased indoor tanning frequency among a subgroup of tanners with
previously low knowledge of the health or appearance costs of tanning; and Walsh and
Stock (2012) found than UV photo increased sun protection willingness among masculine
men. Finally, Morris et al. (2014) found that UV photo had a positive effect on sun
protection intentions only when participants were primed with mortality.
For the studies including a longer (i.e., longer than immediately following the
intervention) follow-up, the findings were generally positive. Up until a month after the
intervention, participants reduced indoor and outdoor sunbathing frequency and
increased use of sun protection (Chait, Thompson, & Jacobsen, 2015; Gibbons, et al.,
2005). These effects were evident for up to 6 months, including reduced intentions to tan
and increased intentions to use sun protection (Hillhouse, Turrisi, Stapleton, & Robinson,
2008; Jackson & Aiken, 2006).
Three studies did not find an effect of the appearance-based intervention on the main
measured outcome; Christensen et al. (2014) found that participants in the UV photo
condition did not progress in UV-protective stages of change long term, and the health-
oriented intervention was significantly more effective in increasing immediate sun-
protective intentions; and Hevey et al. (2010) found no significant difference between a
health and appearance-framed message on intentions to use sunscreen and sunbeds.
Similarly, Sontag and Noar (2017) reported no difference between a health and
appearance-framed message on UV exposure intentions.
Pertaining to the second research question regarding the contribution of the 20 studies
published since 2012 (i.e., those not included in Williams et al., 2013a), there was a
similar selection of interventions, apart from the inclusion of two studies utilizing facial
morphing (Owen, Grogan, Clark-Carter, & Buckley, 2016; Williams, Grogan, Clark-Carter,
& Buckley, 2013b). This technique had positive results on participants’ sun protection
intentions and behaviour when compared to a health literature intervention. Moreover,
three of the four studies specifically targeting a male population were found in this
sample. Although most research is still conducted on a female sample, this suggests that
research into UV exposure is increasingly considering men’s motivation to tan and their
barriers to sun protection. The majority of these studies reported modest results or
positive findings confined to a particular combination of conditions (e.g., mortality
priming or two-sided arguments). This suggests that appearance-focused interventions to
reduce UV exposure may need to consider drawing on other aspects of behaviour change
or persuasion theory to enhance efficacy.
Results of meta-analysis
Table 2 presents the summary of the meta-analyses results (with combined effect sizes),
and Figure 1 plots effect sizes and standard errors. The meta-analysis was carried out on
four subsets categorized according to the type of intervention utilized; this is because
some participants took part in more than one intervention, and thus, it was not possible to
analyse the sample as one.
Ten studies (Christensen et al., 2014; Dwyer, 2014; Heckman et al., 2013; Mahler
et al., 2013, 2006, 2007; Morris et al., 2014; Pagoto, Schneider, Oleski, Bodenlos, & Ma,
8Sofia Persson et al.
2010; Walsh & Stock, 2012) examined the effectiveness of UV photo on the combined
outcome variable, and on sun-protective intentions specifically. For the overall effect of
this intervention on all outcomes, the effect size was small, r
+
=.19; k=10, N=1,564,
95% CI: 0.084–0.296, p<.001. The effect size on sun-protective intentions only was also
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
–0.2 –0.1 0 0.1 0.2 0.3 0.4 0.5 0.6
Standard Error
Effect size for combined outcom e variable
UV photo + photoageing informaon
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
–0.1 0 0.1 0 .2 0.3 0.4 0.5 0.6 0.7
Standard Error
Effect size for combined outcome variable
UV photo
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
0 0.1 0.2 0.3 0.4 0.5 0 .6 0.7 0.8
Standard Error
Effect size for combined outcome variable
Photoageing informaon
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
–0.1 0 0.1 0.2 0.3 0.4 0.5 0.6
Standard Error
Effect size for combined outcome variable
Other intervenons
Figure 1. Figures demonstrating of effect sizes and SE. Vertical line demonstrating the combined effect
size (r
+
).
Table 2. Meta-analyses results
Outcome variable r
+
p
95% confidence
interval k(studies) N(participants)
Relationship between UV photointerventions and outcome variables
Combined outcome variable .19 <.001 0.084–0.296 10 1,564
SPI .165 .012 0.036–0.295 8 1,251
Relationship between photoageing interventions and outcome variables
Combined outcome variable .327 <.001 0.206–0.447 4 863
SPI .272 .039 0.203–0.341 3 840
Relationship between UV photo combined with photoageing information and outcome variables
Combined outcome variable .261 <.017 0.047–0.475 6 918
SPI .424 .023 0.279–0.568 3 319
Relationship between other interventions and outcome variables
Combined outcome variable .191 <.001 0.117–0.265 14 3,895
SPI .223 .067 0.015 to 0.461 5 836
UV exposure .154 .040 0.007–0.302 6 1,878
UVEI .235 <.001 0.133–0.371 7 1,798
SPI =sun protection intentions; UVEI =UV exposure intentions.
