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Sun protection practices in preadolescents and adolescents: A school-based survey of almost 25,000 Connecticut schoolchildren
CURRENT
ISSUES
Sun protection practices in preadolescents and adolescents: A school-based survey of almost 25,000 Connecticut schoolchildren Patricia F. Coogan, ScD,a Alan Geller, RN, MPH,a,b Mary Adams, MS, MPH,d Lori Steinberg Benjes, MD,b and Howard K. Koh, MD, MPHa,b,c Boston, Massachusetts, and Hartford, Connecticut Sun protection practices in children and adolescents fall well below national recommendations. We present the results of a survey of sun protection use and other health-related behaviors in a sample of Connecticut Caucasian students aged 9 through 18 years (N = 24,645). Our objectives were to estimate the prevalence of sun protection use and to evaluate the relationship between sun protection use and health-risk behaviors and attitudes about appearance. We present data from 1988 through 1995 from the Connecticut Health Check, a health risk appraisal survey sponsored by the Connecticut Department of Public Health. Students enrolled in public and private elementary junior as well as senior high schools took the self-administered anonymous survey, which included multiple-choice questions about use of sun protection, cigarettes, and alcohol and about body image and self-esteem. We report prevalence proportions for use of sun protection by demographic features. We compared the proportion of students in 3 categories of outcome (always, sometimes, and never use sun protection) who reported various health-risk behaviors. Twenty percent of the sample reported always using sun protection; this is well below national goals set forth in the Healthy People 2000 recommendations. Sun protection use was inversely related to age and was higher among girls than boys at all ages. At all ages, students who did not use sun protection were more likely than those who did to report other health risk behaviors, such as use of cigarettes and alcohol. The data suggested that use of sun protection is associated with positive attitudes about appearance and self-image. Use of sun protection may be one component of an overall mode of health awareness and behavior. Programs promoting safe sun practices should target boys and be integrated into an overall campaign aimed at other risk-taking behaviors. (J Am Acad Dermatol 2001;44:512-9.)
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ighty-five percent of skin cancer cases could be prevented by limiting exposure to the sun, but most people still associate a suntan with good health and attractiveness.1-4 Thus it is difficult
From the Department of Epidemiology and Biostatistics, Boston University School of Public Healtha and the Department of Dermatology, Boston University School of Medicineb; the Massachusetts Department of Public Health, Bostonc; and the Connecticut Department of Public Health, Hartford.d Supported by the Environmental Protection Agency, Centers for Disease Control and Prevention, and National Institutes of Health. The opinions and interpretations expressed by Dr Howard K. Koh are his own and do not necessarily reflect those of the Massachusetts Department of Public Health or any of its agents or governing authorities. Reprint requests: Alan Geller, RN, MPH, The Cancer Prevention and Control Center, 720 Harrison Ave, DOB801A, Boston University Medical Center, Boston, MA 02118. E-mail: [email protected]. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/1/111621 doi:10.1067/mjd.2001.111621
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to change attitudes toward sun exposure, especially during adolescence, when much of the damage that can lead to skin cancer occurs.1 Of all age groups, adolescents spend the most time in the sun1-4 and are keenly attuned to their appearance. Therefore it is important to understand patterns of sun protection use in adolescents and children. We present the prevalence of sun protection use in a large sample of Connecticut Caucasian students aged 9 through 18 years enrolled in public and private elementary, junior, and senior high schools. We also evaluated the relationship between sun protection use and health-risk behaviors as well as attitudes about appearance. To our knowledge, this is the largest population of students aged 9 through 18 years surveyed on sun protection.
METHODS Survey Since 1985, the Connecticut Department of Public Health has promoted the use of the
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Table I. Use of sun protection among white students, by gender and age, Connecticut Health Check Survey (N = 24,645) Ages 9-12 Boys No. (%)
Always Sometimes No need No, and burn Total
742 (26.7) 1333 (47.9) 570 (20.5) 136 (4.9) 2781 (100)
Ages 13+ Girls No. (%)
Boys No. (%)
Girls No. (%)
Total No. (%)
1054 (35.8) 1479 (50.3) 293 (10.0) 116 (3.9) 2942 (100)
1443 (14.4) 5472 (54.6) 2768 (27.6) 340 (3.4) 10,023 (100)
1775 (20.0) 5545 (62.3) 1238 (13.9) 341 (3.8) 8899 (100)
5014 (20.3) 13,829 (56.1) 4869 (19.8) 933 (3.8) 24,645 (100)
Connecticut Health Check, a computerized health risk appraisal survey, as a motivational and educational tool for students in grades 4 through 12. In the first 2 years, the program was marketed statewide. Since then, the program has been promoted by informal means, including demonstrations at the annual conference for Connecticut school health educators, by newspaper stories, and by word of mouth. Schools choose to participate in the program, which includes urban, suburban, and rural schools. A more detailed description of the methods has been published elsewhere.5 We present data from 1988 through 1995, which include between 20 and 40 schools each year, with participating schools varying from year to year. The Connecticut State Department of Education has rated all schools according to the socioeconomic status of the areas in which their students live, ranging from A (affluent) to I (low socioeconomic status).6 Schools from each of the 9 socioeconomic categories participated in the survey. Within each school, all students in a selected class (often a health education class) completed a survey of health behaviors that included questions on sun protection, use of cigarettes and alcohol, body image, self-esteem, and a variety of other topics. Three versions of the questionnaire were used (preteen, junior high, and high school versions), with similar but not identical questions. Because the schools chose the version to use, different versions were often used in the same grade. For example, 76% of subjects in grade 6 took the junior high version, whereas 24% took the preteen version. Students recorded answers on a card and then inserted it into an optical scanning device to assure anonymity. A confidential report was immediately generated with a score and suggestions for improvement in health-related behaviors. Sun protection was ascertained by a single question: “Do you protect your skin with a sunscreen or covering so you won’t get a sunburn?” The high school and junior high school versions of the survey
included 5 responses: (1) “no, don’t need to”; (2) “yes—always”; (3) “not always—but I don’t burn”; (4) “not always—and I burn sometimes”; and (5) “don’t protect skin and do burn.” The first two responses were identical on the preteen version, but were followed by only two additional ones: (3) “not always but I tan and don’t burn” and (4) “no—and I burn.” For most analyses we collapsed responses into 3 categories: (1) “yes—always”; (2) “sometimes” (including “not always but I don’t burn” and “not always and I burn”); and (3) “no” (including “no don’t need to” and “no—and I do burn.” Because the incidence of skin cancer is highest among lightly pigmented persons, the study was limited to non-Hispanic white students. Students who answered “white” to a single question with response categories of “white,” “Black,” “Hispanic,” “Asian,” or “other” were included in the study. Of 24,708 total Caucasian students surveyed over the 8 survey years included herein, 63 were excluded because they had incomplete questionnaires or had incompatible ages for their grades (older than the 95th percentile of age for a given grade). The final population included 24,645 non-Hispanic white students. Statistical analysis Crude rates for prevalence of sun protection use over the survey years are reported because ageadjustment did not alter the results. Logistic regression models with a 3-category outcome variable (always, sometimes, never use sun protection) were used to evaluate the effects of age, sex, and survey year, which were included in the model as single terms.7 The proportion of students in 3 categories of sun protection use who reported various health-risk behaviors are compared with the Mantel-Haenszel chi-square test for trend.8 For the latter analyses, we present data for two age categories, 9 through 12 years and 13 through 18 years. Although the prevalence of the health-risk behaviors varied among the younger and older teenagers in the 13- to 18-year
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Fig 1. Percentage of white male and female students who always use sun protection, by age, 1988-1995 (N = 24,645).
