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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 methodological 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. 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).
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 =0.2790.568, 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 200516 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 AprilMay 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
1275 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: 0.0840.296, 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 informaon
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 informaon
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 intervenons
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 0.0840.296 10 1,564
SPI .165 .012 0.0360.295 8 1,251
Relationship between photoageing interventions and outcome variables
Combined outcome variable .327 <.001 0.2060.447 4 863
SPI .272 .039 0.2030.341 3 840
Relationship between UV photo combined with photoageing information and outcome variables
Combined outcome variable .261 <.017 0.0470.475 6 918
SPI .424 .023 0.2790.568 3 319
Relationship between other interventions and outcome variables
Combined outcome variable .191 <.001 0.1170.265 14 3,895
SPI .223 .067 0.015 to 0.461 5 836
UV exposure .154 .040 0.0070.302 6 1,878
UVEI .235 <.001 0.1330.371 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: 0.0360.295, 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: 0.2060.447, p<.001. On sun protection intentions only, the
effect size was small r
+
=.272; k=3, N=813, 95% CI =0.2030.341, 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 =0.0470.475, 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 =0.1170.265, p<.001. On UV exposure
intentions only, the combined effect size was small, r
+
=.235; k=7, N=1,798, 95%
CI =0.1330.371, p<.001. On actual UV exposure, the effect size was small, r
+
=.1542,
k=6, N=1,878, 95% CI =0.0070.302, 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 (1635 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.
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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, 263266. 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, 9931008. 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 idenfied through
database searching
(n = 171)
Screening
Included Eligibility Idenficaon
Addional records idenfied
through ancestry search
(n =530 )
Total records idenfied (n = 701)
Records screened
(n = 701 )
Records excluded
(n = 654)
Full-text arcles assessed
for eligibility
(n = 47)
Full-text arcles excluded,
with reasons
(n = 17)
n = 6: focused on helath
consequences of UV
exposure
n = 3: not examining
relevant research
quesons
7 = no intervenon
1 = undetected duplicate
Papers included in
qualitave synthesis
(n = 30)
Individual studies
included in quantave
synthesis (meta-analysis)
(n = 34)
18 Sofia Persson et al.
... One intervention study by Velasqause et al. (2016) indicated that while half of the students aged 9-12 years did not have sufficient knowledge about the relationship between self-caring behaviors and skin cancer, they perceived the risk of association between sunlight and skin cancer and observed skincare behaviors, including the use of sunscreen and skincare at critical hours after learning through lectures and games [11]. Similarly, Persson et al. (2018) conducted a review study and determined that interventions were significantly effective in preventing sun exposure immediately after the intervention and 12 months after the intervention [27]. Dehbari et al. (2015) found a significant relationship between the PMT constructs except for perceived rewards and methods of sun protection [28]. ...
... One intervention study by Velasqause et al. (2016) indicated that while half of the students aged 9-12 years did not have sufficient knowledge about the relationship between self-caring behaviors and skin cancer, they perceived the risk of association between sunlight and skin cancer and observed skincare behaviors, including the use of sunscreen and skincare at critical hours after learning through lectures and games [11]. Similarly, Persson et al. (2018) conducted a review study and determined that interventions were significantly effective in preventing sun exposure immediately after the intervention and 12 months after the intervention [27]. Dehbari et al. (2015) found a significant relationship between the PMT constructs except for perceived rewards and methods of sun protection [28]. ...
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Adolescents are at high risk of skin cancer. Since protecting the skin from the sun's ultraviolet rays is an important way to prevent this disease, the present study aimed to evaluate the effectiveness of teaching skin cancer prevention behaviors using the Protection Motivation Theory (PMT) in male students in Isfahan. An intervention study examined change in attitudes and behaviors among 104, 13-year-old male students from two schools in Isfahan, Iran. The schools were randomized to either receive or not receive a 5-session skin cancer prevention curriculum based in PMT theory. Data were collected using a validated questionnaire that included demographic, PMT, and behavior construct variables. Questionnaires were completed by both groups before and 2 months after the intervention. Data were analyzed using SPSS 20, chi-square test, Mann-Whitney test, paired t-test, and McNemar's test. The results indicated that the mean scores of all constructs of PMT increased in the intervention group compared to the baseline assessment, except for the response cost (P < 0.001). The mean score of students' skin cancer preventive behaviors was 39.6 (21.4) in the intervention group, and it increased to 74.7 (23.5) after educational intervention, while the control group did not exhibit any significant behavior change. The intervention certainly shows the potential for being effective over the short-term. Therefore, it is recommended that PMT-based educational interventions be designed to teach and promote social health, particularly at an early age.
