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JOURNAL OF ADOLESCENT HEALTH 2004;35:486 – 492

ORIGINAL ARTICLE

What Influences University Students’ Intentions to Practice Safe Sun Exposure Behaviors?
ELIZABETH A. GRUNFELD, Ph.D.

Purpose: To apply Protection Motivation Theory to examine adolescents’ intentions to perform safe sun exposure behaviors. Methods: A total of 239 students (aged 18 to 22 years) from two British universities were recruited to the study. The majority of participants were white (68%), 29% were classified as Asian, and the remaining 3% were AfroCaribbean. Participants completed a questionnaire comprising items examining the components of Protection Motivation Theory. Intention to perform safe sun exposure behaviors was examined by asking participants to indicate their agreement with five statements about future sun exposure behaviors. Results: Hierarchical multiple regression analysis revealed that the threat appraisal components of Protection Motivation Theory were stronger predictors of intention to perform safe sun exposure behaviors (accounting for 15% of the variance) than the coping appraisal components (accounting for 3% of the variance). However, previous performance of similar behaviors emerged as the strongest overall predictor of intention to perform safe sun exposure behaviors (beta ‫ ؍‬؊.514, p < .01), followed by perceived vulnerability to developing skin cancer (beta ‫ ؍‬.232, p < .01) and practicing skin and naevi self examination behaviors (beta ‫ ؍‬؊.172, p < .01). Conclusions: The results suggest that a strategic sun protection education campaign is necessary with the aim of encouraging adaptive sun behaviors by emphasizing the risk of skin cancer associated with sunburn. © Society for Adolescent Medicine, 2004

KEY WORDS:

Adolescents Protection motivation theory Sun exposure Skin cancer Health beliefs United Kingdom

From the Psychology Unit, Guy’s, King’s and St Thomas’ Medical School, King’s College London, London, UK. Address correspondence to: Dr. Elizabeth A. Grunfeld, Psychology Unit, Guy’s, King’s and St Thomas’ Medical School, King’s College London, Guy’s Campus, London SE1 9RT. E-mail: beth.grunfeld@kcl.ac.uk Manuscript accepted November 25, 2003.
1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2003.11.093

Skin cancer is one of the most common forms of cancer in the United Kingdom, with approximately 57,000 cases of nonmelanoma skin cancers diagnosed each year, whereas in the United States there are more than 1 million cases each year. The incidence of skin cancer has risen significantly over the past 30 years, in part owing to increased exposure to ultraviolet radiation as a result of a rise in intentional and recreational sunbathing [1]. There are three main types of skin cancer: (a) basal cell carcinoma (accounts for approximately three-quarters of skin cancers and is slow growing and rarely metastasizes), (b) squamous cell carcinoma (accounts for approximately 10,000 cases per annum in the United Kingdom and rarely affects those under 60 years), and (c) cutaneous malignant melanoma (with about 4000 cases in the United Kingdom each year and accounting for about 75% of all skin cancer deaths) [2]. Sun exposure is the major environmental risk factor for the development of both melanoma and nonmelanoma skin cancers [3] and is thought to be responsible for about 65% of cases worldwide [4]. In Western countries there is a strong link between self-reported sunburn and an increased risk of skin cancer [5]. In particular, patterns of sun exposure during childhood and adolescence have been shown to be linked to the subsequent risk of developing skin cancer during adulthood. The relative risk for the three main types of skin cancer is increased as the
© Society for Adolescent Medicine, 2004 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010

