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Primary school-based health promotion program for increasing sun protection behaviors

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Title:
Primary school-based health promotion program for increasing sun protection behaviors
Creator:
Hoffmann, Russell Gilbert, 1968-
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English
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viii, 86 leaves : ; 29 cm.

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Subjects / Keywords:
Adolescents ( jstor )
Child psychology ( jstor )
Control groups ( jstor )
Disease risks ( jstor )
Health promotion ( jstor )
Psychoeducational intervention ( jstor )
Questionnaires ( jstor )
Skin ( jstor )
Skin cancers ( jstor )
Sunscreening agents ( jstor )
Child ( mesh )
Health Behavior ( mesh )
Health Knowledge, Attitudes, Practice ( mesh )
Health Promotion ( mesh )
Infant ( mesh )
Neoplasms -- prevention & control ( mesh )
Patient Education ( mesh )
School Health Services ( mesh )
Sunlight -- adverse effects ( mesh )
Sunscreening Agents -- utilization ( mesh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1995.
Bibliography:
Includes bibliographical references (leaves 80-85).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Russell Gilbert Hoffmann III.

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University of Florida
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Permission granted to the University of Florida to digitize, archive and distributed this item for non-profit and educational purposes only. Any reuse of this item in excess of fair use requires permission of the copyright holder.
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ocm49645337

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PRIMARY SCHOOL-BASED HEALTH PROMOTION PROGRAM
FOR INCREASING SUN PROTECTION BEHAVIORS
















By

RUSSELL G. HOFFMANN III





















A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTORATE OF PHILOSOPHY UNIVERSITY OF FLORIDA 1995













ACKNOWLEDGEMENTS

This dissertation, as well as the work I have

accomplished over the past several years, has been greatly influenced by the two chairmen of my dissertation, Jim Rodrigue and Jim Johnson. I would like to thank Dr. Rodrigue for his support, motivating enthusiasm, and friendship, both on and off the professional "court." I thank Dr. Johnson for his thought-provoking supervision and encouragement to go well beyond mediocrity. Both of these gentlemen have invested their time and resources in me and have fostered my development as a clinical psychologist, as well as a person, for which I am deeply indebted. Also, I wish to acknowledge and thank my supervisory committee, Drs. Stephen Boggs, Gary Geffken, and John Newell for their helpful comments and suggestions.

Few worthwhile tasks are accomplished in life without the help of family and friends. First, I wish to thank my mother, Jeanne Hoffmann, whose personal sacrifices and love provided me with a bounty of opportunities and experiences from which to grow. Moreover, my sisters, in-laws, and life-long friends have each contributed, via encouragement and support, to the successes which I have experienced. Also noteworthy is the friendship and support of my fellow graduate students. In particular, I wish to thank Sam F. Sears Jr. for his comraderie and support in weathering the ii














best and most difficult times of graduate school; boy, did we grow up!

Finally, I thank my wife, Beth, for her love,

friendship, and commitment to our relationship. Together, we tackled the graduate school "monster," and I look forward to reaping the rewards and experiences of life with her.

I am a fortunate individual for having so many generous, caring people in my life.














TABLE OF CONTENTS

PAGE

ACKNOWLEDGEMENTS ............................... ....... ii

LIST OF TABLES ......................................... vi

ABSTRACT ............................................... Vii

CHAPTERS

I REVIEW OF LITERATURE ......................... 1

Skin Cancer .................................. 2
Skin Cancer Information ................. 2
The What, Who, When, and Where of Skin
Cancer ................................ 5
Knowledge and Attitudes Toward Sun Exposure
and Sun Protection Behavior ................ 9
History of Sun Exposure ................. 9
Research on Sun Exposure Habits ......... 10
Skin Cancer Risk Reduction Intervention
Studies .................................... 13
Knowledge-Based Interventions ........... 13
Knowledge and Attitude-Based
Interventions ......................... 16
Sun Protection Interventions Targeting
Children and Adolescents .............. 21
School-Based Health Promotion Interventions.. 26 Theories of Behavior Change .................. 34

II PURPOSE OF STUDY AND HYPOTHESES .............. 40

Purpose ................................. 40
Hypotheses .............................. 41

III METHODS ...................................... 42

Subjects ..................................... 42
Measures ..................................... 42
Knowledge Scale ......................... 45
Attitudes and Beliefs Scale ............. 45
Intentions Scale ........................ 46
Behavior Scale .......................... 46
Permanent Products Index ................ 47
State-Trait Anxiety Inventory for
Children .............................. 48



iv








Child-Rated Skin Type Questionnaire 48
Procedures..................................... 49



Preliminary Analyses ...... o............... 53
Intervention Effectiveness. ............. ...... 53
Intervention Group: Pre-Post Differences .... 54 Multiple Regression Anase ly.....es. 56

V DISCUSSION ...................................... 64

Strengths and Limitations of the Present
Study......................................... 75
Implications of Findings ... .......... o.... 78

REFERENCES .......................... ... ........ .. .. 86

BIOGRAPHICAL SKETCH .....o.......... .. .. .. .. .. .. 95





































v













LIST OF TABLES


Table Pacie

1 Demographic Data ............................. 43

2 Means and Standard Deviations of Knowledge
Score Attitudes and Beliefs Score,
IntenLons Score, and Behavior Score for Intervention and Control Groups and Preand Post-Intervention Assessments ............ 55

3 Hierarchical Multiple Regression Analyses
Evaluating the Contribution of Demographic
Variables and Sun Protection Measures in
Predicting Intentions Score for the
Intervention Group ........................... 58

4 Hierarchical Multiple Regression Analyses
Evaluating the Contribution of Demographic
Variables and Sun Protection Measures in
Predicting Behavior Score for the
Intervention Group ........................... 59

5 Hierarchical Multiple Regression Analyses
Evaluating the Contribution of Demographic
Variables and Sun Protection Measures in
Predicting Intentions Score for the Control
Group ........................................ 60

6 Hierarchical Multiple Regression Analyses
Evaluating the Contribution of Demographic
Variables and Sun Protection Measures in Predicting Behavior Score for the Control
Group ........................................ 61













vi














Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

PRIMARY SCHOOL-BASED HEALTH PROMOTION PROGRAM
FOR INCREASING SUN PROTECTION BEHAVIORS By

RUSSELL G. HOFFMANN III

August 1995

chairman: James H. Johnson cochairman: James R. Rodrigue Major Department: Clinical and Health Psychology

The rate of newly diagnosed skin cancer malignancies has increased dramatically over the past several decades. This increase is largely attributed to ultraviolet radiation exposure. Moreover, sun exposure during childhood has been linked to higher incidence rates of skin cancer in adulthood. Sun exposure throughout life, especially during childhood, is primarily a behavior individuals choose to engage in. Therefore, it is reasonable to conclude that promoting healthy sun-exposure habits will likely result in a reduction of skin cancer rates, particularly if the intervention is introduced during childhood.

The present study examined the effectiveness of a

theory-driven, multimodal intervention to promote safe sunexposure behaviors in elementary school students. One of two schools was randomly assigned to receive the


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intervention (n 128)j while the other served as a nointervention control group (n 97). Results indicated that the intervention significantly increased sun exposure knowledge, intentions to wear sunscreen, and self-reported sunscreen use at a two-week post-intervention assessment. Attitudes and beliefs towards sun protective behaviors predicted intentions to wear sunscreen for both groups and reported sunscreen use for the intervention group, only. Pre-intervention sunscreen use predicted post-intervention sunscreen use for both groups. Generally, the present study provides valuable information for directing future intervention efforts to increase sunscreen use in children.






