Appearance interventions to reduce UV exposure 9
small r
+
=.165; k=8, N=1,251, 95% CI: 0.036–0.295, p=.012. Effect sizes were
heterogeneous, Q(9) =35.38, p<.001.
Four studies (Mahler et al., 2006, 2007, 2013; Tuong & Armstrong, 2014) examined
the effectiveness of photoageing information on sun-protective behaviour and intentions
combined, and sun-protective intentions separately. For the overall effects of photoageing
on all of the above outcome variables, the combined effect size was medium r
+
=.327;
k=4, N=836, 95% CI: 0.206–0.447, p<.001. On sun protection intentions only, the
effect size was small r
+
=.272; k=3, N=813, 95% CI =0.203–0.341, p=.039. Effect
sizes were heterogeneous, Q(9) =7.65, p=.054, using Higgins, Thompson, Deeks, and
Altman’s (2003) proposed significance level of .10.
Six studies (Gibbons et al., 2005; Mahler, Kulik, Butler, Gerrard, & Gibbons, 2008;
Mahler et al., 2005; Mahler, Kulik, et al., 2010; Sontag & Noar, 2017; Stock et al., 2009)
examined the effectiveness of UV photography combined with photoageing information
on a combination of three outcome variables: sun- protective behaviour and intentions, UV
exposure, and sun-protective intentions separately. For the effectiveness of this
intervention on the above outcome variables, the combined effect size was small,
r
+
=.261; k=6, N=918, 95% CI =0.047–0.475, p=.017. The combined effect size on
sun protection intentions only was medium, r
+
=.424; k=3, N=319, 95% CI =0.279–
0.568, p=.023. Effect sizes were heterogeneous, Q(13) =54.89, p<.001.
Fourteen studies (Chait et al. 2015; Cooper, Goldenberg, & Arndt, 2014; Cornelis
et al., 2014; Heckman, Handorf, Darlow, Ritterband, & Manne, 2017; Hevey et al., 2010;
Hillhouse et al., 2008, 2017; Jackson & Aiken, 2006; Mahler, Beckerley, et al., 2010;
Mahler, Kulik, et al., 2010; Owen et al., 2016; Stapleton et al., 2010, 2015; Williams
et al., 2013b) examined the effectiveness of interventions not classed as either of the
above on a combination of all of the outcome variables, as well as sun protection
intentions, UV exposure, and UV exposure intentions separately. For the effects of these
interventions on the above outcome variables, the combined effect size was small,
r
+
=.191; k=14, N=3,895, 95% CI =0.117–0.265, p<.001. On UV exposure
intentions only, the combined effect size was small, r
+
=.235; k=7, N=1,798, 95%
CI =0.133–0.371, p<.001. On actual UV exposure, the effect size was small, r
+
=.1542,
k=6, N=1,878, 95% CI =0.007–0.302, p=.040. Finally, the effect on sun protection
intentions was small but non-significant, r
+
=.223; k=5,N=773, 95% CI =0.015 to
0.461, p=.067. Effect sizes were heterogeneous, Q(6) =26.67, p<.001.
Summary of risk of bias scores
As only two unpublished studies were included in the analysis, it was not possible to asse ss
publication bias by directly comparing effect sizes of published and unpublished studies.
Thus, a trim and fill analysis was performed (Duval & Tweedie, 2000) using STATA version
11 (StataCorp, 2009). Results revealed that there was no bias in interventions utilizing UV
photo, photoageing information, or interventions classed as neither. It did, however,
reveal a publication bias in interventions utilizing UV photo in combination with
photoageing information, filling three studies, rendering the results non-significant,
p=.410. To ensure the meta-analytical effect sizes were not adversely impacted by
underpowered studies from relatively small samples, an Egger’s regression was also
performed (Egger et al., 1997) using STATA version 11 (StataCorp, 2009). Results
revealed no small-study bias in any of intervention types.
10 Sofia Persson et al.
Discussion
Summary of evidence
The current study provides a valuable contribution to the existing literature, as it includes
20 individual articles (consisting of 22 independent studies) published between 2012 and
2017 that were not included in Williams et al. (2013a), providing an updated examination
and analysis of current directions within research on appearance-based interventions.
Furthermore, as the meta-analysis contains more individual studies, it represents a more
reliable reflection of the effectiveness of these interventions. Additionally, the current
review includes two unpublished papers, a factor that goes some way towards
counteracting publication bias.