during adolescence individuals become increasingly responsible for their own sun exposure behaviors. It is of concern. tanning bed use. perceived vulnerability. sunbathing at midday) and alternative adaptive health responses (e. a social environment where a tan is desirable.. the studies have not examined adolescents’ attitudes toward carrying out responsive behaviors (i. Evidence suggests that the majority of skin cancers are preventable. Measures The questionnaire items were structured so as to represent the components of PMT [15].e. The aim of the current study was to apply PMT to examine the role of cognitive appraisal of sun exposure and of alternative adaptive responses with regard to intentions to practice safe sun exposure behaviors. therefore. and (b) coping appraisal. Tanning bed use is also a risk factor for the development of skin cancer. although previous studies have identified positive attitudes toward tanning and sun exposure behaviors among this cohort. sunscreen use) [15]. poor sunhat use.. The likelihood that an individual would perform adaptive health responses increases when one perceives strong self-efficacy and response efficacy and perceives few costs associated with performing that behavior. risky sun behaviors (i. There was not a significant difference among the samples recruited from the two universities in terms of age. In contrast.e. Parents are primarily responsible for sun exposure during early childhood [13]. Protection motivation theory comprises two main components: (a) threat appraisal. and perceptions about the rewards associated with maladaptive behavior. the study aimed to examine if the components of PMT were good predictors of intentions to practice adaptive and maladaptive behaviors in relationship to sun exposure. It has been estimated that the lifetime risk of developing nonmelanoma skin cancers could be reduced by over 75% through the appropriate use of sunscreen [12]. The main reason for the importance of early exposure is that a large amount of an individual’s exposure occurs during childhood and adolescence. 29% were classified as Asian. which reflects the predominance of female students on undergraduate psychology programs. although it may also be associated with increased sensitivity to sun exposure among this age group [9]. It has been suggested that educational programs should target adolescents.December 2004 HEALTH BELIEFS AND SUN EXPOSURE BEHAVIORS 487 result of severe sunburns received between the ages of 15 and 20 years [6 – 8]. response efficacy. In line with institutional requirements regarding the use of human participants. language. and one perceives low vulnerability and severity of the risks associated with that behavior. the likelihood of performing maladaptive behaviors is increased when one holds positive beliefs about the rewards associated with that maladaptive behavior. All students had English as a first. and attitudes toward the potential costs associated with performing adaptive behaviors. or ethnicity. The mean age was 19 years (range 18 to 22 years). Methods Participants The sample comprised 239 students recruited from two British universities.g. which includes self-efficacy. sporadic use of sun creams. and frequent sunburn) are associated with a preference for tanned skin.g. Protection motivation theory (PMT) predicts that peoples’ intentions to engage in certain health behaviors are influenced by their cognitions (attitudes and beliefs) about both the maladaptive responses (e. as there was a wide range of studies in which students could choose to participate.. sun avoidance and use of sunscreens) or adolescents’ perceived self-efficacy (beliefs of their ability) to be able to carry out such behaviors. however. or primary. and poor compliance with the application of sunscreen [14]. gender. stressing the importance of sunscreen and sunhat use and the importance of sun avoidance. participation was voluntary. However.. which includes perceived severity. however. All items . the study was reviewed and approved by the Psychology Ethics Committee at Aston University. Specifically. and a belief that sunburn is an acceptable means of obtaining a tan [10]. and the remaining 3% were Afro-Caribbean. that sun-protective behaviors deteriorate during the teenage years with high sunburn rates. There were 39 (16%) male students and 200 (84%) female students. The majority of participants were white (68%). and recent research has suggested about one-third of 17-year-olds in the United States use tanning beds [10]. it has also been shown that among this age group. Adolescents who use tanning beds are also more likely to have a parent or caregiver who also does so [11]. All participants were recruited either as part of an undergraduate psychology student project or in partial fulfilment of the requirements of an undergraduate psychology course. In addition.