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CHAPTER I
REVIEW OF LITERATURE


Skin cancer is now the most common malignancy in the United States (American Cancer Society, 1988; Glass & Hoover, 1989; Williams & Pennella, 1994). The deadliest form.of skin cancer, malignant melanoma, is increasing at a rate higher than any other form of cancer (Friedman, Rigel, Silverman, Kopf, & Vossaert, 1991). Of the 600,000 individuals who are diagnosed with skin cancer each year, most can be treated successfully; however, several thousand cases are terminal (American Cancer Society, 1988). In addition to the human cost, there is an exorbitant financial cost in treating individuals with skin cancer (Keesling & Friedman, 1987).

Ninety-five percent of skin cancers are attributed to ultraviolet radiation exposure (Skolnick, 1991), both intentional (e.g., sun tanning) and unintentional (e.g., outdoor occupation). Moreover, sun exposure during childhood has been linked to higher skin cancer incidence rates (Truhan, 1991). Of increasing concern are recent scientific findings suggesting that the intensity of ultraviolet radiation exposure may be increasing due to ozone depletion (Amron & Moy, 1991). If the ozone layer is thinning, skin cancer rates and deaths with this disease are estimated to skyrocket (Skolnick, 1991).

1




2


In light of the foregoing, interventions designed to

increase healthy sun-exposure behaviors, particularly during childhood, may prove beneficial in reducing skin cancer rates. Therefore, the purpose of this study is to examine the efficacy of an intervention designed to increase sun exposure knowledge and modify beliefs, intentions, and behaviors associated with ultraviolet radiation exposure. The study is designed to address one of Logan Wright's (1967) founding tenets of pediatric psychology, i.e., prevention, and, more recently, Robert's (1985) call for health promotion studies to promote and improve the quality of life during childhood and adulthood.

Skin Cancer

Skin Cancer Information

The skin, weighing approximately 6 pounds and comprised of two layers, is the largest organ in the human body (National Cancer Institute, 1990). The epidermis is the outer layer of skin and is composed of squamous cells (top layer) and basal cells (bottom layer). At the deepest layer of the epidermis, melanocytes can be found. Melanocytes produce melanin which gives the skin its color. The dermis lies under the epidermis, and contains supportive structures for the skin, such as sweat glands, blood and lymph vessels, and hair follicles. The function of the skin is to protect the body from several damaging agents, such as the heat, infection, and light (1990). In addition, the skin benefits the body in many ways, such as assisting in regulating body temperature and gathering vitamin D. Like other organs, the




3


skin is susceptible to many diseases, of which skin cancer is the most dangerous.

Skin cancer is the most common type of cancer, with

over 600,000 new detections per year (ACS, 1988). Cells in the body undergo normal, controlled processes of growth and division to replace dying cells and repair damaged areas (NCI, 1990). However, cells in the body, at times, lose their ability to regulate the natural process of growth and division (NCI, 1990). Cells that grow rapidly and/or out of control produce tumors, or groups of abnormal cells. Tumors can be either benign or malignant. Benign tumors are not cancerous, and instead, tend to develop without spreading throughout the body and seldom pose a serious health threat. Malignant tumors are cancerous, meaning that they damage healthy tissues, and tend to spread throughout the body (i.e., metastasize). Skin cancer, then, refers to malignant tumors in skin cells. There are several types of skin cancer that are defined by the cell type which is affected. Specifically, there are squamous cell and basal cell cancers, and cancer occurring in the melanocytes, formally known as malignant melanoma (NCI, 1990).

Basal cell and squamous cell cancers are much more

common than melanoma, and typically are not a serious health risk because they rarely metastasize. Basal cell malignancies usually are small, slow growing bumps or nodules that occur on frequently exposed areas of skin (i.e., head, neck, hands) (ACS, 1985). Although typically not life threatening, if this form of cancer is left




4


untreated, it often continues to grow, damaging adjacent tissue. The second most common form of skin cancer, squamous cell carcinoma, also occurs on frequently exposed areas of the skin and appears as red blotches. Although not typically life threatening, this form of cancer differs from basal cell carcinoma in that it can spread to other areas of the skin.

The most dangerous form of skin cancer is malignant

melanoma which accounts for 75% of skin cancer deaths (ACS, 1992). The American Cancer Society (1992) estimated that 21% of the 32,000 new cases of melanoma in 1992 would be fatal. What makes malignant melanoma more lethal than the two other forms of skin cancer is the abnormal cell's tendency to break away from the original tumor, travel through the lymphatic system and bloodstream, and spread throughout the body (NCI, 1990). The spread of melanoma usually results in damage to other vital organs, often resulting in death.

Changes in the prevalence rate of malignant melanoma over the past decade have been staggering. In the United States, malignant melanoma has increased 1500% over the past 50 years (ACS, 1992; Williams & Pennella, 1994). During the 1930's 1 in 1,500 persons developed malignant melanoma during their lifetime, and now the current estimate in about 1 in 120 (Hurwitz, 1988). By the year 2000, it is estimated that 1 in 90 persons will develop skin cancer during their life (ACS, 1992). The reason for this dramatic rise in melanoma is only starting to be understood, but one known




5


contributing factor is increased ultraviolet radiation exposure.

The What, Who. When, and Where of skin Cancer

Several factors are believed to be related to the

etiology of skin cancer. There are endogenous factors, such as family history of skin cancer, and the prevalence of moles (i.e., nevi), that appear to increase vulnerability for some individuals (these will be covered in next section). Exogenous, or environmental factors, appear to play a primary role in the development of skin cancer. Exposure to toxins, such as caustic materials found in factories, appears to play a minor role in the development of skin malignancies (DeLeo, 1988). However, the major exogenous factor increasing skin cancer risk is sun exposure (Council on Scientific Affairs, 1989; MacKie, Freudenberger, & Aitchison, 1989; Sober, 1986; Truhan, 1991). Ultraviolet radiation exposure can cause erythema and sunburn, which are short-term insults to the skin, or more long-term damage, such as photoaging, alteration of the immune system, and skin cancer (Council on Scientific Affairs, 1989). Leading exogenous risk factors for developing skin cancer include childhood sunburns, primary indoor work with frequent outdoor exposure (i.e., outdoor recreation), and overall frequency of sun exposure (MacKie et al., 1989). The effects of solar radiation on the skin are well documented, and their role in damaging the skin and in the development of skin cancer is becoming increasingly apparent.




6


As noted previously, there are several endogenous

factors that place individuals at risk for developing skin cancer. For instance, a family history of malignant melanoma combined with atypical moles, i.e., dysplastic nevi, increases one's risk of skin cancer (Friedman et al., 1991; MacKie et al., 1989) and accounts for approximately. 5% of melanomas (Mackie et al., 1989). Other more common risk factors that account for a greater percentage of skin cancer cases include increased number of nevi and presence of freckles, ethnic characteristics (e.g., fair skin, blond or red hair, and blue eyes), and living close to the equator (MacKie et al., 1989). Thus, many individuals are at risk for developing skin cancer due to biological variables, over which they have no control. However, many individuals choose to place themselves at even higher risk for skin cancer by engaging in behaviors that expose them to a primary cause of skin cancer: the sun.

Although most people are exposed to exogenous risk factors, such as the sun, throughout their life, the majority of sun exposure primarily occurs during childhood and adolescence. However, skin cancer may not present itself for several decades following exposure to exogenous risk factors. The majority of detected skin cancers occur after age 30, and more commonly after age 50 (Kirkpatrick, Lee, and White, 1990). This time-lag between the cause (sun exposure) and effect (skin cancer) interferes with the association between the two, thus making prevention difficult.