Appearance-based interventions were generally successful in reducing UV exposure,
supporting the findings reported by Williams et al. (2013a). The inclusion in the current
review of research utilizing facial morphing indicates that this could be an effective
intervention for behaviour change. However, three studies did not find an effect of
appearance-based intervention when compared to a health-based intervention, which
was not identified by Williams et al. (2013a). One observation made in the current review
is that two of these studies used active rather than passive control. This therefore calls for
further investigation.
The results of the meta-analyses indicate that appearance-based interventions were
associated with a small positive effect on intentions and behaviours. The largest effect
sizes were associated with UV photography combined with photoageing information.
These results may indicate that providing individuals with two sources of information –
visual and descriptive –with subjective and objective focus could be an effective way to
influence UV-related behaviours. The component of photoageing information can also be
manipulated according to theory, which may be beneficial, as it could enhance health
interventions with theoretical constructs. For instance, Mahler et al. (2005) utilized
Theory of Alternative Behaviours (Jaccard, 1981) by aiming to alter participants’
perceptions of UV exposure and providing an alternative to tanning (sunless tanning
products). Other effective theoretical constructs in this sample included Social Compar-
ison Theory (Festinger, 1957) and Theory of Planned Behaviour (Cialdini, Kallgren, &
Reno, 1991). As these interventions appeared to be effective in reducing UV exposure and
increasing sun protection among students as well as the general public, it is likely they
could be widely implemented. However, due to the issue of publication bias in this
sample, it is difficult to draw definitive conclusions. Future research could benefit from
investigating this issue further, to determine whether two sources of information could
increase the effectiveness of appearance-focused interventions in reducing UV exposure.
There are a number of things to consider when interpreting the results of the meta-
analysis. The most common outcome variable was sun-protective intentions, which limits
the conclusions that can be drawn on other variables. Given the relatively small number of
studies, it was not possible to include follow-up length as a mediator in the analysis, and it
is therefore difficult to determine whether the techniques used would have long-term
effect on behaviour, as well as immediate effect on intentions. Considerable variability of
research methodologies (e.g., control group conditions and inclusion/exclusion of darker
skin tones) and reporting style (e.g., inclusion of baseline comparisons and non-significant
variables) between the studies makes it difficult to directly compare results between the
studies. Furthermore, there was a wide span of effect sizes in the subset of the meta-
analysis which included any intervention that did not utilize UV photo or photoageing
information. This suggests that some of these interventions are more effective than others
Appearance interventions to reduce UV exposure 11
and should be further investigated in future research. Lastly, the meta-analysis identified a
publication bias among studies utilizing UV photo in combination with photoageing
information. We would therefore encourage researchers and journals alike to consider
null results for publication.
Sample limitations and recommendations for future research
While skin cancer incident rates do not differ significantly between genders (Skin Cancer
Foundation, 2016), there was an overwhelming majority of female participants. Given that
the current review identified only four studies of male participants, future research would
benefit from including men in the study population, particularly as men also value a
tanned appearance (Cancer Research UK, 2016; Day, Wilson, Hutchinson, & Roberts,
2016). As men may perceive tanning and appearance norms in different terms than
women, such as reluctance to engage in practices regarded as feminine (Grogan, 2016),
future appearance interventions with men may need to consider the role of masculinity.
Moreover, study samples were overwhelmingly young (16–35 years); as age increases,
the risks of skin damage build-up, so it therefore seems relevant to include an older
population in future studies (Cancer Research UK, 2016). Most participants were White;
as populations with darker skin are by no means immune to skin cancer, future research
would benefit from more ethnically diverse samples (Skin Cancer Foundation, 2016).
Finally, some studies included a sample where a large number of participants had
experienced skin cancer themselves, or known a family member to do so (Mahler et al.,
2013), whereas others did not include this as a variable in the analyses; this is a factor that
could skew results and should be considered in future studies.
The majority of the studies were conducted in the United States, raising concerns
about generalizability of findings to other areas; they were also conducted in locations
with high level of sun exposure (such as Florida), and it might therefore be difficult to
predict whether interventions are effective in countries with fewer days of sun.
Qualitative research has indicated that people living in locations with fewer hours of sun
(such as the United Kingdom) associate UV exposure with leisure time and holidays; this
may affect the effectiveness of an intervention to impact motivations to reduce UV
exposure among these participants (Persson, Benn, Dhingra, & Grogan, 2017).
Twelve studies based their sample size on aprioripower calculations, with the
remaining studies stating a lack of power, or not specifying power calculations. This is
problematic, as a potential lack of power in a majority of the examined studies may limit the
conclusions that can be drawn from their results, as it can over- or underestimate t he effect of
the intervention, particularly in combination with publication bias (Charles, Giraudeau,
Dechartres, Baron, & Ravaud, 2009; Minarik et al.,2016).Itisthereforerecommendedthat
future research consistently include aprioripower calculations, as well as comparing any
intervention with an active, rather than a passive, control condition.