Fig 2. Percentage of white male and female students who always use sun protection, by survey year (n = 23,316).
age group, the relationship between the behaviors and sun protection use was comparable.
RESULTS Slightly more than 20% of all Caucasian students reported always using sun protection (Table I); 56% reported sometimes using sun protection, and 20% stated that they had no need for it. Of these latter students, 69% were male and 31% were female. Almost 4% stated that they did not use sun protection although they did burn; of these, 51% were
male and 49% were female. In subsequent analyses, these latter two responses are combined into one category of “never use.” Use of sun protection was inversely related to age, and girls were more likely than boys to use sun protection at all ages (Fig 1). The prevalence of students who reported always using sun protection was highest among 9-year-old girls (47%) and was lowest among 17-year-old boys (11.8%). Among boys and girls, use steadily diminished through age 15, remained relatively stable to age 17, and then began to increase.
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Table II. Percentage of white students in 3 categories of sun protection use who engage in health-risk behaviors, Connecticut Health Check Survey, children aged 9-12 years (n = 5723) Male schoolchildren
Current smoker* Intends to smoke when older† Sometimes/rarely use seatbelt‡ Rarely/never use bike helmet§
Always (n = 742)
Sometimes (n = 1333)
Never (n = 706)
2.3 1.5 22.5 43.7
1.7 2.4 27.1 53.9
5.8 4.3 42.5 69.9
Female schoolchildren
Current smoker* Intends to smoke when older† Sometimes/rarely use seatbelt‡ Rarely/never use bike helmet§
Always (n = 1054)
Sometimes (n = 1479)
Never (n = 409)
1.4 <1 17.7 42.3
2.6 <1 22.3 51.3
6.6 6.0 31.3 66.7
Chi-square test for trend: P value for all variables ≤ .001. *Positive response to:“Do you smoke cigarettes now?” †Positive response to:“Do you think you will smoke when you are older?” ‡Answered “rarely or never” to:“Do you wear a seatbelt when riding in a car?” §Answered “rarely or never” to:“Do you wear a helmet when you ride your bicycle?”
The prevalence of students who report always using sun protection fluctuated over 7 years of the survey among both boys and girls (Fig 2). (The first survey year, 1988, is not included because only ages 9-12 were surveyed that year.) Prevalence of “always use” declined slightly between 1989 and 1990, increased through 1993, then began a modest decline in 1995. Age, sex, and year of survey were statistically significant independent predictors of sun protection use (P for all variables = .0001). Overall, there was a slight upward trend in “always use of sun protection” over these survey years. Among younger students, a higher proportion of those who reported “never” compared with “sometimes” or “always” reported current smoking, intent to smoke, and rarely using a seatbelt or bike helmet (P ≤ .001 for all variables) (Table II). Among older students, “never” users were more likely than “sometimes” or “always” users to consume cigarettes, alcohol, marijuana, and to rarely use a seatbelt (P < .001 for all variables) (Table III). Use of sun protection was related to some variables relevant to self-image (Tables IV and V). Girls aged 9 through 12 years who always used sun protection were less likely to be dieting than were those who never used it (P = .008). There was no such relationship in young boys in whom the overall prevalence of dieting was much lower. However, among boys, those who never used sun protection were more likely to think themselves too fat (P =
.004), whereas there was no difference among girls (P = .32). Among both sexes aged 9 through 12 years, a higher proportion of those who always used sun protection liked themselves “most of the time” than did those who never used it (P = .001 for both sexes). There was no relationship between sun protection use and perception of the importance of “fitting in” (P = .44) or of depression (P = .43) among boys aged 9 through 12 years. However, girls who never used sun protection were more likely to believe that it is very important to fit in (P = .03) and to report depression (P = .001), compared with those who always or sometimes used it. We had information only on dieting and depression among students 13 years and older (Table V). As for the younger students, there was no relationship between dieting and sun protection among boys, but girls who never used sun protection were slightly more likely to be on a diet than were those who always or sometimes used it (P = .045). Depression was more common among “never” users among both boys (P = .001) and girls (P = .001).
DISCUSSION These data suggest that sun protection use among children and adolescents, particularly boys, falls well below national recommendations.9 Students who reported always using sun protection were the least likely to engage in other health-risk behaviors; those who reported never using sun protection were the
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Table III. Percentage of white students in 3 categories of sun protection use who engage in health-risk behaviors, Connecticut Health Check Survey, children aged 13 years and older (n = 18,922) Male schoolchildren
Current smoker* Consumes alcohol 1+ times/wk† Current marijuana user‡ Rarely or never uses seatbelt§
Always (n = 1443)
Sometimes (n = 5472)
Never (n = 3108)
15.5 18.5 7.3 23.2
17.0 26.0 9.4 30.3
25.4 32.4 13.6 47.2
Female schoolchildren
Current smoker* Consumes alcohol 1+ times/wk† Current marijuana user‡ Rarely or never uses seatbelt§
Always (n = 1775)
Sometimes (n = 5545)
Never (n = 1579)
16.9 15.9 5.2 21.0
22.2 23.1 8.0 25.3
34.0 32.1 12.2 40.6
Chi-square test for trend: P value for all variables ≤.001. *Positive response to:“Do you smoke cigarettes now?” †Response to:“Do you ever drink alcohol (beer, wine, wine coolers, liquor or mixed drinks—even sips?)” ‡Response to:“Have you ever smoked marijuana?” §Answered “rarely or never” to:“Do you wear a seatbelt when riding in a car?”