Cronbach alpha for the summed scale was 0. The lower the score.488 GRUNFELD JOURNAL OF ADOLESCENT HEALTH Vol. Completion of the questionnaire took approximately 20 to 30 minutes.78. self-examination behavior. The higher the score. Rewards. Cronbach alpha for the summed scale was 0. The questionnaire was easily understood by all of the participants. The higher the score. The scores on the nine items were averaged to produce a score of attitudes toward the severity of sun exposure.” The scores on the six items were averaged to produce an attitude to the rewards of maladaptive behavior score. The scores on the three items were averaged to produce a self-efficacy score. “People with a tan look healthier.65. “Wearing sunscreen is uncomfortable”). The costs of implementing alternative adaptive responses were assessed by asking participants to rate the extent to which they agreed with six statements (e. Cronbach alpha for the summed scale was 0. size. Cronbach alpha for the summed scale was 0.. tanning bed use.. premature aging.. and skin cancer. Participants indicated how much they agreed with nine statements about the response efficacy of alternative responses to sun exposure (e.e. the greater the intention to perform safe sun exposure behaviors). the higher the response efficacy. the greater the perceived severity associated with sun exposure. 6 were tested on a small sample of students (n ϭ 8) to assess comprehensibility and suitability (i.g. avoidance of midday sun. shape and colour of nevi). the greater the perceived selfefficacy. Intentions to practice sunsafe behaviors were examined by asking participants to indicate their agreement with five statements about future safe sun exposure behaviors (e.g. An example statement was. The second part of the questionnaire was comprised of items framed according to the components of PMT. Threat appraisal. “I feel confident that I can avoid the midday sun”). Response efficacy. .67.g. personal and familial history of skin cancer. To assess rewards associated with maladaptive behavior (sun exposure) the participants indicated the degree to which they agreed or disagreed with a series of six statements about the rewards associated with sun exposure. 35. The higher the score. the more negative the attitude toward the rewards associated with sun exposure. Cronbach alpha for the summed scale was 0. Perceived severity of sun exposure was assessed by asking participants to rate the extent to which they agreed with nine statements about the seriousness of sunburn. The scores on the nine items were averaged to produce a response efficacy score.g.53. Coping appraisal. Procedure The participants were provided with the questionnaire. which they were asked to complete within their own time and then return the completed questionnaire either to the researcher or to the Psychology office. The scores on the six items were averaged to produce a response costs score. No. that they did not cause embarrassment or distress).. Severity.29. Vulnerability. and sources of information about sun exposure and skin cancer.. Participants rated their perceived vulnerability for possible risks associated with sun exposure (sun burn.g. the greater the perceived risk. Self-efficacy. premature aging. Demographic and health information. “Avoiding the midday sun will reduce my chances of getting skin cancer”). the more negative the attitude toward implementing alternative adaptive responses. Self-efficacy for initiating alternative responses was measured by asking participants to rate three statements about their ability to undertake adaptive behaviors (e. and use of sun screens). Participants completed questions relating to their skin type. Behavioral intentions. The scores on the five items were averaged to produce an intention score (the lower the score. Participants were required to indicate on a five-point scale (“strongly agree” to “strongly disagree”) the extent to which they agreed with a series of statements. The lower the score. The scores on the 11 items were averaged to produce a perceived vulnerability score. 2. and skin cancer). Cronbach alpha for the summed scale was 0. The higher the score..68. knowledge of the importance of different changes in skin appearance (e. This score was used as the independent variable for multiple regression analysis. Response costs. Components of PMT. The questionnaire comprised two main sections: 1.