Conclusions
This review and meta-analysis provide a valuable perspective on current research on
appearance-based interventions to reduce UV exposure. The findings suggest that
appearance-based interventions are associated with small positive effects on reducing
sun-seeking behaviours and/or increasing sun-protective behaviours. These results were
generally supported by a meta-analysis. With the previously discussed high levels of skin
cancer rates across western Europe and the United States, this would suggest that
12 Sofia Persson et al.
implementation of these interventions could have scope to prevent skin cancer in a large
number of people.
We recommend that practitioners who are looking to increase sun protection
intentions administer UV photo in combination with photoageing information, as this was
associated with the largest effect size. These interventions could be administered to men
and women alike, over a wide age span, and they appear to be effective when
implemented in a clinical and/or research setting.
A number of methodological issues may limit the conclusions that can be drawn from
the results. However, within the current context, this review contributes significantly to
the existing body of research into appearance-based interventions to reduce UV exposure
and recommends that future research consistently employ a rigorous methodology (e.g.,
inclusion of power calculations) and focus on more varied outcomes and a diverse sample
population from a wider array of cultures. As motivations for UV exposure might differ in
populations living in locations with less opportunities for sun exposure, this review
specifically recommends that additional future research on the effectiveness of
appearance-focused interventions is conducted in places such as the United Kingdom
and northern Europe.
Conflict of interest
All authors declare no conflict of interest.
References
*Paper included in review.
Ajzen, I., & Madden, T. J. (1986). Prediction of goal-directed behaviour: Attitudes, intentions, and
perceived behavioural control. Journal of Experimental Social Psychology,22, 453–474.
https://doi.org/10.1016/0022-1031(86)90045-4
*Bae, Y. C., Bae, E. J., Wang, J., & Gilchrest, B. (2017). Changes in self-perceptions of photoaging
severity and skin cancer risk after objective facial skin quality analysis. Journal of Drugs in
Dermatology,16, 435–459. https://doi.org/10.1016/j.jaad.2016.02.434Issn
Beck, A. T. (1967). Depression –Clinical experimental and theoretical aspects. New York, NY:
Harper and Row.
Cancer Research UK. (2016). Skin cancer –Non melanoma. Retrieved from http://www.cancer
researchuk.org/about-cancer/type/skin-cancer/
*Chait, S. R., Thompson, J. K., & Jacobsen, P. B. (2015). Preliminary development and evaluation of
an appearance-based dissonance induction intervention for reducing UV exposure. Body
Image,12,68–72. https://doi.org/10.1016/j.bodyim.2014.09.004
Charles, P., Giraudeau, B., Dechartres, A., Baron, G., & Ravaud, P. (2009). Reporting of sample size
calculation in randomised controlled trials: Review. BMJ,338, b1732. https://doi.org/10.1136/
bmj.b1732
Cheetham, I., & Ogden, J. (2016). Enhancing sun safety in young women: The relative impact of
format and temporal framing on beliefs and behaviour. Cogent Psychology,3(1), 1210069.
https://doi.org/10.1080/23311908.2016.1210069
Cheng, S., Guan, X., Cao, M., Liu, Y., & Zhai, S. (2011). Randomized trial of the impact of a sun safety
program on volunteers in outdoor venues. Photodermatology Photoimmunology &
Photomedicine,27(2), 75–80. https://doi.org/10.1111/j.1600-0781.2011.00567.x, 75 - 80.
*Christensen, K., Champion, J., & Wagner, C. (2014). The effects of appearance-based and health-
based interventions on sun protection attitudes, intentions, and behaviours of college students.
Psycho-Oncology,23, 317.
Appearance interventions to reduce UV exposure 13
Cialdini, R. B., Kallgren, C. A., & Reno, R. R. (1991). A focus theory of normative conduct. Advances
in Experimental Social Psychology,24, 201–234. https://doi.org/10.1016/S0065-2601(08)
60330-5
Cohen, J. (1992). A power primer. Psychological Bulletin,112, 155–159. https://doi.org/10.1037/
0033-2909.112.1.155
*Cooper, D. P., Goldenberg, J. L., & Arndt, J. (2014). Perceived efficacy, conscious fear of death and
intentions to tan: Not all fear appeals are created equal. British Journal of Health Psychology,19
(1), 1–15. https://doi.org/10.1111/bjhp.12019
*Cornelis, E., Cauberghe, V., & De Pelsmacker, P. (2014). Being healthy or looking good? The
effectiveness of health versus appearance-focused arguments in two-sided messages. Journal of
Health Psychology,19, 1132–1142. https://doi.org/10.1177/1359105313485310
Cox, C. R., Cooper, D. P., Vess, M., Arndt, J., Goldenberg, J. L., & Routledge, C. (2009). Bronze is
beautiful but pale can be pretty: The effects of appearance standards and mortality salience on
sun-tanning outcomes. Health Psychology,28, 746–752. https://doi.org/10.1037/n0016388
Day, A. K., Wilson, C. J., Hutchinson, A. D., & Roberts, R. M. (2016). Australian young adults’ tanning
behaviour: The role of ideal skin tone and sociocultural norms. Australian Journal of
Psychology,69,86–94. https://doi.org/10.1111/ajpy.12121
Dodd, L. J., & Forshaw, M. J. (2010). Assessing the efficacy of appearance-focused interventions to
prevent skin cancer: A systematic review of the literature. Health Psychology Review,4(2),
93–111. https://doi.org/10.1080/17437199.2010.485393
Duval, S., & Tweedie, R. (2000). Trim and fill: A simple funnel-plot-based method of testing and
adjusting for publication bias in meta-analysis. Biometrics,56, 455–463. https://doi.org/10.