most likely to engage in these behaviors. Self-reported use of sun protection was also associated with positive attitudes about appearance and self-image among children aged 9 through 12 years. We had few data on such attitudes in older adolescents, but those who never used sun protection were more likely to report depression and dieting. To our knowledge, this is the largest survey to date on sun protection in students of this age group. Although the population was not a random sample of Connecticut schoolchildren, schools serving districts from all socioeconomic strata participated in this survey. In addition, the yearly distribution of gender and race in this sample was similar to that of all children enrolled in grades 4 through 12 in Connecticut public schools for all survey years.10 Therefore we believe that these data are broadly representative of all students in school in Connecticut. Another possible limitation is the reliance on selfreport of sun protection use. However, Lower, Girgis, and Sanson-Fisher11 recently reported high levels of concordance between adolescent selfreport of sunscreen use and their parental report. Because this was a general survey on health risk behaviors, only one question was asked on sun protection. We had no information on the specific type of sun protection behavior (eg, use of clothing, time spent in the shade, use of sunscreen) or on skin type. Thus it is likely that there is some misclassification as to use of sun protection. Furthermore, we
could not consider the adequacy of sun protection. Nevertheless, we believe that the information we had was sufficient to distinguish students who were more or less likely to use sun protection. Our findings are similar to those found elsewhere, although queries about sun protection varied so that results are not directly comparable. Cockburn et al2 found that only 30% of Australian adolescents used adequate sun protection measures. Banks et al3 reported that although 80% of Virginia teenagers spent most summer weekends in the sun, only 26% used sunscreen more than half the time they were in the sun. In a Chicago area survey, only 1 in 8 high school students reported sunscreen use.4 In a national telephone study of sunbathing and sunscreen use, 34% of persons aged 16 to 25 years frequently sunbathed (at least 11 times) in the last year, and only 38% were routine users of sunscreen.12 In a telephone survey of 658 Midwest teenagers (aged 11-19 years), high sunburning rates were reported despite knowledge that sun exposure can cause skin cancer. In the survey, boys were more likely to receive occupational sun exposure, whereas girls were more likely to sunbathe recreationally.13 An emerging literature has begun to document factors associated with childhood and adolescent sun protection practices and sunbathing.1-4,12-25 Factors positively correlated with sunscreen use include parental insistence on sunscreen use, perceived susceptibility to skin damage, hyperreactivity
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Table IV. Psychosocial characteristics of white students by category of sun protection use, Connecticut Health Check Survey, children aged 9-12 years (n = 5723) Male schoolchildren
Currently on a diet* Do you think you are†: Too fat Too thin Just right Do you like yourself†: Most of the time Sometimes Rarely or never How important is it to fit in?† Very Somewhat Not very Felt depressed or unhappy for at least 2 mo in past 6 mo*
Always (n = 742)
Sometimes (n = 1333)
Never (n = 706)
P for trend
19.1
12.2
8.4
.80
9.7 13.0 77.2
7.3 14.2 78.9
12.5 21.6 65.9
.004
86.2 11.8 2.1
82.1 15.4 2.5
73.0 22.7 4.3
.001
30.7 41.2 28.1 5.1
30.9 43.8 25.3 3.2
33.2 40.4 26.4 4.8
.44
.43
Female schoolchildren
Currently on a diet* Do you think you are†: Too fat Too thin Just right Do you like yourself†: Most of the time Sometimes Rarely or never How important is it to fit in?† Very Somewhat Not very Felt depressed or unhappy for at least 2 mo in past 6 mo?*
Always (n = 1054)
Sometimes (n = 1479)
Never (n = 409)
P for trend
22.1
24.6
32.2
.008
8.7 20.6 70.7
7.1 21.3 71.6
7.0 31.8 61.2
.32
79.0 19.0 1.9
71.3 26.1 2.7
58.7 35.3 6.0
.001
29.3 43.7 27.0 2.8
28.9 49.7 21.3 4.0
39.8 35.8 24.4 10.6
.032
.001
*Answered by 1446 boys and 1659 girls who took junior high version of survey. †Answered by 1335 boys and 1283 girls who took preteen version of survey.
of the skin to sunlight, a history of painful sunburn, intentions to use sunscreen, and the belief that sunscreen protects from harmful effects of the sun. Conversely, positive attitudes toward tanning, the feeling that sunbathing is relaxing, perceived lack of susceptibility to skin damage, and valuing physical appearance were predictive of sunbathing. In a study (n = 205) using slides of variably tanned models to determine the effects of suntan on judgments of healthiness and attractiveness, teenagers perceived a “medium tan” as most healthy and attractive and “no tan” as least healthy and attractive. Students had lower ratings for persons who had deliberately
tanned compared with those who tanned during recreation.25 The relationship of adolescent sun protection behavior to social norms set by peers deserves further scrutiny. Teenage sunscreen use is associated with friends’ use of sunscreen and friends’ use of sunbeds and sunbathing. According to the social learning theory, adolescents model their peers’ behavior and alter their practice based on the expected reward or punishment.26 Peers cluster in groups that reinforce the same behaviors; alternative behaviors are often grounds for exclusion from the group. This peer modeling creates the “in” and the “out” groups. In con-
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Table V. Psychosocial characteristics of white students by category of sun protection use, Connecticut Health Check Survey, children aged 13+ years (n = 18,922) Male schoolchildren
Currently on a diet Felt depressed or unhappy for at least 2 mo in past 6 mo?*
Always (n = 1443)
Sometimes (n = 5472)
Never (n = 3108)
P for trend
13.2 3.1
9.0 2.3
10.5 4.2
.091 .001
Female schoolchildren
Currently on a diet Felt depressed or unhappy for at least 2 mo in past 6 mo?*
Always (n = 1775)
Sometimes (n = 5545)
Never (n = 1579)
P for trend
34.0 4.1
32.1 3.6
37.5 6.3
.045 .001
*Answered by 1446 boys and 1659 girls who took junior high version of survey.