... Several studies, e.g., from Sweden, USA, or Canada [17,25,26,73], showed a high cosmetic value toward tanned skin among students-especially in females-and the misconception that tanned skin is healthy. ese findings argue for addressing the aspect of the significance of appearance in educational interventions by using appearance-based approaches, such as UV photography of the skin, revealing skin damage (solar lentigines) yet invisible to the naked eye [74]. Focusing not exclusively on knowledge transfer, but on target group- Journal of Skin Cancer relevant aspects might result in improved sun-protective behavior in this target group of multipliers [74][75][76]. ...
... ese findings argue for addressing the aspect of the significance of appearance in educational interventions by using appearance-based approaches, such as UV photography of the skin, revealing skin damage (solar lentigines) yet invisible to the naked eye [74]. Focusing not exclusively on knowledge transfer, but on target group- Journal of Skin Cancer relevant aspects might result in improved sun-protective behavior in this target group of multipliers [74][75][76]. At this point, however, it must be noted that tanned skin is considered attractive mainly in Western countries. ...
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Ultraviolet radiation (UVR) is the most important risk factor for developing skin cancer. University students can be considered as a particularly high-risk group for long- and short-term adverse effects of UVR due to intensive solar UVR exposure and high rates of sunburn. While validated questionnaires for assessing solar UVR exposure and sun protection behavior are available in German, a questionnaire for assessing the level of knowledge about this topic is still missing. We conducted a literature search for cross-sectional studies assessing skin cancer and sun protection knowledge among university students in Medline (via PubMed) and analyzed existing questionnaires and topics contained therein. We chose to translate the “Skin Cancer and Sun Knowledge Scale” referring to the TRAPD method into the German language and pilot-tested the translation with an opportunity sample of German students. The literature search revealed 36 eligible studies. Four major topics were identified within the studies: knowledge on skin cancer, risk factors, UVR, and sun protection measures. One hundred and seven German university students (86.0% female) with a mean age of 26.25 years (SD ± 4.58; range: 19–46) participated in our pilot study. The internal reliability of the scale was KR-20 = 0.624. We discovered an improvable level of knowledge in terms of skin cancer among the study population. Statistical analyses revealed no significant associations between the level of knowledge and UVR exposure or tanning behavior, respectively. The skin cancer and sun protection knowledge of German university students should be examined thoroughly. While the psychometric properties of the SCSK require further thorough investigation, first empirical experiences indicate the suitability of the tool to assess the level of knowledge regarding skin cancer and sun protection.
... Interventions of this type demonstrate the consequences of health behaviours on our physical appearance in an attempt to draw attention to the broader effects of the behaviour and personalize the risk [8]. Interventions have utilized the availability of software that displays realistic effects of smoking [6,9], alcohol [10], and UV PEC Innovation 1 (2022) 100021 exposure [11]. The majority of these software programmes work by displaying a time progression of the ageing process on a photograph of the face, considering the impact of the health behaviour informed by research on skin ageing. ...
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Objectives Appearance-related interventions to promote healthy behaviour have been found effective to communicate health risks. The current study aimed to explore women smokers' experiences of age-progression software showing the effects of smoking on the face. Methods A qualitative design was implemented, utilizing both individual interviews and focus groups within a critical realist framework. Fifteen, 19–52 year-old women smokers were administered an age-progression intervention. All participants responded to the intervention, engaged in semi-structured interviews, and were invited back to attend one of three focus groups. Data were analysed using inductive thematic analysis. Results Four main themes were identified: Health versus Appearance, Shock Reaction, Perceived Susceptibility, and Intention to Quit. Participants found the intervention useful, voicing need for a comprehensive approach that includes both appearance and health. Despite increases in appearance-based apps which could diminish impact, women's accounts of shock induced by the aged smoking-morphed images were similar to previous work conducted more than ten years previously. Conclusions The study provides novel insights in how women smokers currently perceive, and react to, an age-progression intervention for smoking cessation. Innovation Findings emphasise the implementation of this intervention type accompanied by health information in a range of patient settings.
... Due to the modifiability of the main risk factor for skin cancer, UV radiation, interest to influence people to adopt healthier sun exposure habits has been raised. This can be accomplished through skin cancer awareness campaigns [11][12][13][14][15]. To optimize these campaigns, it is important to have knowledge of sun exposure behavior within the population. ...