1111/j.0006-341X.2000.00455.x
*Dwyer, L. A. (2014). Enhancing UV photography among men with choice-promoting
information (3607894 Ph.D.), The George Washington University, Ann Arbor, MI. Retrieved
from ProQuest Dissertations & Theses A&I database.
Dykstra, J. L. (2007). Avoiding reactance: The utility of ultraviolet photography, persuasion, and
parental protectiveness in improving the effectiveness of a UV exposure intervention
(3274866 Ph.D.). Iowa State University, Ann Arbor, MI. Retrieved from ProQuest Dissertations &
Theses A&I database.
Egger, M., Davey-Smith, G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a
simple graphical test. British Medical Journal,315, 629–634. https://doi.org/10.1136/bmj.315.
7109.629
Festinger, L. (1957). A theory of cognitive dissonance. Evanstone, IL: Row, Peterson.
Fishbein, M., Hennessey, M., Yzer, M., & Douglas, J. (2003). Can we explain why some people do and
some people do not act on their intentions? Psychology Health & Medicine,8(1), 3–18. https://
doi.org/10.1080/1354850021000059223
Gibbons, F. X., & Gerrard, M. (1995). Predicting young adults’ health risk behavior. Journal of
Personality and Social Psychology,69, 505–517. https://doi.org/10.1037//0022-3514.69.
3.505.
Gibbons, F. X., Gerrard, M., Blanton, H., & Russell, D. W. (1998). Reasoned action and social reaction:
Willingness and intention as independent predictors of health risk. Journal of Personality and
Social Psychology,74, 1164–1180. https://doi.org/10.1037/0022-3514.74.5.1164
*Gibbons, F. X., Gerrard, M., Lane, D. J., Mahler, H. I. M., & Kulik, J. A. (2005). Using UV photography
to reduce use of tanning booths: A test of cognitive mediation. Health Psychology,24, 358–363.
https://doi.org/10.1037/0278-6133.24.4.358
Greenberg, J., Pyszczynski, T., & Solomon, S. (1986). The causes and consequences of a need for self-
esteem: A terror management theory. In R. F. Baumeister (Ed.), Public self and private self (pp.
189–212). New York, NY: Springer New York. https://doi.org/10.1007/978-1-4613-9564-5
Grogan, S. (2016). Body image. London, UK: Routledge.
Grogan, S., & Loosemore, E. (2015). Men’s accounts of reactions to two sources of information on
negative effects of UV exposure: Facial morphing and a health promotion fact sheet.
International Journal of Men’s Health,14(2), 183. https://doi.org/10.3149/jmh.1402.183
14 Sofia Persson et al.
*Heckman, C., Handorf, E., Darlow, S., Ritterband, L., & Manne, S. (2017). An online skin cancer risk-
reduction intervention for young adults: Mechanisms of effect. Health Psychology,36, 215–225.
https://doi.org/10.1037/hea0000420
*Heckman, C., Zhu, F., Manne, S., Kloss, J., Collins, B., Bass, S., & Lessin, S. (2013). Process and
outcomes of a skin protection intervention for young adults. Journal of Health Psychology,18,
561–573. https://doi.org/10.1177/1359105312449193
Hernandez, C., Wang, S., Abraham, I., Angulo, M. I., Kim, H., Meza, J. R., ... Uddin, S. (2014).
Evaluation of educational videos to increase skin cancer risk awareness and sun-safe behaviours
among adult Hispanics. Journal of Cancer Education,29, 563–569. https://doi.org/10.1007/
s13187-014-0624-z
Hevey, D., Pertl, M., Thomas, K., Maher, L., Craig, A., & Chuinneagain, S. N. (2010). Body
consciousness moderates the effect of message framing on intentions to use sunscreen. Journal
of Health Psychology,15, 553–559. https://doi.org/10.1177/1359105309355335
Higgins, J., Thompson, S., Deeks, J., & Altman, D. (2003). Measuring inconsistency in meta-analyses.