veying a public health message to adolescents, it is critical to understand and address the issues of peer modeling and peer pressure.27 The correlation observed here between sun protection use and smoking behavior has been noted elsewhere; in one large survey of adolescents, frequent sunbathers were more likely to be heavy smokers than non-sunbathers14; another survey found that sunscreen was used less frequently by smokers.2 Although our data are on sun protection use, these findings may be in accordance with Keesling and Friedman28 who speculated that sunbathing was associated with a high-risk taking attitude and a lack of harm avoidance. In the current study, subjects who did not use sun protection were more likely to practice other risk behaviors as well; these included rarely wearing a seatbelt or bike helmet and using alcohol and marijuana. Thus not wearing sunscreen may be added to this category of risk behaviors. Several threads might tie together those persons who practice a variety of risky behaviors, including unprotected sun exposure. For those who recognize the danger of a sunburn or smoking, they may actively choose to be self-destructive because of poor self-image and low self-esteem. Some may seek an outlet from stress in their lives or find the warmth of the sun therapeutic, in the same way as they enjoy the “high” of marijuana. The effects of premature aging and skin cancer are typically delayed well beyond the teenage years and may seem too remote to affect current behavior. Finally, sun protection could be one component of an overall mode of health awareness or health behavior that is either accepted or rejected by an adolescent. If an adoles-
cent rejects the notion of health awareness, he or she may engage in health-threatening behaviors that range from smoking and drinking to more modest rebellions like refusal to use sun protection. Further evidence to explain the relationship of diminished self-esteem and risky behavior was found in girls aged 9 to 12 years who never used sun protection. They were more likely to think of “fitting in” as very important. Similarly, boys in this age group were more likely to think of themselves as too fat, which may be a sign of low self-esteem. In addition, older boys and girls who never used sun protection more frequently reported depression, which can be associated with reduced self-esteem and risk-taking behaviors. Conversely, girls who used sun protection were also more likely to report liking themselves “most of the time.” They were less likely to be dieting, which in adolescence can be an early sign of decreased self-esteem. Accordingly, those girls who used sun protection appeared to have a higher selfesteem. It appears that psychosocial variables (fitting in, depression, dieting) are more consistently associated with using sun protection among girls than boys. Conversely, associations between risky behaviors and lack of sun protection appear fairly uniform between boys and girls. Further behavioral research should attempt to identify other associations with sun protection use among boys at all ages as well as documenting the reasons for decreased sun protection with increasing age. Modifying adolescent practice of sun protection will be a daunting task. Even in Australia, where comprehensive sun protection programs have led to profound changes in sun protection use and concomi-
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tant reductions in sunburning,1 adolescents show the fewest improvements in use of sun protection. It is hoped that behavior change programs early in life will have the strongest yield in changing behavior, although these will likely require reinforcement during the teenage years. Numerous epidemiologic studies have linked unprotected sun exposures in youth to melanoma.29 Nonthreatening safe sun messages must be directed to children and adolescents and reinforced over time. Recent interventions have attempted to reach children, parents, and their caregivers in schools and recreational sites (beaches, pools, camps, sporting programs).30 Future educational programs may require innovative campaigns, specifically targeted to boys and perhaps as part of an overall campaign aimed at other risk-taking behaviors. REFERENCES 1. Arthey S, Clarke VA. Suntanning and sun protection: a review of the psychological literature. Soc Sci Med J 1995;40:265-74. 2. Cockburn J, Hennrikus D, Scott R, et al. Adolescent use of sunprotection measures. Med J Aust 1989;151:136-40. 3. Banks BA, Silverman RA, Schwartz RA, et al. Attitudes of teenagers toward sun exposure and sunscreen use. Pediatrics 1992;89:40-2. 4. Mermelstein RJ, Riesenberg LA. Changing knowledge and attitudes about skin cancer risk factors in adolescents. Health Psychol 1992;11:371-6. 5. Coogan PF, Adams M, Geller AC, et al. Factors associated with smoking among children and adolescents in Connecticut. Am J Prev Med 1998;15:17-24. 6. Connecticut State Department of Education. Division of Teaching and Learning. Bureau of Research and Teacher Assessment. Research Bulletin Number 1: Educational Reference Groups, 1996. November 1996. 7. SAS Institute Inc. SAS/STAT User’s Guide, Version 6; vol 2. 4th ed. Cary (NC): SAS Institute; 1990. 8. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Nat Cancer Inst 1959;22: 719-48. 9. Healthy People 2000. National Health Promotion and Disease Prevention Objectives. US Department of Health and Human Services Public Health Service; 1991. 10. Connecticut State Department of Education. Bureau of Evaluation and Student Assessment. Extract of Racial Survey, Public School Enrollment Data in Connecticut. Issued Oct 1, 1996. 11. Lower T, Girgis A, Sanson-Fisher R. How valid is adolescents’ selfreport as a way of assessing sun protection practices? Prev Med 1998;27:385-90.
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12. Koh HK, Bak SM, Geller AC, et al. Sunbathing habits and sunscreen use in 2459 Caucasian adults: results of a national survey. Am J Public Health 1997;87:1214-7. 13. Robinson JK, Rademaker AW, Sylvester JA, et al. Summer sun exposure: knowledge, attitudes, and behaviors of Midwest adolescents. Prev Med 1997;26:364-72. 14. Wichstrom L. Predictors of Norwegian adolescents’ sunbathing and use of sunscreen. Health Psychol 1994;13:412-20. 15. Reynolds KD, Blaum JM, Jester PM, et al. Predictors of sun exposure in adolescents in a southeastern US population. J Adolesc Health 1996;409-15. 16. Hillhouse JJ, Stair AW III, Adler CM. Predictors of sunbathing and sunscreen use in college undergraduates. J Behav Med 1996;19: 543-61. 17. Bennetts K, Borland R, Swerissen H. Sun protection behavior of children and their parents at the beach. Psychol Health 1991;5: 279-87. 18. Zinman R, Schwartz S, Gordon K, et al. Predictors of sunscreen use in childhood. Arch Pediatr Adolesc Med 1995;149:804-7. 19. Hill D, White V, Marks R, Borland R. Changes in sun-related attitudes and behaviours, and reduced sunburn prevalence in a population at high risk of melanoma. Eur J Cancer Prev 1993; 2:447-56. 20. Cody R, Lee C. Behaviors, beliefs, and intentions in skin cancer prevention. J Behav Med 1990;13:373-89. 21. Lowe JB, Balanda KP, Gillespie AM, et al. Sun-related attitudes and beliefs among Queensland school children: the role of gender and age. Aust J Public Health 1993;17:202-8. 22. Hill D, Rassaby J, Gardner G. Determinants of intentions to take precautions against skin cancer. Commun Health Studies 1984; 8:33-44. 23. McGee WS. Adolescence and sun protection. N Z Med J 1992; 105:401-3. 24. Broadstock M, Borland R, Gason R. Effects of suntan on judgments of healthiness and attractiveness by adolescents. J Appl Soc Psychol 1992;22:157-72. 25. Miller AG, Ashton WA, McHoskey JW, et al. What price attractiveness? Stereotype and risk factors in suntanning behavior. J Appl Soc Psychol 1990;15:1272-300. 26. Bandura A. Social learning theory. Morristown (NJ): General Learning Press; 1971. 27. Furby L, Beyth-Marom R. Risk taking in adolescence: a decisionmaking perspective. Dev Review 1992;12:1-44. 28. Keesling B, Friedman HS. Psychosocial factors in sunbathing and sunscreen use. Health Psychol 1987;6:477-93. 29. Koh HK, Geller AC, Miller DR, et al. Skin cancer: prevention and control. In: Greenwald P, Kramer BS, Weed DL, editors. Cancer prevention and control. New York: Marcel Dekker; 1995. p. 611-4. 30. Glanz K, Geller AC, Graffunder C, editors. Health education and behavior: skin cancer prevention for children and their caregivers. Thousand Oaks (CA): Sage Publications; 1999. p. 26.