7


Skin cancers develop on all areas of the skin (Council on Scientific Affairs, 1989). In addition, skin cancer sites differ by gender, with women having more skin cancers on the arms and lower legs, and men developing more skin cancers between the hips and shoulders and on the head and neck (NCI, 1990). Skin cancers are usually detected by either physicians, or by individuals educated on the ABCD's of skin cancer detection. The ABCD of skin cancer detection stands for: A-asymmetry, meaning that one part of the nevi does not match the other; B-border, meaning that the border is uneven; C-color, meaning that the color of the nevi is uneven; and D-diameter, denoting the change in size of the nevi (NCI, 1990). Detection of skin cancer at its earliest stages is crucial for minimizing long-term health problems.

Treatment of skin cancer depends on malignancy type and stage of development. Most skin carcinomas at early stages of development can be removed via surgical resection, with minimal complications (NCI, 1990). However, more advanced stages of skin cancer may require a combination of nevi resection and chemotherapy or radiation therapy. Overall, a considerable amount of health care resources is being spent on a disease whose prevalence could be dramatically reduced if a primary prevention approach was taken instead of the traditional tertiary care approach.

Prevention of skin cancer consists of educating people regarding endogenous and exogenous risk factors, and making specific behavioral changes to reduce exposure to risk factors. Education consists of reviewing the previously




8


mentioned information regarding skin cancer, and targeting specific groups which can maximize their risk reduction. For example, given that severe sunburn during childhood and adolescence increases risk for development of skin cancer, if the sun exposure behaviors of children and'adolescents could be modified so that they avoided getting sunburns, then it is reasonable to conclude that skin cancer rates would decline. Furthermore, if exposure time could be reduced, especially during peak sun hours, then incidence rates would likely decline further.

Risk reduction has assumed center stage in the battle against skin cancer. Several cancer institutes and government health agencies have produced skin cancer informational brochures. It is generally agreed upon that several 11sunsafell or 11sunsmart" behaviors can be used to reduce one's ultraviolet radiation exposure. These preventive behaviors include: 1) wearing protective clothing (e.g., long-sleeve shirts, pants, and hats); 2) wearing a sun screen with a sun protection factor (SPF) of at least 15; 3) refraining from sun exposure between 10:00 A.M. and 3:00 P.M.; and 4) reducing overall exposure to sun, especially during early childhood (ACS, 1992; Council on Scientific Affairs, 1989; NCI, 1990; Skolnick, 1991). Reduction in the prevalence and severity of skin cancer, then, appears to be a function of increasing knowledge about skin cancer, and decreasing high risk behaviors. Indeed, Stern, Weinstein, and Baker (1986) found that regular sunscreen (SPF 15) use during childhood and adolescence




9


could reduce the lifetime nonmelanoma incidence rates by 78 percent.

As has been reviewed in this section, skin cancer is a formidable health problem that no one is immune to, and some are at high risk. Its human and economic costs are increasing exponentially. Fortunately, skin cancer is preventable if sun exposure behaviors are modified, especially during childhood and adolescence. Next, research related to sun exposure and sun protection interventions will be reviewed.



Knowledge and Attitudes Toward Sun Exposure
and Sun Protection Behaviors History of Sun Exposure

Society's interest in exposing themselves to the sun. has a fascinating and colorful past (see review by Keesling & Friedman, 1987). Before the 1900s, the more pale a person's skin, the higher their perceived social standing. Pale skin was an indicator of higher social status because members of the lower class were more likely to work outdoors and, consequently, be tanned. However, beginning with the Industrial Revolution, members of the lower class began to work indoors, and degree of tanning no longer served to differentiate the social classes. Keeling and Friedman (1987) identified three factors that changed society's view towards skin color. First, in the early 1900's, pale skin became associated with poor health and physical illness (e.g., tuberculosis), whereas a tan was




10


associated with overall good health. Second, the upper classes' reaction to the Industrial Revolution was to embrace tanned skin as an index of one's higher social status and ability to spend outdoor leisure time in sports. A final influence was the work of a French fashion designer who promoted tanned skin and a sunburn as a fashion statement.

Although only a few decades passed before the healthy benefits of sun exposure were debunked, and some physicians spoke out that sunbathing was actually a health danger, the social climate still promoted suntanning (Keesling & Friedman, 1987). Only over the past three decades have sunscreens been developed, and the general public has only recently started to recognize the risks associated with sun exposure. However, millions of people around the world still continue to engage in behaviors that increase their exposure to the harmful effects of ultraviolet radiation. The following section will review research examining factors related to sunbathing, and variables related to sunsmart behavior, or sun protective behaviors. Research on Sun Exposure Practices

Several recent studies suggest that knowledge of sun exposure dangers is fairly high among adults (Johnson & Lookingbill, 1984; Hill et al., 1992) as well as adolescents (Hill et al., 1992). Despite these rapidly expanding educational efforts, unhealthy attitudes towards the effects of sun exposure (i.e., suntans look good) are commonplace (e.g., Grob et al., 1993; Keesling & Friedman, 1987).




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Moreover, adults, adolescents and young children continue to spend considerable amounts of time outdoors during peak sun hours (e.g., Grob et al., 1993; Hill et al., 1992; Johnson& Lookingbill, 1984). While outdoors, children do not use sunscreen regularly (e.g., Banks, Silverman, Schwartz, & Tunnessen, 1992; Hill et al., 1992;), and most children and adolescents have experienced at least one, if not more, sunburns (e.g., Banks et al., 1992; Johnson & Lookingbill, 1984). Even those who routinely use sunscreen often do not reapply it when it is recommended (e.g., after swimming; Banks et al., 1992).

Several factors appear to be related to children and adolescent sunscreen use. Females tend to practice sun protective behaviors more frequently than males (e.g., Banks et al., 1992; Johnson & Lookingbill, 1984; Mermelstein & Reisenberg, 1992), as do individuals whose friends use sunscreen (e.g., Banks et al., 1992; Keesling & Friedman, 1987). Moreover, parents of children having negative sun exposure experiences (e.g., sunburns) were more likely to put sunscreen on their children (Maducoc, Wagner, & Wagner, 1992). Finally, children and adolescents having high sensitivity skin types (i.e. lighter skin tone that burns easily; Weinstock, 1992) used sunscreen more often than children and adolescents with low sensitivity skin types (e.g., Banks et al., 1992; Grob et al., 1993; Mermelstein & Reisenberg, 1992). However, it should be noted that individuals tend to underrate their skin sensitivity (Grob et al., 1992).




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As can be seen, sun exposure has an interesting history in our society, and is a significant part of leisure activities for children, adolescents, and adults. Sun exposure has been viewed as a healthy behavior in the past, and only recently has information regarding the risks of ultraviolet radiation been fully determined and disseminated. It is not surprising that there is only a moderate knowledge base related to sun exposure and skin cancer, and many people are unaware of particularly salient information, such as SPF and effective sun protective behaviors. Although skin cancer information and its prevention are important, many researchers have noted that knowledge is not sufficient for increasing sun protective behaviors.

A particular subset of the population, Caucasian

children and adolescents, have been identified as the most likely to engage in risky sun exposure behaviors, and are most susceptible to skin cancer. This subset is most likely to benefit from sun protection interventions. Researchers have concluded that the use of sun protective behaviors would reduce the probability of sunburning, as well as longer term dangers of sun-exposure (i.e. skin cancer). Moreover, many authors have stressed that intervention programs should be targeted towards younger people since they engage most often in risky sun-exposure behaviors, and because reduction in sun exposure rates during childhood are most likely to reduce rates of skin cancer during adulthood.




13


Issues that have been recognized as particularly

difficult to address in this population have been modifying positive attitudes towards sun exposure, lack of immediate cause and effect relationship between sun exposure and skin cancer, and overall lack of awareness about sun exposure dangers. Variables that have been described as potentially useful in overcoming these challenges have been the inclusion of parents in interventions, altering social attitudes about sun exposure, and increasing knowledge of children and their caregivers about ultraviolet radiation dangers. The following chapter will examine the utility of these variables, as well as others, in changing the beliefs, attitudes, and behaviors associated with the practice of sun protective behaviors.