BMJ,327, 557–560. https://doi.org/10.1136/bmj.327.7414.557
*Hillhouse, J., Turrisi, R., Stapleton, J., & Robinson, J. (2008). A randomized controlled trial of an
appearance-focused intervention to prevent skin cancer. Cancer,113, 3257–3266. https://doi.
org/10.1002/cncr.23922
Hillhouse, J., Turrisi, R., Stapleton, J., & Robinson, J. (2010). Effect of seasonal affective disorder and
pathological tanning motives on efficacy of an appearance-focused intervention to prevent skin
cancer. Archives of Dermatology,146,485–491. https://doi.org/10.1001/archdermatol.2010.85
Hillhouse, J., Turrsi, R., Cleveland, M., Scaglione, N., Baker, K., & Florence, C. (2016). Theory-driven
longitudinal study exploring indoor tanning initiation in teens using a person-centered approach.
Annals of Behavioral Medicine,50(1), 48–57. https://doi.org/10.1007/s12160-015-9731-2
*Hillhouse, J., Turrsi, R., Scaglione, N., Cleveland, M., Baker, K., & Florence, C. (2017). A web-based
intervention to reduce indoor tanning motivations in adolescents: A randomised controlled trial.
Prevention Science,18, 131–140. https://doi.org/10.1007/s11121-016-0698-4
Jaccard, J. (1981). Attitudes and behaviour: Implications of attitudes toward behavioural
alternatives. Journal of Experimental Social Psychology,17, 286–307. https://doi.org/10.
1016/0022-1031(81)90029-9
Jackson, K. M., & Aiken, L. S. (2000). A psychosocial model of sun protection and sunbathing in
young women: The impact of health beliefs, attitudes, norms, and self-efficacy for sun
protection. Health Psychology,19, 469–478. https://doi.org/10.1037/0278-6133.19.5.469
*Jackson, K. M., & Aiken, L. S. (2006). Evaluation of a multicomponent appearance-based sun-
protective intervention for young women: Uncovering the mechanisms of program efficacy.
Health Psychology,25(1), 34–46. https://doi.org/10.1037/0278-6133.25.1.34
Kahneman, D., & Tversky, A. (1979). Prospect theory: An analysis of decisions under risk.
Econometrica,47, 313–327. https://doi.org/10.2307/1914185
Lazovich, D., Choi, K., Rolnick, C., Jackson, J. M., Forster, J., & Southwell, B. (2013). An intervention
to decrease adolescent indoor tanning: A multi-method pilot study. Journal of Adolescent
Health,52(5), S76–S82. https://doi.org/10.1016/j.jadohealth.2012.08.009
Maddux, J. E., & Rogers, R. W. (1983). Protection motivation theory and self-efficacy: A revised
theory of fear appeals and attitude change. Journal of Experimental Social Psychology,19,
469–479. https://doi.org/10.1016/0022-1031(83)90023-9
*Mahler, H. I. M., Beckerley, S. E., & Vogel, M. T. (2010). Effects of media images on attitudes toward
tanning. Basic and Applied Social Psychology,32, 118–127. https://doi.org/10.1080/
01973531003738296
*Mahler, H. I. M., Kulik, J. A., Butler, H. A., Gerrard, M., & Gibbons, F. X. (2008). Social norms
information enhances the efficacy of an appearance-based sun protection intervention. Social
Science & Medicine,67, 321–329. https://doi.org/10.1016/j.socscimed.2008.03.037
*Mahler, H. I. M., Kulik, J. A., Gerrard, M., & Gibbons, F. X. (2006). Effects of two appearance-based
interventions on the sun protection behaviours of southern California beach patrons. Basic and
Applied Social Psychology,28, 263–272. https://doi.org/10.1207/s15324834basp2803_5
Appearance interventions to reduce UV exposure 15
*Mahler, H. I. M., Kulik, J. A., Gerrard, M., & Gibbons, F. X. (2007). Long-term effects of appearance-
based interventions on sun protection behaviours. Health Psychology,26, 350–360. https://doi.
org/10.1037/0278-6133.26.3.350
*Mahler, H. I. M., Kulik, J. A., Gerrard, M., & Gibbons, F. X. (2010). Effects of upward and downward
social comparison information on the efficacy of an appearance-based sun protection
intervention: A randomized, controlled experiment. Journal of Behavioural Medicine,33,
496–507. https://doi.org/10.1007/s10865-010-9279-3
*Mahler, H. I. M., Kulik, J. A., Gerrard, M., & Gibbons, F. X. (2013). Effects of photoaging information
and UV photo on sun protection intentions and behaviours: A cross-regional comparison.