ISSUES
Sun protection practices in preadolescents and adolescents: A school-based survey of almost 25,000 Connecticut schoolchildren Patricia F. Coogan, ScD,a Alan Geller, RN, MPH,a,b Mary Adams, MS, MPH,d Lori Steinberg Benjes, MD,b and Howard K. Koh, MD, MPHa,b,c Boston, Massachusetts, and Hartford, Connecticut Sun protection practices in children and adolescents fall well below national recommendations. We present the results of a survey of sun protection use and other health-related behaviors in a sample of Connecticut Caucasian students aged 9 through 18 years (N = 24,645). Our objectives were to estimate the prevalence of sun protection use and to evaluate the relationship between sun protection use and health-risk behaviors and attitudes about appearance. We present data from 1988 through 1995 from the Connecticut Health Check, a health risk appraisal survey sponsored by the Connecticut Department of Public Health. Students enrolled in public and private elementary junior as well as senior high schools took the self-administered anonymous survey, which included multiple-choice questions about use of sun protection, cigarettes, and alcohol and about body image and self-esteem. We report prevalence proportions for use of sun protection by demographic features. We compared the proportion of students in 3 categories of outcome (always, sometimes, and never use sun protection) who reported various health-risk behaviors. Twenty percent of the sample reported always using sun protection; this is well below national goals set forth in the Healthy People 2000 recommendations. Sun protection use was inversely related to age and was higher among girls than boys at all ages. At all ages, students who did not use sun protection were more likely than those who did to report other health risk behaviors, such as use of cigarettes and alcohol. The data suggested that use of sun protection is associated with positive attitudes about appearance and self-image. Use of sun protection may be one component of an overall mode of health awareness and behavior. Programs promoting safe sun practices should target boys and be integrated into an overall campaign aimed at other risk-taking behaviors. (J Am Acad Dermatol 2001;44:512-9.)
E
ighty-five percent of skin cancer cases could be prevented by limiting exposure to the sun, but most people still associate a suntan with good health and attractiveness.1-4 Thus it is difficult
From the Department of Epidemiology and Biostatistics, Boston University School of Public Healtha and the Department of Dermatology, Boston University School of Medicineb; the Massachusetts Department of Public Health, Bostonc; and the Connecticut Department of Public Health, Hartford.d Supported by the Environmental Protection Agency, Centers for Disease Control and Prevention, and National Institutes of Health. The opinions and interpretations expressed by Dr Howard K. Koh are his own and do not necessarily reflect those of the Massachusetts Department of Public Health or any of its agents or governing authorities. Reprint requests: Alan Geller, RN, MPH, The Cancer Prevention and Control Center, 720 Harrison Ave, DOB801A, Boston University Medical Center, Boston, MA 02118. E-mail: [email protected]. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/1/111621 doi:10.1067/mjd.2001.111621
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to change attitudes toward sun exposure, especially during adolescence, when much of the damage that can lead to skin cancer occurs.1 Of all age groups, adolescents spend the most time in the sun1-4 and are keenly attuned to their appearance. Therefore it is important to understand patterns of sun protection use in adolescents and children. We present the prevalence of sun protection use in a large sample of Connecticut Caucasian students aged 9 through 18 years enrolled in public and private elementary, junior, and senior high schools. We also evaluated the relationship between sun protection use and health-risk behaviors as well as attitudes about appearance. To our knowledge, this is the largest population of students aged 9 through 18 years surveyed on sun protection.
METHODS Survey Since 1985, the Connecticut Department of Public Health has promoted the use of the
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Table I. Use of sun protection among white students, by gender and age, Connecticut Health Check Survey (N = 24,645) Ages 9-12 Boys No. (%)
Always Sometimes No need No, and burn Total
742 (26.7) 1333 (47.9) 570 (20.5) 136 (4.9) 2781 (100)
Ages 13+ Girls No. (%)
Boys No. (%)
Girls No. (%)
Total No. (%)
1054 (35.8) 1479 (50.3) 293 (10.0) 116 (3.9) 2942 (100)
1443 (14.4) 5472 (54.6) 2768 (27.6) 340 (3.4) 10,023 (100)
1775 (20.0) 5545 (62.3) 1238 (13.9) 341 (3.8) 8899 (100)
5014 (20.3) 13,829 (56.1) 4869 (19.8) 933 (3.8) 24,645 (100)
Connecticut Health Check, a computerized health risk appraisal survey, as a motivational and educational tool for students in grades 4 through 12. In the first 2 years, the program was marketed statewide. Since then, the program has been promoted by informal means, including demonstrations at the annual conference for Connecticut school health educators, by newspaper stories, and by word of mouth. Schools choose to participate in the program, which includes urban, suburban, and rural schools. A more detailed description of the methods has been published elsewhere.5 We present data from 1988 through 1995, which include between 20 and 40 schools each year, with participating schools varying from year to year. The Connecticut State Department of Education has rated all schools according to the socioeconomic status of the areas in which their students live, ranging from A (affluent) to I (low socioeconomic status).6 Schools from each of the 9 socioeconomic categories participated in the survey. Within each school, all students in a selected class (often a health education class) completed a survey of health behaviors that included questions on sun protection, use of cigarettes and alcohol, body image, self-esteem, and a variety of other topics. Three versions of the questionnaire were used (preteen, junior high, and high school versions), with similar but not identical questions. Because the schools chose the version to use, different versions were often used in the same grade. For example, 76% of subjects in grade 6 took the junior high version, whereas 24% took the preteen version. Students recorded answers on a card and then inserted it into an optical scanning device to assure anonymity. A confidential report was immediately generated with a score and suggestions for improvement in health-related behaviors. Sun protection was ascertained by a single question: “Do you protect your skin with a sunscreen or covering so you won’t get a sunburn?” The high school and junior high school versions of the survey
included 5 responses: (1) “no, don’t need to”; (2) “yes—always”; (3) “not always—but I don’t burn”; (4) “not always—and I burn sometimes”; and (5) “don’t protect skin and do burn.” The first two responses were identical on the preteen version, but were followed by only two additional ones: (3) “not always but I tan and don’t burn” and (4) “no—and I burn.” For most analyses we collapsed responses into 3 categories: (1) “yes—always”; (2) “sometimes” (including “not always but I don’t burn” and “not always and I burn”); and (3) “no” (including “no don’t need to” and “no—and I do burn.” Because the incidence of skin cancer is highest among lightly pigmented persons, the study was limited to non-Hispanic white students. Students who answered “white” to a single question with response categories of “white,” “Black,” “Hispanic,” “Asian,” or “other” were included in the study. Of 24,708 total Caucasian students surveyed over the 8 survey years included herein, 63 were excluded because they had incomplete questionnaires or had incompatible ages for their grades (older than the 95th percentile of age for a given grade). The final population included 24,645 non-Hispanic white students. Statistical analysis Crude rates for prevalence of sun protection use over the survey years are reported because ageadjustment did not alter the results. Logistic regression models with a 3-category outcome variable (always, sometimes, never use sun protection) were used to evaluate the effects of age, sex, and survey year, which were included in the model as single terms.7 The proportion of students in 3 categories of sun protection use who reported various health-risk behaviors are compared with the Mantel-Haenszel chi-square test for trend.8 For the latter analyses, we present data for two age categories, 9 through 12 years and 13 through 18 years. Although the prevalence of the health-risk behaviors varied among the younger and older teenagers in the 13- to 18-year
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Fig 1. Percentage of white male and female students who always use sun protection, by age, 1988-1995 (N = 24,645).