December 2004 HEALTH BELIEFS AND SUN EXPOSURE BEHAVIORS 489 Table 1.122 . greater self-efficacy for implementing adaptive behaviors (t ϭ Ϫ3.e.5) 2.314** .4) 2.017 Ϫ. 78% reported using a sunscreen when on holiday. Participants were asked about their previous sun exposure behaviors: 58% reported aiming to get a suntan while on holiday and only 34% reported attempting to avoid the midday sun while on holi- Table 2.05.5) 2. 96% reported that a change in the size of an existing nevus would be important or very important.6 (0.024.031 Ϫ. friends (52%). Only 12% of the sample reported that they regularly or frequently examined their skin for changes in nevi.5) 1. participants who had previously performed sun-safe behaviors reported greater self-efficacy for performance of adaptive behaviors and less negative attitudes toward the performance of such behaviors.251.7 (0. sometimes tan” (24%). sometimes burn” (39%). The most commonly identified source was magazines (67%).6 (2.125 Ϫ.4 (4.064 .045 Ϫ.400** Knowledge .01.001) and greater implementation of safe sun behaviors in the past (t ϭ 10. p Ͻ .074 Ϫ.313** .244** . and “always burn.172** . never tan” (4%). The high intention group demonstrated greater knowledge of the different changes in skin appearance that might be associated with skin cancer (t ϭ 2.116 Ϫ.206** .6 (0. Seven percent of the sample reported having a relative who had experienced skin cancer and 11% knew of a nonfamily contact who had experienced skin cancer.055 Previous Behavior Rewards Severity Vulnerability Response Costs Response Efficacy . however.350** Ϫ.6) Low Intention Group 3. Participants scoring below 3 were classified as the “high intention” group (would definitely or probably carry out adaptive responses such as avoidance of midday sun) and those scoring 3 or over were classified as the “low intention” group (would probably not or definitely not carry out adaptive responses).928. ** p Ͻ .2 (0.072 .8 (0..4) 3.5) 2. Only 2% reported frequent use of a tanning-bed.021 Ϫ. Results Participants were asked to describe their skin type according to the following classifications: “always tan. Participants were asked to indicate the information sources they had used to gain information about skin cancer or sun safety. a large percentage reported the importance of various factors in self-checking for nevi.5) 2.3 (0. more positive attitudes toward implementing adaptive behaviors (i.061 .138* . For example. Means and SD (in Parentheses) for the Protection Motivation Subscales as a Function of Intention Group Subscale Knowledge Previous behavior Rewards Severity Vulnerability Response costs Response efficacy Self-efficacy High Intention Group 3. p Ͻ .044 .1 (0. p Ͻ .5 (0. The intercorrelations among the subscales can be found in Table 2. p Ͻ .7) day.114 Ϫ. “always tan.01). “always burn. Intercorrelations Between Subscales for Protection Motivation Theory Intention Knowledge Previous behavior Rewards Severity Vulnerability Response costs Response efficacy Self-efficacy * p Ͻ .1 (0. parents (51%).001).088 . Seventy-eight percent reported that the appearance of new nevi would be important or very important.1 (0.0 (0. avoidance of midday sun) (t ϭ Ϫ3. 85% reported that a change in the shape of a nevus would be of significance.614** .001 . However.112 .6) 3.5 (0.4) 3.05). Ϫ.6) 1.0 (0. and logical relationships among the subscales were apparent. The means and standard deviations obtained for each of the subscales (according to intention group) can be found in Table 1.182** Ϫ.027 .7 (0.434** Ϫ.030 Ϫ.438** .243 .130* Ϫ. and information leaflets (37%).6) 2. never burn” (33%).4) 2.034 .018 .049 .9) 2.7) 0. and 87% reported that a change in the colour of a nevus would be a significant indicator. Protection Motivation Theory Subscales The participants were divided into high and low intention groups on the basis of their averaged intention score.311. followed by newspapers (59%).