Psychology & Health,28, 1009–1031. https://doi.org/10.1080/08870446.2013.777966
Mahler, H., Kulik, J., Harrell, J., Correa, A., Gibbons, F., & Gerrard, M. (2005). Effects of UV
photographs, photoaging information, and use of sunless tanning lotion on sun protection
behaviors. Archives of Dermatology,141(3), 373–380.
McWhirter, J. E., & Hoffman-Goetz, L. (2015). Systematic review of population-based studies on the
impact of images on UV attitudes and behaviours. Health Promotion International,30, 397–
410. https://doi.org/10.1093/heapro/dat031
Miles, A., Waller, J., Hiom, S., & Swanston, D. (2005). SunSmart? Skin cancer knowledge and
preventive behaviour in a British population representative sample. Health Education
Research,20, 579–585. https://doi.org/10.1093/her/cyh010
Minarik, T., Berger, B., Althaus, L., Bader, V., Biebl, B., Brotzeller, F., ... Sauseng, P. (2016). The
importance of sample size for reproducibility of tDCS effects. Frontiers in Human
Neuroscience,10, 5. https://doi.org/10.3399/fnhum.2016.00453
*Morris, K. L., Cooper, D. P., Goldenberg, J. L., Arndt, J., & Gibbons, F. X. (2014). Improving the
efficacy of appearance-based sun exposure interventions with the terror management health
model. Psychology & Health,29, 1245–1264. https://doi.org/10.1080/08870446.2014.922184
Noar,S.M.,Myrick,J.G.,Zeitany,A.,Kelley,D.,Morales-Pico,B.,&Thomas,N.E.(2015).Testingasocial
cognitive theory-based model of indoor tanning: Implications for skin cancer prevention messages.
Health Communication,30,164–174. https://doi.org/10.1080/10410236.2014.974125
Olson, A. L., Gaffney, C. A., Starr, P., & Dietrich, A. J. (2008). The impact of an appearance-based
educational intervention on adolescent intention to use sunscreen. Health Education Research,
23, 763–769, 767p. https://doi.org/10.1093/her/cym005
Owen, A., Grogan, S., Clark-Carter, D., & Buckley, E. (2016). Effects of an appearance-focussed
versus health-focussed intervention on men’s attitudes towards UV exposure. International
Journal of Men’s Health,15(1), 34. https://doi.org/10.3149/jmh.1501.34
*Pagoto, S. L., Schneider, K. L., Oleski, J., Bodenlos, J. S., & Ma, Y. (2010). The sunless study a beach
randomized trial of a skin cancer prevention intervention promoting sunless tanning. Archives
of Dermatology,146, 979–984. https://doi.org/10.1001/archdermatol.2010.203
Pagoto, S. L., Schneider, K. L., Oleski, J., Bodenlos, J. S., Merriam, P., & Ma, Y. (2009). Design and
methods for a cluster randomized trial of the Sunless Study: A skin cancer prevention
intervention promoting sunless tanning among beach visitors. BMC Public Health,9, 50.
https://doi.org/10.1186/1471-2458-9-50
Persson, S., Benn, Y., Dhingra, K., & Grogan, S. (2017). “It’s a bit of an eye opener”: A qualitative
study of women’s attitudes towards tanning, sun protection and a facial morphing intervention.
Psychology & Health, Advance Online Publication. https://doi.org/10.1080/08870446.2017.
1357815
Petty, R. E., & Cacioppo, J. T. (1984). Source factors and the elaboration likelihood model of
persuasion. Advances in Consumer Research,11, 668.
PRISMA (2011). Transparent reporting of systematic reviews and meta-analyses. Retrieved from
http://prisma-statement.org/prismastatement/flowdiagram.aspx
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking:
Toward an integrative model of change. Journal of Consulting & Clinical Psychology,51, 390–
395. https://doi.org/10.1037/0022-006X.51.3.390
16 Sofia Persson et al.
Rosenstock, I. M. (1974). Historical origins of the health belief model. Health Education
Monographs,2, 328–335. https://doi.org/10.1177/109019817400200403
Skin Cancer Foundation (2016). Skin cancer facts & statistics. Retrieved from http://www.skinca
ncer.org/skin-cancer-information/skin-cancer-facts#ethnicity
*Sontag, J., & Noar, S. (2017). Assessing the potential effectiveness of pictoral messages to deter
young women from indoor tanning: An experimental study. Journal of Health
Communication,22, 294–303. https://doi.org/10.1080/10810730.2017.1281361
*Stapleton, J. L., Manne, S. L., Darabos, K., Greene, K., Ray, A. E., Turner, A. L., & Coups, E. J. (2015).