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Background: Skin cancer incidence is rapidly increasing. The main risk factor, sun exposure, can be modified. Informational campaigns can be effective in raising skin cancer awareness and target the high-risk population. Still, sun exposure habits in people at high risk of skin cancer are not well-known. Objective: To investigate if and how sun exposure habits differ between low-risk and high-risk individuals. Methods: During the Swedish Euromelanoma campaign of 2018, questionnaires were collected containing information regarding sun exposure habits and risk factors for skin cancer. Data on 4,141 participants was used to investigate the association between risk factors and sun exposure habits. Results: A fair skin type and a previous history of skin cancer were significantly associated with enhanced sun protective behavior. Family history of skin cancer, childhood sunburns and the presence of large/atypical nevi had no effect on sun exposure habits. Going on sunny holidays were particularly unaffected by being at high risk of skin cancer. Conclusion: Individuals at high risk of developing skin cancer showed suboptimal sun exposure habits and harmful traveling behaviors. We suggest that future skin cancer campaigns inform on accurate sun protection behavior during sunny holidays and associated risk factors. Risk factors such as childhood sunburns, numerous common and large/atypical nevi, as well as family history of skin cancer seem to be less recognized by the population.
... Indoor tanning (IT) increases risk of developing melanoma, the most common cancer in women aged 25-29 (Little and Eide, 2012), and keratinocyte carcinomas (Burgard et al., 2018;Gandini et al., 2019;O'Sullivan et al., 2019), and remains popular with some US teen girls (Centers for Disease Control and Prevention, 2020;Niu et al., 2018;Turrisi et al., 2012;Holman et al., 2013;Hillhouse et al., 2017). IT interventions directed at tanners via print materials, websites, and UV photography have been effective, especially appearance-focused interventions (Turrisi et al., 2012;Persson et al., 2018). However, they may be less effective in practice because indoor tanners may have low motivation to access and read them and UV photography equipment is not widely available. ...
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Indoor tanning (IT) increases risk of developing skin cancer. A social media campaign to reduce mother’s permissiveness toward their teenage daughters IT was evaluated. Mothers (N=869) of daughters aged 14-17 in 34 states without bans on IT by minors were enrolled in a randomized trial with assessments at baseline and 12-months follow-up in 2017-19. A year-long adolescent health campaign was delivered to all mothers. The intervention group received posts on preventing IT and the control group, posts about preventing prescription drug misuse. Daughters (n=469; 54.0%) completed the assessments at baseline and 12 months. At 12-month follow-up, intervention-group mothers were less permissive of IT by daughters (unadjusted means=1.70 [95% CI: 1.59, 1.80] v. 1.85 [1.73, 1.97] [5-point Likert scale], b=-0.152), reported more communication about avoiding IT with daughters (4.09 [3.84, 4.35] v. 3.42 [3.16, 3.68] [sum of 7 yes/no items], b=0.213), and had lower intentions to indoor tan (1.41 [1.28, 1.55] v. 1.60 [1.43, 1.76] [7-point likelihood scale], b=-0.221) than control-group mothers. Daughters confirmed intervention-group mothers communicated about IT (3.81 [3.49, 4.14] v. 3.20 [2.87, 3.53] [sum of 7 yes/no items], b=0.237) and shared IT posts (unadjusted percentages=52.4% v. 36.4%, b=0.438) more than control-group mothers. No differences were found in IT behavior, self-efficacy to refuse permission, and negative attitudes toward IT. A social media campaign may be an effective strategy to convince mothers to withhold permission for IT, which may help increase the effectiveness of state laws designed to reduce IT by minors by requiring parental permission.
... Specific to college students, a previous systematic review focused on tanning behaviors, attitudes, beliefs, and intentions in college students supported that appearance is a factor in tanning behavior, as well as emotion, health perceptions, and the influence of parents, peers, and the media. 66 A systematic review and metaanalysis specifically investigating appearance-based interventions to reduce UV exposure found appearance-based intervention to be a significantly effective type of intervention, 67 and the update 5 years later found a moderate effect size for UV photography and photoaging information on meta-analysis; 68 the decrease in effect is likely due to studies that used an active control group that received baseline sun protection information rather than no education. McWhirter et al found in a systematic review of population-based studies that visual images specifically may be particularly effective in influencing attitudes and behaviors to UV radiation. ...