Fig 2. Percentage of white male and female students who always use sun protection, by survey year (n = 23,316).
age group, the relationship between the behaviors and sun protection use was comparable.
RESULTS Slightly more than 20% of all Caucasian students reported always using sun protection (Table I); 56% reported sometimes using sun protection, and 20% stated that they had no need for it. Of these latter students, 69% were male and 31% were female. Almost 4% stated that they did not use sun protection although they did burn; of these, 51% were
male and 49% were female. In subsequent analyses, these latter two responses are combined into one category of “never use.” Use of sun protection was inversely related to age, and girls were more likely than boys to use sun protection at all ages (Fig 1). The prevalence of students who reported always using sun protection was highest among 9-year-old girls (47%) and was lowest among 17-year-old boys (11.8%). Among boys and girls, use steadily diminished through age 15, remained relatively stable to age 17, and then began to increase.
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Table II. Percentage of white students in 3 categories of sun protection use who engage in health-risk behaviors, Connecticut Health Check Survey, children aged 9-12 years (n = 5723) Male schoolchildren
Current smoker* Intends to smoke when older† Sometimes/rarely use seatbelt‡ Rarely/never use bike helmet§
Always (n = 742)
Sometimes (n = 1333)
Never (n = 706)
2.3 1.5 22.5 43.7
1.7 2.4 27.1 53.9
5.8 4.3 42.5 69.9
Female schoolchildren
Current smoker* Intends to smoke when older† Sometimes/rarely use seatbelt‡ Rarely/never use bike helmet§
Always (n = 1054)
Sometimes (n = 1479)
Never (n = 409)
1.4 <1 17.7 42.3
2.6 <1 22.3 51.3
6.6 6.0 31.3 66.7
Chi-square test for trend: P value for all variables ≤ .001. *Positive response to:“Do you smoke cigarettes now?” †Positive response to:“Do you think you will smoke when you are older?” ‡Answered “rarely or never” to:“Do you wear a seatbelt when riding in a car?” §Answered “rarely or never” to:“Do you wear a helmet when you ride your bicycle?”
The prevalence of students who report always using sun protection fluctuated over 7 years of the survey among both boys and girls (Fig 2). (The first survey year, 1988, is not included because only ages 9-12 were surveyed that year.) Prevalence of “always use” declined slightly between 1989 and 1990, increased through 1993, then began a modest decline in 1995. Age, sex, and year of survey were statistically significant independent predictors of sun protection use (P for all variables = .0001). Overall, there was a slight upward trend in “always use of sun protection” over these survey years. Among younger students, a higher proportion of those who reported “never” compared with “sometimes” or “always” reported current smoking, intent to smoke, and rarely using a seatbelt or bike helmet (P ≤ .001 for all variables) (Table II). Among older students, “never” users were more likely than “sometimes” or “always” users to consume cigarettes, alcohol, marijuana, and to rarely use a seatbelt (P < .001 for all variables) (Table III). Use of sun protection was related to some variables relevant to self-image (Tables IV and V). Girls aged 9 through 12 years who always used sun protection were less likely to be dieting than were those who never used it (P = .008). There was no such relationship in young boys in whom the overall prevalence of dieting was much lower. However, among boys, those who never used sun protection were more likely to think themselves too fat (P =
.004), whereas there was no difference among girls (P = .32). Among both sexes aged 9 through 12 years, a higher proportion of those who always used sun protection liked themselves “most of the time” than did those who never used it (P = .001 for both sexes). There was no relationship between sun protection use and perception of the importance of “fitting in” (P = .44) or of depression (P = .43) among boys aged 9 through 12 years. However, girls who never used sun protection were more likely to believe that it is very important to fit in (P = .03) and to report depression (P = .001), compared with those who always or sometimes used it. We had information only on dieting and depression among students 13 years and older (Table V). As for the younger students, there was no relationship between dieting and sun protection among boys, but girls who never used sun protection were slightly more likely to be on a diet than were those who always or sometimes used it (P = .045). Depression was more common among “never” users among both boys (P = .001) and girls (P = .001).
DISCUSSION These data suggest that sun protection use among children and adolescents, particularly boys, falls well below national recommendations.9 Students who reported always using sun protection were the least likely to engage in other health-risk behaviors; those who reported never using sun protection were the
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Table III. Percentage of white students in 3 categories of sun protection use who engage in health-risk behaviors, Connecticut Health Check Survey, children aged 13 years and older (n = 18,922) Male schoolchildren
Current smoker* Consumes alcohol 1+ times/wk† Current marijuana user‡ Rarely or never uses seatbelt§
Always (n = 1443)
Sometimes (n = 5472)
Never (n = 3108)
15.5 18.5 7.3 23.2
17.0 26.0 9.4 30.3
25.4 32.4 13.6 47.2
Female schoolchildren
Current smoker* Consumes alcohol 1+ times/wk† Current marijuana user‡ Rarely or never uses seatbelt§
Always (n = 1775)
Sometimes (n = 5545)
Never (n = 1579)
16.9 15.9 5.2 21.0
22.2 23.1 8.0 25.3
34.0 32.1 12.2 40.6
Chi-square test for trend: P value for all variables ≤.001. *Positive response to:“Do you smoke cigarettes now?” †Response to:“Do you ever drink alcohol (beer, wine, wine coolers, liquor or mixed drinks—even sips?)” ‡Response to:“Have you ever smoked marijuana?” §Answered “rarely or never” to:“Do you wear a seatbelt when riding in a car?”