030 . by a belief that a suntan is healthy and enhances one’s appearance [18]. the addition of knowledge.028 . The results of these studies suggest that campaigns to improve sun protective behaviors should target current beliefs regarding the glamour and attractiveness of suntanned skin. As expected. However.01.008 Ϫ. Hierarchical Multiple Regression Analysis for Predictors of Intention to Perform Sun-safe Behaviors Step/predictor R2 Adjusted R2 .17]. previous performance of similar sunsafe behaviors was a strong predictor of future intention to perform sun-safe behaviors. For some young people. The results of the hierarchical multiple regression analysis revealed that the threat appraisal components of protection motivation theory were stronger predictors of intention to perform sun-safe behaviors than were the coping appraisal components. severity. and selfexamination behavior increased the variance explained by the model to 43%. The strongest predictor of intention to perform sun-safe behaviors was previous performance of similar behaviors. and thinner [19]. very few of the participants in the current study reported having a family member who had experienced skin cancer.040 Response costs Response efficacy Self-efficacy Threat appraisal . 6 Table 3. No. followed by perceived vulnerability and self-examination behavior. whereas approximately one-third attempted to avoid the midday sun while on vacation. the development of wrinkled skin) or the advantages of the use of fake-tan creams to obtain a tanned appearance. This incongruence could be explained. There is a trend toward light to moderate tans rather than dark tans.754 .009 .514** Ϫ. as evidenced by the appearance of models in magazines [20]. and instead it may be important to emphasize the aesthetic disadvantages of tanning (i.459 Knowledge Previous similar behavior Self-examination behavior ** p Ͻ . The coping appraisal variables accounted for less than 3% of the explained variance. followed by the threat appraisal variables (rewards.490 GRUNFELD JOURNAL OF ADOLESCENT HEALTH Vol. The intention variable was entered as the dependent variable. Despite awareness among participants of the importance of self-examination of skin changes. in part.178 8. and vulnerability) with previous behavior and knowledge being entered on the third step. The study focused on a sample of adolescents because solar exposure in early life is associated with increased incidence of melanoma in later life. In addition.434 19. previous performance of similar behaviors. Previous research has shown that children and adolescents do not associate sunburn with an increased risk for the development of skin cancers [10].e. In addition. previous performance of similar behaviors emerged as the strongest overall predictor. whereas adding the threat appraisal variables increased the explained variance to almost 18%. only one-tenth of the sample reported performing selfexamination behaviors. 35. over half the sample reported seeking to gain a tan during their summer vacation.232** . and selfefficacy) were entered on the first step. as it has been shown that young people perceive that a person with tanned skin looks younger. an understanding of the beliefs of teens and young adults is a key component in the development of health education campaigns aimed at reducing skin cancers. sexier. response efficacy. changing perceptions of the attractiveness of tanned skin would require a huge cultural shift in perceptions of attractiveness.027 F 3.002 . However.021 Rewards Severity Vulnerability Additional variables .036 Ϫ. The coping appraisal variables (response costs. perceived vulnerability for the development of skin cancer may also be a significant factor in the development of intentions to perform sun-safe behaviors. and as such they may not perceive skin cancer to be a common disease or themselves to be at high risk for developing the disease. few are willing to change their behavior to reduce their risk [16. As suggested by the present study. It may be . These results are in line with previous findings demonstrating that although adults and teenagers may be aware of the risks of sun exposure.172** Beta in Final Equation Coping appraisal . However.001 .. Discussion The study examined whether the components of protection motivation theory were good predictors of intentions to practice adaptive and maladaptive sun exposure behaviors. Multiple Regression Analysis Hierarchical multiple regression analysis was performed to examine predictors of intention to seek help (Table 3).047 . the positive beliefs associated with tanned skin have been shown to outweigh the potential future risk of developing melanoma [16]. Therefore.

Cancer Surv 1996. sunburning rates and tanning bed use among more than 10. Wilson L. Cokkinides VE. Conclusions The current findings and those of previous studies suggest that a multiple strategy approach is necessary for the development of an appropriate sun protection education campaign. In: Cacioppo JT. Brodland DG. Scientific recommendations and human behaviour: Sitting out in the sun. 3. Kricker A. Knight RG. such an approach could highlight the damage that sun exposure can do to the skin and outline .51:698 –703. and their friends and parents. alternatives to sun exposure. Social Psychophysiology: A Sourcebook. however. Lowe JB. References 1. et al. Rogers RW. Suntanning: Differences in perceptions throughout history.15:271–81. could increase perception of control over the execution of such behaviors. Stern RS. Stone B. Aust N Z J Public Health 2001.122:537–45. Rampen FHJ. 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