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College and university students are a group known for excessive sun exposure and indoor tanning. Health education campaigns for avoidance of ultraviolet (UV) radiation have been relatively unsuccessful in this population. This systematic review examines interventions aimed at post-secondary school young adults on college and university campuses for skin cancer awareness, photoprotection, and change in UV-exposure-related behavior. Fifty-nine studies were identified for inclusion according to predetermined criteria. Study heterogeneity was high; methods of intervention were individual or group-based, and were mostly visually delivered and/or passive learning. Most interventions occurred at a single time point. Intervention success was assessed by evaluating subject behavior, intention, attitudes, knowledge, and emotion. Multicomponent interventions, generally consisting of UV photography and a passively delivered educational component, may be more effective than a single component alone. Overall, study quality was poor. Sample size of the majority of studies was <150 subjects. Most studies used self-report of behavior and had a short follow-up time. Generalizability of findings may be impacted as women, particularly white/Caucasian women, were overrepresented in the studies identified by this systematic review. For this specific target population, themes arising from the review include the importance of self-relevance and message framing. Self-affirmation was identified as a potential challenge in designing interventions for this target group, which can lead to defensiveness and a negative reaction to the health message. The findings of this systematic review may inform future research in this field, as well as guide planning of effective interventions in this target population.
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Background Melanoma is the second most common cancer in young adults. Social media may be a means to conduct interventions to increase sun safety in young adults. Purpose We conducted a randomized proof-of-concept pilot trial to evaluate the feasibility and acceptability of a dissonance-based social media intervention designed to promote sun safety in young adult tanners. Methods Young adult tanners (N = 66) were randomized into two 4-week interventions in which participants were incentivized to create content for a social media campaign on healthy skin or healthy lifestyle. Feasibility outcomes included retention, participation, acceptability, and contamination. We also examined the impact of participation on motivation to engage in the target health behaviors and outdoor tanning intentions. Results Retention was 100%. Most Healthy Skin (88%) and Healthy Lifestyle participants (91%) created ≥1 post. Acceptability was high with 94% and 97% of participants in Healthy Skin and Healthy Lifestyle conditions, respectively, agreeing they would recommend the campaign to a friend. At 4 weeks, Healthy Skin participants reported greater declines in motivation to tan indoors (p = .0017) and outdoors (p = .0003), and greater increases in motivation to wear sunscreen (p = .0009) and protective clothing (p = .0342). Healthy Skin participants reported greater declines in intentions to tan outdoors in the next year (p = .0286). Conclusions A dissonance-based, social media sun safety intervention was feasible and acceptable. Future research should examine the efficacy and longer-term effects of this intervention in young adults at elevated risk for skin cancer. Trial Registration Clinicaltrials.gov NCT03834974 https://clinicaltrials.gov/ct2/show/NCT03834974
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Background College students participate in high levels of tanning, a skin cancer risk behavior due to ultraviolet radiation exposure, yet little is known about Asian college students’ behavior. This study examined the relationship between tanning attitudes, acculturation to the USA (cultural assimilation), and tanning behavior.Method An online survey was used to recruit 211 Asian college students in the northeastern USA (47.4% born outside of the USA) to respond to questions about recent tanning behavior, sun protection strategies, attitudes about tanning, and acculturation to the USA.ResultsAttitudes about tanning, particularly desire for a darker skin tone and social norms, along with acculturation to the USA, were predictive of intentional tanning. The sample reported high levels of sun protection, which was associated with low acculturation.Conclusion The significant role of acculturation in this study indicates that it may be a useful factor to include in future tanning intervention studies of relevant populations.
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Background: Knowledge of its potential cancer risk is often not enough to motivate individuals to avoid indoor tanning. Previous research has found that emotions toward indoor tanning and appearance motivations may prompt people to continue despite the risks. Methods: We conducted two online surveys of US young adult women. Study one included a convenience sample of female undergraduates (N = 502) at a university in the northwestern USA. Study two included young women from a nationwide US online panel (N = 270). Results: Results suggest that emotional associations, both positive and negative, with indoor tanning explain greater variances in indoor tanning behavior than demographics and previously established psychosocial predictors of tanning alone. Appearance motivations were also positively associated with indoor tanning in both samples. Conclusions: This research has implications for health care providers and health communicators, as indoor tanning prevention messages and campaigns should consider the association between both positive and negative emotions on tanning behaviors as well as appearance motivations.
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