Skin Cancer Risk Reduction Intervention Studies Knowledge-Based Interventions

Several researchers have attempted to promote sun

protection behaviors through educational programs. These programs have focused on increasing knowledge of skin cancer and the danger of sun exposure, and teaching sun protective behaviors. Educational interventions have targeted adults, parents, adolescents, and children.

Johnson and Lookingbill (1984) conducted one of the

first educational studies designed to increase knowledge of sunscreens and sun-exposure risks by providing subjects with an informational brochure and free sunscreen samples. One month following the dissemination of sun exposure




14


information, phone interviews were conducted with 342 of the original 489 subjects to evaluate their current knowledge of sunscreen and sun exposure risks. Results indicated that 89% of subjects reported reading the informational brochure, and there was a significant increase in participants, knowledge of SPF and sun exposure risks (i.e., skin cancer and wrinkling) compared to initial subject report. Moreover, 41% of the participants reported using the free sunscreen sample, but only 10% bought a sunscreen over the four week time period. Of the identified sun-exposed sunscreen nonusers during the initial contact, only 35% tried the free sample of sunscreen and a minimal number of participants (7%) bought sunscreen. Overall, this educational intervention was successful in increasing knowledge of sunscreens and sun-exposure risks, but was minimally effective in promoting unsafe behaviors.

In a broader, community-based public health education

program, Kelley (1991) focused on educating adults, children (preschool through 6th grade), and their parents using a statewide skin cancer awareness campaign. The education program used a multimedia approach (brochures, videotapes# public service announcements, informative news reports, billboards, artwork, and posters) in Texas, and provided some participants with sun protective devices (i.e., sunscreen and hats). The efficacy of this broad, 6-month intervention was assessed by an independent survey agency, who polled over 1000 randomly selected Texans pre- and postintervention, and asked participants 23 questions pertaining





15


to skin cancer knowledge and sun-exposure behaviors There was demonstrated a 17% increase in skin cancer awareness post education campaign, with a 23% increase in the number of respondents reporting that they had heard or seen something related to skin cancer in the media. A 7% increase was noted in correctly identifying melanoma as the most serious type of skin cancer. Also, a slight increase

(8%) was noted in adults who perceived having a sunburn as an adult was a serious cancer risk, but a 14% elevation was observed post-intervention in the number of respondents identifying sunburn during childhood as 'a serious skin cancer risk. A salient finding was that, in general, the respondents polled post-intervention had not changed their sun-exposure behaviors, with the exception of a slight change in those reporting avoidance of the sun (10% increase from pre-intervention). The authors concluded that, once again, educational interventions are effective in increasing knowledge of skin cancer and sun-exposure preventive behaviors, but do not necessarily translate into behavior change.

Katz and Jernigan (1991) identified deficiencies in

skin cancer knowledge among high school and college students and designed an educational intervention to modify these deficiencies. Their educational intervention focused on increasing awareness of skin cancer risk factors, preventive measures, and warning signs for early detection. A waitlist education control group design was used, with 40 subjects receiving the intervention immediately and 31




16


control subjects receiving the intervention after posttesting of the experimental group. It was noted that high school participants' skin cancer knowledge was significantly lower than that of college students, but they perceived themselves as equally knowledgeable on this topic. Students receiving the educational intervention significantly increased their knowledge of targeted aspects of skin cancer compared to control group, and that the control group, as well, significantly increased their knowledge following intervention. Two weeks follow-up testing revealed that knowledge scores significantly deteriorated for both groups compared to scores immediately following intervention, but the follow-up scores were significantly higher than preintervention scores. Katz and Jernigan (1991) concluded that both high school and college students are relatively uninformed about how to recognize and prevent skin cancer, and that these knowledge deficits can be improved via a brief educational intervention. Knowledge and Attitude-Based Interventions

In addition to increasing knowledge about the dangers

associated with sun exposure and measures to protect oneself from ultraviolet radiation, a few researchers have attempted to modify attitudes towards skin cancer prevention. Mermelstein and Riesenberg (1992) sampled 1703 high school students regarding their knowledge of skin cancer and protective measures, sun exposure habits, and intention to practice sun safe behaviors. In addition, the authors examined perceived susceptibility to damage caused by




17


ultraviolet radiation, perceived benefits of sun exposure, and awareness of changing attitudes towards the use of sun protective measures. Results of pre-intervention skin cancer knowledge tests demonstrated that females and students with high sensitivity skin types answered significantly more items correct than males and those with low skin sensitivity. In addition, females and high sensitivity subjects perceived themselves as more susceptible to skin cancer, practiced more sun protective behaviors, and were more aware of changing attitudes compared to their counterparts. However, both females and high skin sensitivity students perceived significantly more benefits to sun exposure than males and low skin sensitivity participants.

Mermelstein and Reisenberg (1992) examined factors which predicted behavioral intention to practice unsafe behaviors. The authors found that perceived susceptibility accounted for the largest proportion (25%) of the variance associated with intentions, with benefits, gender, awareness, skin type, and knowledge providing unique, yet minor contributions. Additional analysis of factors predicting sunscreen use found that behavioral intention to use sunscreen accounted for 27% of the variance, with susceptibility and skin type accounting for an additional 5% and 2%, respectively. The authors concluded that multiple factors are associated with sunscreen use, but further research is needed to examine beliefs that promote sun protective behavior.




is


To address issues related to motivation and perceived negative aspects of sun exposure, Jones and Leary (1992) exposed 128 college students to one of three conditions: 1) a health-based intervention consisting of an essay discussing skin cancer and health risks associated with tanning; 2) an appearance-based essay focusing on the negative effects of tanning on appearance (i.e. photoaging, sunburn); and 3) a control group. Following the intervention, subjects were asked questions regarding their concern about sun exposure effects, their intentions to work on a suntan during the upcoming summer, and their intention to use sunscreen. Results showed that subjects were significantly more influenced by the appearance-based essay compared to the health-based essay, as indicated by their higher rate of concern regarding the effects of sun exposure and their higher intentions to use sunscreen. In the appearance-based intervention, subjects with high appearance motivation endorsed higher intentions to.work on their tan compared to low appearance motivated subjects. There were no differences in intentions between high and low appearance motivated subjects in the health-based essay condition. The authors concluded that providing information related to the negative aspects of sun exposure appears to be more effective in communicating ultraviolet radiation dangers than simply providing health-related information. Moreover, focusing on the harmful sun exposure effects and its impact on appearance appears to increase intentions to practice sun safe behaviors.




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In a similar research vein, Cody and Lee (1990)

examined the effects of an information-based intervention versus an emotional-appealing intervention on skin cancer knowledge and intentions to practice sun protective behaviors. Three hundred and twelve Australian college students were randomly assigned to one of three conditions: 1) seeing an informational video on skin cancer and its prevention; 2) seeing an emotional video which portrayed one adult dying from skin cancer and another who was successfully treated for skin cancer, and reviewed skin cancer causes and preventive behaviors; and 3) control video group. Knowledge of skin cancer, perceived susceptibility to skin cancer, perceived benefits of sun protective behaviors, and perceived barriers to skin cancer prevention were assessed pre-intervention, immediately following the video, and 10 months following the intervention. Analyses revealed that immediate postvideo skin cancer knowledge and intentions to practice sun safe behaviors significantly increased for both experimental groups compared to the control group, but that the positive intentions were maintained only for the emotional video group at long-term follow-up. Moreover, scores on measures of perceived susceptibility, severity and barriers to skin cancer increased from prevideo to postvideo. Regression analyses revealed that perceived susceptibility, severity, benefits and barriers accounted for 32% of the variance associated with prevideo skin protection behaviors. These four variables also accounted for 30% of the variance associated





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with postvideo and follow-up intentions to practice skin protective behaviors. The authors indicated that both videotape interventions were effective in increasing knowledge, beliefs and intentions related to skin cancer.