Randomized controlled trial of a web-based indoor tanning intervention: Acceptability and
preliminary outcomes. Health Psychology,34, 1278–1285. https://doi.org/10.1037/hea0000254
*Stapleton, J., Turrisi, R., Hillhouse, J., Robinson, J. K., & Abar, B. (2010). A comparison of the
efficacy of an appearance-focused skin cancer intervention within indoor tanner subgroups
identified by latent profile analysis. Journal of Behavioural Medicine,33, 181–190. https://doi.
org/10.1007/s10865-009-9246-z
StataCorp. (2009). Stata statistical software (11th ed.). Dallas, TX: College Station.
*Stock, M. L., Gerrard, M., Gibbons, F. X., Dykstra, J. L., Mahler, H. I. M., Walsh, L. A., & Kulik, J. A.
(2009). Sun protection intervention for highway workers: Long-term efficacy of UV
photography and skin cancer information on men’s protective cognitions and behaviour.
Annals of Behavioural Medicine,38, 225–236. https://doi.org/10.1007/s12160-009-9151-2
Taylor, M., Westbrook, D., & Chang, P. (2016). Using UV photoaged photography to better
understand Western Australian teenagers’ attitudes towards adopting sun-protective
behaviours. International Journal of Adolescent Medicine and Health,28(1), 45–53.
https://doi.org/10.1515/ijamh-2014-0071
Thomas, K., Hevey, D., Pertl, M., Ni Chuinneagain, S., Craig, A., & Maher, L. (2011). Appearance
matters: The frame and focus of health messages influences beliefs about skin cancer. British
Journal of Health Psychology,16, 418–429. https://doi.org/10.1348/135910710X520088
*Tuong, W., & Armstrong, A. W. (2014). Effect of appearance-based education compared with health-
based education on sunscreen use and knowledge: A randomized controlled trial. Journal of the
American Academy of Dermatology,70, 665–669. https://doi.org/10.1016/j.jaad.2013.12.007
*Walsh, L. A., & Stock, M. L. (2012). UV photography, masculinity, and college men’s sun protection
cognitions. Journal of Behavioural Medicine,35, 431–442. https://doi.org/10.1007/s10865-
011-9372-2
Walsh, L. A., Stock, M. L., Peterson, L. M., & Gerrard, M. (2014). Women’s sun protection cognitions
in response to UV photography: The role of age, cognition, and affect. Journal of Behavioural
Medicine,37, 553–563. https://doi.org/10.1007/s10865-013-9512-y
Welch, M., Chang, P., & Taylor, M. (2016). Photoaging photography: Mothers’ attitudes toward
adopting skin-protective measures pre-and post-viewing photoaged images of their and their
child’s facial sun damage. Sage Open,6(4), 1–11. https://doi.org/10.1177/2158244016672906
Williams, A. L., Grogan, S., Buckley, E., & Clark-Carter, D. (2013). Men’s experiences of an
appearance-focussed facial-ageing sun protection intervention: A qualitative study. Body Image,
10, 263–266. https://doi.org/10.1016/j.bodyim.2013.01.003
Williams, A. L., Grogan, S., Clark-Carter, D., & Buckley, E. (2013a). Appearance-based interventions
to reduce ultraviolet exposure and/or increase sun protection intentions and behaviours: A
systematic review and meta-analyses. British Journal of Health Psychology,18(1), 182.
https://doi.org/10.1111/j.2044-8287.2012.02089.x
*Williams, A. L., Grogan, S., Clark-Carter, D., & Buckley, E. (2013b). Impact of a facial-ageing
intervention versus a health literature intervention on women’s sun protection attitudes and
behavioural intentions. Psychology & Health,28, 993–1008. https://doi.org/10.1080/
08870446.2013.777965
Wilson, D. B. (2005). SPSS macros for meta-analytic data. Retrieved from http://mason.gmu.edu/
~dwilsonb/ma.html
Appearance interventions to reduce UV exposure 17
World Health Organization (WHO). (2018). Skin cancers. Retrieved from http://www.who.int/
uv/faq/skincancer/en/index1.html
Received 15 March 2017; revised version received 12 December 2017
Supporting Information
The following supporting information may be found in the online edition of the article:
Table S1. Summary table describing theoretical basis and critical points.
Table S2. Key characteristics of studies and interventions.
Appendix S1. PRISMA (2011) checklist.
Appendix: PRISMA (2011) flow diagram
Records idenfied through
database searching
(n = 171)
Screening
Included Eligibility Idenficaon
Addional records idenfied
through ancestry search
(n =530 )
Total records idenfied (n = 701)
Records screened
(n = 701 )
Records excluded
(n = 654)
Full-text arcles assessed
for eligibility
(n = 47)
Full-text arcles excluded,
with reasons
(n = 17)
n = 6: focused on helath
consequences of UV
exposure
n = 3: not examining
relevant research
quesons
7 = no intervenon
1 = undetected duplicate
Papers included in
qualitave synthesis
(n = 30)
Individual studies
included in quantave
synthesis (meta-analysis)
(n = 34)
18 Sofia Persson et al.