most likely to engage in these behaviors. Self-reported use of sun protection was also associated with positive attitudes about appearance and self-image among children aged 9 through 12 years. We had few data on such attitudes in older adolescents, but those who never used sun protection were more likely to report depression and dieting. To our knowledge, this is the largest survey to date on sun protection in students of this age group. Although the population was not a random sample of Connecticut schoolchildren, schools serving districts from all socioeconomic strata participated in this survey. In addition, the yearly distribution of gender and race in this sample was similar to that of all children enrolled in grades 4 through 12 in Connecticut public schools for all survey years.10 Therefore we believe that these data are broadly representative of all students in school in Connecticut. Another possible limitation is the reliance on selfreport of sun protection use. However, Lower, Girgis, and Sanson-Fisher11 recently reported high levels of concordance between adolescent selfreport of sunscreen use and their parental report. Because this was a general survey on health risk behaviors, only one question was asked on sun protection. We had no information on the specific type of sun protection behavior (eg, use of clothing, time spent in the shade, use of sunscreen) or on skin type. Thus it is likely that there is some misclassification as to use of sun protection. Furthermore, we
could not consider the adequacy of sun protection. Nevertheless, we believe that the information we had was sufficient to distinguish students who were more or less likely to use sun protection. Our findings are similar to those found elsewhere, although queries about sun protection varied so that results are not directly comparable. Cockburn et al2 found that only 30% of Australian adolescents used adequate sun protection measures. Banks et al3 reported that although 80% of Virginia teenagers spent most summer weekends in the sun, only 26% used sunscreen more than half the time they were in the sun. In a Chicago area survey, only 1 in 8 high school students reported sunscreen use.4 In a national telephone study of sunbathing and sunscreen use, 34% of persons aged 16 to 25 years frequently sunbathed (at least 11 times) in the last year, and only 38% were routine users of sunscreen.12 In a telephone survey of 658 Midwest teenagers (aged 11-19 years), high sunburning rates were reported despite knowledge that sun exposure can cause skin cancer. In the survey, boys were more likely to receive occupational sun exposure, whereas girls were more likely to sunbathe recreationally.13 An emerging literature has begun to document factors associated with childhood and adolescent sun protection practices and sunbathing.1-4,12-25 Factors positively correlated with sunscreen use include parental insistence on sunscreen use, perceived susceptibility to skin damage, hyperreactivity
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Table IV. Psychosocial characteristics of white students by category of sun protection use, Connecticut Health Check Survey, children aged 9-12 years (n = 5723) Male schoolchildren
Currently on a diet* Do you think you are†: Too fat Too thin Just right Do you like yourself†: Most of the time Sometimes Rarely or never How important is it to fit in?† Very Somewhat Not very Felt depressed or unhappy for at least 2 mo in past 6 mo*
Always (n = 742)
Sometimes (n = 1333)
Never (n = 706)
P for trend
19.1
12.2
8.4
.80
9.7 13.0 77.2
7.3 14.2 78.9
12.5 21.6 65.9
.004
86.2 11.8 2.1
82.1 15.4 2.5
73.0 22.7 4.3
.001
30.7 41.2 28.1 5.1
30.9 43.8 25.3 3.2
33.2 40.4 26.4 4.8
.44
.43
Female schoolchildren
Currently on a diet* Do you think you are†: Too fat Too thin Just right Do you like yourself†: Most of the time Sometimes Rarely or never How important is it to fit in?† Very Somewhat Not very Felt depressed or unhappy for at least 2 mo in past 6 mo?*
Always (n = 1054)
Sometimes (n = 1479)
Never (n = 409)
P for trend
22.1
24.6
32.2
.008
8.7 20.6 70.7
7.1 21.3 71.6
7.0 31.8 61.2
.32
79.0 19.0 1.9
71.3 26.1 2.7
58.7 35.3 6.0
.001
29.3 43.7 27.0 2.8
28.9 49.7 21.3 4.0
39.8 35.8 24.4 10.6
.032
.001
*Answered by 1446 boys and 1659 girls who took junior high version of survey. †Answered by 1335 boys and 1283 girls who took preteen version of survey.
of the skin to sunlight, a history of painful sunburn, intentions to use sunscreen, and the belief that sunscreen protects from harmful effects of the sun. Conversely, positive attitudes toward tanning, the feeling that sunbathing is relaxing, perceived lack of susceptibility to skin damage, and valuing physical appearance were predictive of sunbathing. In a study (n = 205) using slides of variably tanned models to determine the effects of suntan on judgments of healthiness and attractiveness, teenagers perceived a “medium tan” as most healthy and attractive and “no tan” as least healthy and attractive. Students had lower ratings for persons who had deliberately
tanned compared with those who tanned during recreation.25 The relationship of adolescent sun protection behavior to social norms set by peers deserves further scrutiny. Teenage sunscreen use is associated with friends’ use of sunscreen and friends’ use of sunbeds and sunbathing. According to the social learning theory, adolescents model their peers’ behavior and alter their practice based on the expected reward or punishment.26 Peers cluster in groups that reinforce the same behaviors; alternative behaviors are often grounds for exclusion from the group. This peer modeling creates the “in” and the “out” groups. In con-
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Table V. Psychosocial characteristics of white students by category of sun protection use, Connecticut Health Check Survey, children aged 13+ years (n = 18,922) Male schoolchildren
Currently on a diet Felt depressed or unhappy for at least 2 mo in past 6 mo?*
Always (n = 1443)
Sometimes (n = 5472)
Never (n = 3108)
P for trend
13.2 3.1
9.0 2.3
10.5 4.2
.091 .001
Female schoolchildren
Currently on a diet Felt depressed or unhappy for at least 2 mo in past 6 mo?*
Always (n = 1775)
Sometimes (n = 5545)
Never (n = 1579)
P for trend
34.0 4.1
32.1 3.6
37.5 6.3
.045 .001
*Answered by 1446 boys and 1659 girls who took junior high version of survey.