Utilizing skin cancer information, peer modeling, free sunscreen, risk protection feedback and goals, and a "written commitment," Lombard, Neubauer, Canfield, and Winett (1991) attempted to increase the practice of sun protective behaviors by pool patrons at two neighborhood pools. After establishing an observed base rate for sun safe behaviors, the interventions were initiated. Results indicated that a modest increase in pool patron preventive behaviors was observed compared to baseline. Primarily, changes were noted in increased frequency of hats worn in sun and number of people in the shade. There were several confounds to this study (e.g., no interrater reliability index, raters known by pool patrons), but this is the first study to use behavioral observation of sun protection behaviors.

In summary, several components have been identified as essential for interventions focusing on skin cancer prevention and promotion of sun protective behaviors. Education is a necessary but not sufficient element in efforts to reduce sun exposure. Other components, such as one's attitudes and beliefs regarding the importance of protecting oneself from the sun, appear to be very important to enhance the effectiveness of interventions. Also, one's skin sensitivity and susceptibility to skin cancer appear to




21


be important variables. Moreover, highlighting negative aspects of sun exposure and use of video presentation appear to positively change intentions to practice sun protective behaviors. Finally, community interventions focusing on reducing sun exposure are an area worthy of further exploration. It must be noted that sun protection research is relatively scarce, and further research in this area is desperately needed if true reduction in skin cancer prevalence is to occur.

Sun Protection Interventions Targeting Children and Adolescents

Several interventions promoting reduction of sun

exposure have been examined. However, these studies have been focused primarily on young adults or the entire age span. In this section, sun protection interventions focusing on children and adolescents will be critically reviewed, and direction for future research will be highlighted.

In a study by Fork, Wagner, and Wagner (1992), a

focused educational intervention was conducted with peers of elementary school students. The authors.educated 7 third through fifth graders on skin cancer prevention, and trained them to present information to a group of 9 first grade students. Both the trained presenters and the first grade students were pretested on their skin cancer prevention knowledge, and post-tested one week after the 5-one hour intervention sessions. Despite methodological limitations, (e.g., lack of a control group, small sample size, and




22


limited scope) results indicated that the peer educational interventions were effective in increasing knowledge of skin cancer prevention behaviors.

Mermelstein and Reisenberg (1992) conducted an

intervention study examining the effectiveness of a brief sun exposure educational presentation on increasing skin cancer knowledge, personal susceptibility to skin cancer, and intentions to practice unsafe behaviors. The experimental group demonstrated significantly higher skin cancer knowledge and increased perceived susceptibility compared to control group, but no differences were noted in intentions to practice sun protective behaviors. Although this educational intervention demonstrated some effectiveness, the authors noted that additional content is needed addressing sun exposure attitudes for an intervention to effectively increase intentions to practice sun protective behaviors.

Hughes, Altman, and Newton (1993) developed a

comprehensive intervention program to increase sun exposure knowledge and to improve attitudes and behaviors associated with practicing unsafe behaviors. Five hundred and fortythree students from 7 schools participated in the study. Design of the study included 5 groups: group A read a text related to sun protection and received an informational leaflet; group B received the same intervention as group A with the addition of a video on sun exposure risks; group C received the same intervention as group A with the addition of designing a public education poster; group D received the




23


same intervention as group A but discussed materials on a second occasion; and group E served as a no information control group. Within each of the seven schools in the study, five classes were selected to participate and randomly assigned to one of the five conditions. Two months after implementing the interventions in May of 1990, 466 participants completed a questionnaire tapping knowledge and attitudes related to sun exposure and skin cancer. Following the participants' summer school break, a second questionnaire was completed by 266 participants examining attitudes toward sun exposure and skin cancer and sun-risk behaviors practiced over the summer break.

Results of the Hughes et al. (1993) study indicated

that mean skin cancer knowledge and sun exposure attitudes were significantly improved for all intervention groups compared to the control group. However, no difference in the practice of sun protective behaviors was found between experimental and control groups. Findings also suggested that adolescents with healthier sun exposure attitudes and higher skin cancer knowledge practiced more sun protective behaviors. Hughes and colleagues concluded that various educational intervention formats are equally effective at increasing both skin cancer knowledge and sun exposure attitudes, but none of these interventions were effective at increasing sun protective behaviors. This study is praiseworthy for its inclusion of multiple indices of change (e.g., knowledge, attitude, and behavior), as well as the inclusion of a control group, but the study is hindered by




24

the multiple confounds, such as a high attrition rate and the lack of pre-intervention testing.

The most successful sun protection intervention to date was conducted in Australia by Girgis, Sanson-Fisher, Tripodi, and Golding (1993). This intervention targeted increasing sun protective behaviors at school for 9-11 year olds. Over 600 students participated in the study, and schools were randomly assigned to one of three conditions: an intensive intervention, a standard intervention, and a control group. The intensive intervention was developed by the New South Wales cancer council, and it targeted increasing children's knowledge, and developing attitudes and skills to reduce their skin cancer risk. The intervention was implemented over four weeks within several curriculum areas. The standard intervention consisted of a 30-minute lecture on the dangers of sun exposure and ways to practice sun protective behaviors, as well as free posters and sunscreen. The control group received no intervention. At 5-weeks post-intervention, the intensive intervention was the only treatment successful at increasing the number of students practicing frequent sun protective behaviors. The strongest predictor of sun protective behaviors was frequency of pre-intervention sun protective behaviors. At 8-months post-intervention, the same predictors of sun protective behaviors emerged, except that participation in the intensive intervention group became a stronger predictor of the targeted behavior then pre-intervention sun protective behaviors. Also, higher number of opportunities




25


to practice sun protective behaviors was negatively predictive of actual practice.

The Girgis et al. (1993) study provides an excellent

example of how purely information-based interventions yield little results in actual behavior change. Although the content of the intensive intervention was unclear, it did appear to incorporate a multimodal design, which was likely a salient factor in increasing sun protective behaviors. overall, this study sets forth a foundation for future efforts in this area. In particular, it will be important to determine if the increase in sun protective behaviors generalizes to nonschool settings (e.g., after school, weekends). Also, it will be important to study variations in intervention length and intensity to identify the most efficient and effective intervention design. Finally, it.is uncertain whether the findings of the Girgis et al. (1993) study are directly applicable to studies conducted in other countries, given that sun protection issues are likely to be more salient, and more widely known by individuals in Australia versus other, less tropical locations in the world.

In summary, few studies have been conducted on sun protection interventions, especially for children and adolescents. A review of the literature suggests that the school system may be an ideal location for sun protection interventions. Preliminary findings of the sun protection interventions suggest that a wide variety of intervention techniques, such as using multimedia, discussion groups, and




26


peer educators, can effectively increase skin cancer knowledge and awareness of sun exposure dangers. Moreover, many of these intervention approaches have a positive effect on increasing one's awareness of their susceptibility to skin cancer, and changing attitudes towards risky sunexposure behaviors. However, interventions that have effectively changed intentions to practice sun protective behaviors as well as the behaviors themselves remain relatively elusive. Possible reasons for the limited success of these interventions are the lack of methodological sophistication and restricted generalizability.

Although the few interventions focusing on increasing sun protective behaviors in children and adolescents have had limited success, further empirical research is needed. Given the potential detrimental impact of sun exposure during childhood, and the ability to avoid most, if not all, of these dangers via modification of sun practices, it would appear that further research would likely have significant implications for reducing skin cancer rates. It is not often that psychologists have the opportunity to make such a unique contribution to the physical health of the population, as well as averting the psychological sequel following physical illness (e.g., skin cancer).


School-Based Health Promotion Interventions

Although there has been a relative dearth of

interventions promoting sun protective behaviors in




27


children, there have been various health promotion interventions targeted towards other risky behaviors in younger populations. It is important to examine other health promotion interventions used for children and adolescents to identify salient issues related to reducing health risks, as well as improving intervention strategies. The health promotion interventions for children and adolescents have been characterized by using multiple foci, including increasing knowledge, changing attitudes and motivation, and, ultimately, changing behaviors related to a variety of modifiable health risks. A primary prevention approach has been taken to target health risks, with a goal of reducing behaviors associated with diseases and injuries, thus reducing their incidence and prevalence rates in the years to come. Some of the specific health behaviors targeted for intervention have included improving cardiovascular health, decreasing tobacco and substance use, increasing use of bicycle helmets, and improving dental hygiene.

Researchers have focused on increasing knowledge related to the health risks associated with certain behaviors in hopes of reducing the frequency of such high. risk behaviors. Initial research on decreasing alcohol and illicit drug use during adolescence demonstrated substantial increases in knowledge of the dangers associated with alcohol/drug use, but failed to change behaviors (see reviews of this literature by Shaps, Bartalo, Moskowitz, Palley, & Churgin, 1981; and Logan, 1991). Other studies




28


have been effective in increasing children's knowledge related to the health dangers associated with behaviors, such as tobacco use, not wearing a bicycle helmet, and poor dietary and exercise habits, but all have noted the necessity of other intervention strategies to change attitudes, beliefs, and behaviors (Butcher et al., 1988; Flay, 1985; Pendergrast, Seymore-Ashworth, Duflant, & Litaker, 1992). Overall, interventions focusing solely on increasing children's knowledge of specific health risks and behaviors known to reduce risks have been effective only in increasing knowledge, and have not demonstrated notable increases in frequency of risk reducing behaviors.

Attempts to modify attitudes, health beliefs, and intentions have also received attention in the child/adolescent health promotion literature. For example, Pendergrast et al. (1992) provided elementary school students and their parents with information about bicycle safety. Although students reported that they felt helmets provided important protection, there was no difference in the number of students intending to wear a helmet on their next bike ride compared to pretest data. Children's intention to wear a helmet was predicted by having lower parental perceptions of social barriers to use, sibling ownership of a helmet, and having a positive attitude towards the use of a helmet. Parcel, Simons-Morton, O'Hara, Baranowski, and Wilson (1989) conducted an extensive health promotion campaign to change dietary behaviors in children. The intervention consisted of education and physical




29

education components and improving the quality of school lunches. The authors found that subjects in the experimental group demonstrated increased knowledge of healthy foods and higher rates of behavioral expectancies towards healthy foods compared to a control group. In addition, the intervention contributed to positive changes in behavior. Health promotion interventions have demonstrated that attitudes, beliefs and intentions are open to modification and play a critical role in actual behavior change.

The most salient goal for most health promotion/disease prevention interventions is actual positive change in health risk behaviors. However, for many studies, this goal has been elusive. For studies that have successfully achieved behavior change, several common factors have emerged. First, studies have focused on more broad-band approaches, using multimodal interventions. For instance, Parcel et al. (1989) demonstrated that they were successfully able to change elementary school students' diet and exercise by intervening at multiple levels. The authors targeted students and emphasized the importance of a healthy diet and exercise, utilized peer support by communicating information and practicing behaviors in the classroom and school environment, and changed environmental factors such as the nutrition of school lunches. Other interventions targeting cardiovascular health promotion have adopted similar multimodal intervention strategies and have produced comparable behavior changes (Arbeit et al., 1992; Carleton




30


et al., 1991). Moreover, interventions incorporating several modalities have been successful in positively changing other health behaviors, including seat belt use, drug and alcohol use, and tobacco use (Botvin, Baker, Renick, Filazzola, & Botvin, 1984; Flay et al., 1985; Morrow, 1989).

A second commonality of child health promotion studies is that they are model driven. Although'a variety of health models have been used, many consist of similar health variables, and all provide an integrated structure to carry out the research projects. For instance, many primary prevention studies to reduce smoking behaviors have used a psychosocial prevention model which incorporates several common variables (Flay, 1985). Specifically, the psychosocial prevention model emphasizes the negative physical effects of smoking, negative social norms related to smoking, social pressures to smoke, and behavioral skills needed to resist social influences to smoke (Flay, 1985). Other research programs have emphasized the social learning model, such as the Heart Smart cardiovascular health promotion project, and rational based theories utilized in several drug use prevention projects (Johnson, Nicklas, Arbeit, Franklin, & Berenson, 1988; see Tones, 1987 for review of drug use prevention). The above mentioned models are just two of the approaches taken towards health promotion in children. In the following chapter, other theoretical models of health promotion will be introduced




31


and their appropriateness for the present proposal's focus on skin cancer prevention will be discussed.

A third commonality of effective health promotion studies is that they tend to last longer than one class period. In acknowledging that behavior change is a complicated, long-term process, several researchers have implemented interventions that occur over several days to several months. For example, most of the cardiovascular health promotion projects and alcohol/drug use interventions have been conducted in classroom curriculums, at which time initial knowledge of the health problem is addressed, and subsequent classes target behaviors to change or reduce one's health risk (Logan, 1991; Olson, 1989). The goal of these longer term interventions appears to be merging the targeted healthy behavior into the participants' daily life, with the hope of maintaining compliance to the specified healthy behavior.

A fourth component of successful intervention

strategies has been incorporating parent and/or community involvement in promoting behavior change. For instance, in attempting to change dietary behaviors for third grade students, Perry et al. (1988) devised a classroom intervention and a separate home-based intervention involving students' parents. Results showed that the classroom intervention increased knowledge of healthy diets compared to the home-based intervention and control group, but the home-based intervention group demonstrated significantly more dietary behavior changes compared to the




32


classroom intervention and control groups. Perry and her colleagues suggest that education regarding health risks and ways of preventing health problems is important, but that parental involvement plays a key role in actual behavior change. A review of smoking prevention programs for children also concluded that parent involvement in promoting healthy behaviors was most effective in reducing the rate and onset of smoking in children (Oei & Fea, 1987). In an attempt to promote cardiovascular risk reduction behaviors in children, Murray, Perry, and Davis-Hearn (1987) emphasized that the inclusion of community factors in an intervention is essential in individual, health promoting behaviors. overall, it appears that inclusion of salient others in intervention programs promotes behavior change. The involvement of family and the community likely improves perceived social norms towards the targeted behavior, as well as capitalizes on reinforcement paradigms already established within the family and community for engaging in the targeted healthy behaviors.

A fifth similarity of successful health promotion

studies is the practicing of targeted healthy behaviors. In his work on social learning theory, Bandura (1986) emphasized the importance of developing self-efficacy. Self-efficacy is a component of the social learning theory, and, for health promotion studies, consists of increasing participants' knowledge of a given health issue, developing mastery of behaviors associated with prevention of the disease, and providing positive role-modeling of healthy




33


behaviors. Parcel et al. (1989) successfully increased elementary students' self-efficacy for healthful eating and physical activity by modeling healthy behaviors for students, focusing on knowledge and skill development related to eating and physical activity, self-monitoring of these behaviors, and providing awards for appropriate behaviors. Moreover, Basen-Engquist and Parcel (1992) found that self-efficacy regarding condom use predicted a significant proportion of the variance associated with intention to use condoms in a 9th grade sample. Overall, research on self-efficacy in health behaviors has demonstrated that this variable is a key component for an effective intervention.