veying a public health message to adolescents, it is critical to understand and address the issues of peer modeling and peer pressure.27 The correlation observed here between sun protection use and smoking behavior has been noted elsewhere; in one large survey of adolescents, frequent sunbathers were more likely to be heavy smokers than non-sunbathers14; another survey found that sunscreen was used less frequently by smokers.2 Although our data are on sun protection use, these findings may be in accordance with Keesling and Friedman28 who speculated that sunbathing was associated with a high-risk taking attitude and a lack of harm avoidance. In the current study, subjects who did not use sun protection were more likely to practice other risk behaviors as well; these included rarely wearing a seatbelt or bike helmet and using alcohol and marijuana. Thus not wearing sunscreen may be added to this category of risk behaviors. Several threads might tie together those persons who practice a variety of risky behaviors, including unprotected sun exposure. For those who recognize the danger of a sunburn or smoking, they may actively choose to be self-destructive because of poor self-image and low self-esteem. Some may seek an outlet from stress in their lives or find the warmth of the sun therapeutic, in the same way as they enjoy the “high” of marijuana. The effects of premature aging and skin cancer are typically delayed well beyond the teenage years and may seem too remote to affect current behavior. Finally, sun protection could be one component of an overall mode of health awareness or health behavior that is either accepted or rejected by an adolescent. If an adoles-
cent rejects the notion of health awareness, he or she may engage in health-threatening behaviors that range from smoking and drinking to more modest rebellions like refusal to use sun protection. Further evidence to explain the relationship of diminished self-esteem and risky behavior was found in girls aged 9 to 12 years who never used sun protection. They were more likely to think of “fitting in” as very important. Similarly, boys in this age group were more likely to think of themselves as too fat, which may be a sign of low self-esteem. In addition, older boys and girls who never used sun protection more frequently reported depression, which can be associated with reduced self-esteem and risk-taking behaviors. Conversely, girls who used sun protection were also more likely to report liking themselves “most of the time.” They were less likely to be dieting, which in adolescence can be an early sign of decreased self-esteem. Accordingly, those girls who used sun protection appeared to have a higher selfesteem. It appears that psychosocial variables (fitting in, depression, dieting) are more consistently associated with using sun protection among girls than boys. Conversely, associations between risky behaviors and lack of sun protection appear fairly uniform between boys and girls. Further behavioral research should attempt to identify other associations with sun protection use among boys at all ages as well as documenting the reasons for decreased sun protection with increasing age. Modifying adolescent practice of sun protection will be a daunting task. Even in Australia, where comprehensive sun protection programs have led to profound changes in sun protection use and concomi-
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tant reductions in sunburning,1 adolescents show the fewest improvements in use of sun protection. It is hoped that behavior change programs early in life will have the strongest yield in changing behavior, although these will likely require reinforcement during the teenage years. Numerous epidemiologic studies have linked unprotected sun exposures in youth to melanoma.29 Nonthreatening safe sun messages must be directed to children and adolescents and reinforced over time. Recent interventions have attempted to reach children, parents, and their caregivers in schools and recreational sites (beaches, pools, camps, sporting programs).30 Future educational programs may require innovative campaigns, specifically targeted to boys and perhaps as part of an overall campaign aimed at other risk-taking behaviors. REFERENCES 1. Arthey S, Clarke VA. Suntanning and sun protection: a review of the psychological literature. Soc Sci Med J 1995;40:265-74. 2. Cockburn J, Hennrikus D, Scott R, et al. Adolescent use of sunprotection measures. Med J Aust 1989;151:136-40. 3. Banks BA, Silverman RA, Schwartz RA, et al. Attitudes of teenagers toward sun exposure and sunscreen use. Pediatrics 1992;89:40-2. 4. Mermelstein RJ, Riesenberg LA. Changing knowledge and attitudes about skin cancer risk factors in adolescents. Health Psychol 1992;11:371-6. 5. Coogan PF, Adams M, Geller AC, et al. Factors associated with smoking among children and adolescents in Connecticut. Am J Prev Med 1998;15:17-24. 6. Connecticut State Department of Education. Division of Teaching and Learning. Bureau of Research and Teacher Assessment. Research Bulletin Number 1: Educational Reference Groups, 1996. November 1996. 7. SAS Institute Inc. SAS/STAT User’s Guide, Version 6; vol 2. 4th ed. Cary (NC): SAS Institute; 1990. 8. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Nat Cancer Inst 1959;22: 719-48. 9. Healthy People 2000. National Health Promotion and Disease Prevention Objectives. US Department of Health and Human Services Public Health Service; 1991. 10. Connecticut State Department of Education. Bureau of Evaluation and Student Assessment. Extract of Racial Survey, Public School Enrollment Data in Connecticut. Issued Oct 1, 1996. 11. Lower T, Girgis A, Sanson-Fisher R. How valid is adolescents’ selfreport as a way of assessing sun protection practices? Prev Med 1998;27:385-90.
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12. Koh HK, Bak SM, Geller AC, et al. Sunbathing habits and sunscreen use in 2459 Caucasian adults: results of a national survey. Am J Public Health 1997;87:1214-7. 13. Robinson JK, Rademaker AW, Sylvester JA, et al. Summer sun exposure: knowledge, attitudes, and behaviors of Midwest adolescents. Prev Med 1997;26:364-72. 14. Wichstrom L. Predictors of Norwegian adolescents’ sunbathing and use of sunscreen. Health Psychol 1994;13:412-20. 15. Reynolds KD, Blaum JM, Jester PM, et al. Predictors of sun exposure in adolescents in a southeastern US population. J Adolesc Health 1996;409-15. 16. Hillhouse JJ, Stair AW III, Adler CM. Predictors of sunbathing and sunscreen use in college undergraduates. J Behav Med 1996;19: 543-61. 17. Bennetts K, Borland R, Swerissen H. Sun protection behavior of children and their parents at the beach. Psychol Health 1991;5: 279-87. 18. Zinman R, Schwartz S, Gordon K, et al. Predictors of sunscreen use in childhood. Arch Pediatr Adolesc Med 1995;149:804-7. 19. Hill D, White V, Marks R, Borland R. Changes in sun-related attitudes and behaviours, and reduced sunburn prevalence in a population at high risk of melanoma. Eur J Cancer Prev 1993; 2:447-56. 20. Cody R, Lee C. Behaviors, beliefs, and intentions in skin cancer prevention. J Behav Med 1990;13:373-89. 21. Lowe JB, Balanda KP, Gillespie AM, et al. Sun-related attitudes and beliefs among Queensland school children: the role of gender and age. Aust J Public Health 1993;17:202-8. 22. Hill D, Rassaby J, Gardner G. Determinants of intentions to take precautions against skin cancer. Commun Health Studies 1984; 8:33-44. 23. McGee WS. Adolescence and sun protection. N Z Med J 1992; 105:401-3. 24. Broadstock M, Borland R, Gason R. Effects of suntan on judgments of healthiness and attractiveness by adolescents. J Appl Soc Psychol 1992;22:157-72. 25. Miller AG, Ashton WA, McHoskey JW, et al. What price attractiveness? Stereotype and risk factors in suntanning behavior. J Appl Soc Psychol 1990;15:1272-300. 26. Bandura A. Social learning theory. Morristown (NJ): General Learning Press; 1971. 27. Furby L, Beyth-Marom R. Risk taking in adolescence: a decisionmaking perspective. Dev Review 1992;12:1-44. 28. Keesling B, Friedman HS. Psychosocial factors in sunbathing and sunscreen use. Health Psychol 1987;6:477-93. 29. Koh HK, Geller AC, Miller DR, et al. Skin cancer: prevention and control. In: Greenwald P, Kramer BS, Weed DL, editors. Cancer prevention and control. New York: Marcel Dekker; 1995. p. 611-4. 30. Glanz K, Geller AC, Graffunder C, editors. Health education and behavior: skin cancer prevention for children and their caregivers. Thousand Oaks (CA): Sage Publications; 1999. p. 26.