Overall, health promotion studies have demonstrated their effectiveness in increasing knowledge related to a variety of health risks, and promoting positive changes in attitudes, beliefs, and, most importantly, behaviors associated with health risks. Components of health promotion interventions that appear to be essential for increasing knowledge and changing attitudes and beliefs related to health risks include: a) providing information about the specific health risk, b) discussing the benefits of engaging in risk reducing behaviors, c) altering perceived social norms regarding behaviors, and d) providing specific instructions on how to practice healthy behaviors. Several factors appear to be influential in changing health risk behaviors, including a multimodal, model driven, school-based intervention which occurs over more than one




34

class period. These successful interventions include the participation of parents, and consist of modeling healthy behaviors for children and assisting them in the development of these health promoting behaviors. This "formula" has demonstrated its effectiveness in making initial changes in behavior, and increasing the likelihood of incorporating these behaviors into the child's "lifestyle." It appears that many aspects of this "formula" for successful health promotion interventions can be used in the promotion of sun protective behaviors, with the short-term goal of reducing sunburns in children and a long-term goal of reducing the rate of skin cancer in the population.


Theories of Behavior Change

As previously mentioned, an essential element of an effective intervention is the use of a theoretical conceptualization to provide the necessary guidance and infrastructure to the project. Several theories have been used to guide research in the area of health promotion, yet no one theory has come to dominate health promotion interventions, especially those used in the school systems (Parcel, 1984). In the following section, a select number of these health theories will be reviewed, and their application to increasing sun protective behaviors will be highlighted.

During a Child Health Conference in 1981, several

models were identified as germane to guiding future research on children's health behaviors (Bruhn & Parcel, 1982). The




35

models selected were the Cognitive Development Theory (CDT), the Health Belief Model (HBM), the Social Learning Model (SLM) and the Theory of Reasoned Action (TRA). It was determined that aspects of these models captured the variables believed to be pertinent in the health behaviors of children, and further research would identify the validity of these models in research on children's health behaviors. After further empirical research, it appears that the Health Belief Model added little to explaining children's health behaviors and, therefore, will not be included in this study (Bush & Iannotti, 1985). A brief review of the three models used in this study will be presented next.

The importance of Cognitive Development Theory for

guiding health promotion interventions with children is that intervention material must be presented at a level consistent with the child's cognitive development for it to be meaningful and optimally useful.

The Theory of Reasoned Action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975) also provides a theoretical framework within which to consider children's health behavior change. This conceptual approach suggests that the best predictor of a given behavior is the individual's intention to engage in that behavior. Moreover, behavioral intention is defined by the individual's attitude (positive or negative) towards performing the behavior and their subjective norms regarding the targeted behavior. Attitudes toward a given behavior are based on one's belief about the




36


consequences of engaging in the behavior and evaluation of these consequences. The subjective norm consists of perceived beliefs of what important others think about performing the targeted behavior and motivation to comply with the behavior. In summary, TRA is defined by how beliefs, attitudes, and the social norm combine in a hierarchical manner to predict intention, which in turn, predicts behavior. For the present study, TRA provides a conceptual backdrop to structure the sequencing of intervention components and the interrelationships between key variables related to change.

The social Learning Model (SIM), according to Bandura (1977, 1986), suggests that behaviors can be changed in a gradual process by the influence of both positive and negative consequences of the behavior. It is postulated that individuals in a child's environment, such as classmates, teachers, and parents, provide both positive and negative feedback to the child, as well As occasions for vicarious learning, which serve to shape the child's behavior. In addition, perceiving that the changes in one's behavior will be beneficial to oneself is important for increasing the frequency of a given behavior. Furthermore, SIM emphasizes the importance of self efficacy, or one's perception that they are capable of engaging in the targeted behavior, to increase the probability of behavior change. Therefore, by increasing awareness and belief in the healthy aspects of behavior change, one's expectancies for personal benefits are enhanced, thus increasing motivation to




37


participate in the targeted behavior. Social learning theory emphasizes the importance of environmental, individual, and social aspects of learning, and further targets key behavioral principles related to modifying behavior. This theory, therefore, is easily applicable to health promotion interventions.

It is important to consider how these theoretical

models apply to reducing children's ultraviolet radiation exposure. First, the CDT model provides a backdrop for generating an intervention that can be targeted to a specific developmental level. Abstract issues, such as health promotion, need to be specified and focused on distinct health behaviors, such as reducing exposure to sunlight. Also, the concrete, short-term dangers associated with sun exposure (i.e., sunburn) should be emphasized given that the concept of skin cancer in adulthood may be too long-term and vague for children below the formal operational stage of development. Moreover, specific, concrete techniques to reduce sun exposure need to be accentuated for children below the formal operational stage.

Within the constraints defined by cognitive

development, components of the TRA model can be implemented. One of the particular limitations that the CDT places on the TRA model is that children must be at least at the concrete operational stage due to the assumption that the individual can reason logically. The TRA model provides a framework to consider the process of changing sun exposure practices. Specifically, children need to be informed of the




38


consequences associated with sun exposure so that they can evaluate whether it is worth engaging in sun protective behaviors. Successful change in beliefs towards sun protective behaviors increases the probability of enhancing one's attitude towards reducing sun exposure. Moreover, the social norm regarding important others' view of sun exposure and taking protective measures to avoid ultraviolet radiation need to be addressed. This may be accomplished by incorporating SLM into the child's environment to promote healthy sun behavior. The combination of a supportive environment and a positive attitude towards using sun protective measures increases the likelihood of one expressing the intention to engage in these behaviors, which, in turn, raises the probability of increasing the frequency and prevalence of sun protective behaviors.

The role of SIM in reducing sun exposure is that consequences for engaging in targeted behaviors can be manipulated by environmental agents (i.e., teacher, parents, peers), as well as avoiding the negative consequences associated with overexposure to the sun (i.e., sunburn, skin cancer). Moreover, emphasis on the short-term and long-term physical health benefits of sun protective behaviors is likely to shape positive expectancies for engaging in these behaviors. Also, modeling of sun protective behaviors by salient others provides the opportunity for vicarious learning. Finally, practicing specific sun protective behaviors and enhancing their competency to carry out these




39


behaviors increases self-efficacy, which further promotes future sun protective behaviors.












CHAPTER II
PURPOSE OF STUDY AND HYPOTHESES Purposes

As noted previously, several researchers have designed sun protection interventions for children and/or adolescents. However, these studies have had limited success in changing sun protection behaviors. Findings of these studies are constrained by the lack of methodological rigor and limited generalizability. The present study attempted to improve upon previous sun protection interventions. Specifically, the objectives of the present study were:

1. To make a significant contribution to the scientific literature regarding the effectiveness of sun protection interventions on knowledge, beliefs, attitudes, intentions, and behavior change of elementary school children.

2. To develop and evaluate skin cancer and sun protection questionnaires for children.

3. To examine the effectiveness of a theory-based intervention on enhancing knowledge, beliefs, attitudes, intentions, and sun protection behaviors of children.

4. To empirically examine the utility of the conceptual model developed for this project in predicting intention to engage in sun protective behaviors and actual practice of sun protective behaviors.



40





41

Sunscreen use was chosen as the targeted sun protection behavior since engaging in sunscreen use is a selective behavior, in the sense that it has one purpose: to protect the skin from sun exposure. Other sun protective behaviors, such as wearing a hat, or shirt and pants, can be engaged in for reasons in addition to sun protection, and therefore were not examined due to this confound. Moreover, sunscreen use provides the only way to protect areas of the skin at high risk for skin cancer, such as the face and neck.

Hypotheses

This investigation examined the effects of a

multicomponent intervention on children's sun protection beliefs, attitudes, intentions, knowledge, and behaviors. It was predicted that:

1. Following the intervention, children will report: (a) higher levels of sun exposure knowledge, (b) more positive sun protection beliefs and attitudes, (c) more intentions to practice sun protective behaviors, and (d) practicing more sun protective behaviors compared to their preintervention responses as well as compared to children in the control group post-intervention.

2. Higher knowledge and more positive beliefs and attitudes will be significantly predictive of higher behavioral intentions to practice sun protective behaviors postintervention, and the two predictor variables plus behavioral intentions will be significantly predictive of more frequent practice of sun protective behaviors.













CHAPTER III
METHOD



Subiects

Subjects in the study were 225 5th-grade students (128 in the intervention group and 97 in the control group) from

8 5th-grade classes in two elementary schools in Alachua County, Florida. Students in four classes from one school were randomly assigned to receive the intervention and students in the other school were assigned to the control group. Of the 225 students agreeing to participate in the study, 46 students (29 intervention, 17 control) were absent during either pre-or post-testing or during the intervention itself and subsequently dropped from the. analyses.

Pertinent demographic characteristics of the

intervention and control groups are listed in Table 1. ChiSquare indicated that there were no significant betweengroups differences, X2(l, 198) =.02, 2 >.05, child-rated skin type, e2(3, 186) =.46, R >.05, ethnicity, X2(6, 167)=

7.74, R >.05, and SES X2 (3, 167) = 4.90, R >.05.



Measures

Since sun exposure research with children is scarce, several questionnaires were developed to tap the variables of interest for the study. A 10-item questionnaire developed by Johnson (1988) was used to test 5th-grader's 42




43


Table 1

Demographic Data



Variable Intervention Group Control Group

(n=99) (n=82)



Gender

Male 49% 47%

Female 51% 53%

Ethnicity

Caucasian 85% 77%

Afric. Amer. 9% 10%

Hispanic 1% 3%

Other 6% 10%

Skin Type

Very Sensitive 10% 10%

Moderately Sensitive 39% 40%

Moderately Insensitive 30% 34%

Insensitive 19% 16%

SES Strata'

1 0% 0%

2 6% 7%

3 21% 14%

4 31% 47%

5 42% 32%


a Hollingshead (1975) 4-factor index of social status




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skin cancer and sun protection knowledge. An additional three items were rationally generated to tap areas of knowledge not included in the ACS questionnaire. Three other questionnaires were rationally derived and targeted at the following aspects of the study: (a) personal and perceived beliefs and attitudes towards skin cancer and sun protective behaviors, (b) intentions to practice sun protective behaviors, and (c) self-report of practicing sun protective behaviors. The four sections are referred to as the Knowledge Scale, Attitudes and Beliefs Scale, Intentions Scale, and the Behaviors Scale. In addition, several items were included in the multicomponent questionnaire to investigate reasons for not using sunscreen.

Questionnaire items were developed with the cognitive development of the targeted population in mind. Reading level of the four scales were estimated by two fifth grade teachers to be within the ability of the average 5th grade student. In addition, the measures were analyzed for their readability via a computer program. Multiple indicators of the readability of the questionnaires suggested that they are all questionnaires are within the reading level of the targeted sample.

Initially, a pilot study was conducted to examine the

internal consistency and test-retest reliability of the four scales. Subjects in the pilot study were 52 5th-grade students from P.K. Yonge Developmental School, a University of Florida laboratory school with an ethically and socioeconomically diverse student body. Results of the




45


pilot study suggested that all of the questionnaires had internal consistencies (Cronbach's alpha) above .60 (range .60 to .82) and two-week test-retest reliability above .64 (range .64 to .89). Psychometric analyses were also conducted on the full sample following data collection. These analyses revealed that one item on the Knowledge scale (item 7) and two items on the Attitudes and Beliefs scale (items 7 and 9) significantly lowered the internal consistency of the measure (as indicated by the corrected item-to-total correlation and overall alpha if item deleted). Therefore, these items were dropped from the measures and all subsequent analyses were conducted without inclusion of these items.

Knowledge Scale

The revised 12-item (6 items multiple choice, 6 items

true-false) Knowledge Scale assessed children's knowledge of sun exposure risks and sun protection. A total score was derived for the measure by summing up the number of correct items, with a higher score indicating more knowledge. A score of 12 was the highest attainable score. The coefficient alpha for the scale was .63, and the two-week test-retest reliability ranged from r=.59 to r -.61. Attitudes and Beliefs Scale

The 13-item Attitudes and Beliefs Scale was rationally derived and was primarily targeted at tapping subjects' perceptions of sun exposure risks and the costs/benefits of engaging in sun protective behaviors. In addition, two items were aimed at subjects' perceived ability to engage in




46


sun protective behaviors (i.e., self-efficacy). All of the items were based on a 5-point likert scale, with the anchor points being "strongly agree" (1) and "strongly disagree"

(5). The Attitudes and Beliefs Scale score was computed by summing across items with scores potentially ranging from 13 to 65. A lower score on the Attitudes and Beliefs Scale indicates more healthy attitudes and beliefs towards sun exposure and protection. The coefficient alpha for the scale was .72, and the two-week test-retest reliability ranged from r =.61 to r =.64. Intentions Scale
The 6-item. Intentions Scale was designed to capture

subjects' reported plans to engage in sunscreen use across several situations, such as at the beach, while playing outdoors, and after swimming. Items on this scale were directly modeled from previous research on intentions to engage in health-protective behaviors (e.g.,, Abraham, Sheeran, Spears, & Abrams, 1992). The Intentions Scale was also based on a 5-point likert scale, with the anchor points being "strongly agree" (1) and "strongly disagree" (5). The Intentions Scale score was computed by summing across items, and this score ranged from 6 to 30. A lower score on this measure indicates a stronger intention to use sunscreen. The coefficient alpha for the scale was .74, and the testretest reliability was r =.68. Behavior Scale

This visual-analog scale was designed to quantify

sunscreen use during all outdoor activities over a two-week




47


period. Subjects were asked to consider'outdoor activities in which they had participated during the past two weeks and to write these activities on the questionnaire. Then, subjects were asked to keep these activities in mind when they responded to a visual-analogue scale asking how often they used sunscreen during the past two-week period. Anchor points for the 0 mm. to 100 mm. scale were "did not use sunscreen" to "used sunscreen every timet" and subjects were asked to place an 11X11 along the line. In addition to the anchor points, two drawings, one of a full sunscreen bottle and one of an empty sunscreen bottle, accompanied the verbal description. Subjects' responses were measured in millimeters, with higher measurement indicating more sunscreen use. Test-retest reliability of the Behavior scale ranged from r =.59 to r =.85. Permanent Products Index

As a behavioral index of sunscreen use, a permanent

products index was used in the present study. According to Johnson (1991), a permanent product is a tangible item that can be quantified, and is an indirect indicator of the occurrence of a given behavior. An example of a permanent product index often used in compliance research is the pill count, which consists of counting the number of pills left in a bottle at time two, and subtracting this amount from the number of pills at time one. For the present study, the permanent product was packets of sunscreen (.5 oz., SPF 26). Specifically, two containers filled with several packets of sunscreen (equal amounts in each school) were placed in both




48


intervention and control schools. Students in both groups were informed of the availability of the free sunscreen, with the stipulation that they take only one packet at a time. Also, they were encouraged to return the empty packet before taking another full packet. The Permanent Products Index was the number of full packets remaining, as well as number of empty packets returned for both intervention and control groups, at the end of a one-week period beginning on first day of intervention.

State-Trait Anxiety Inventory for Children

To determine if the intervention had any impact on

subjects' level of anxiety, the 20-item State form of the State-Trait Anxiety Inventory for Children (STAI-C; Spielberger, 1973) was completed by all participants at pretesting. Subjects in the intervention group completed the State form of the STAI-C for a second time at the end of the first day of the intervention. This was done to determine the impact of the primarily educational session on children's anxiety. Subjects in the control group completed the State form of the STAI-C for a second time during the post-assessment testing. The STAI-C has demonstrated good internal reliability, ranging from .90 to .92, and has established adequate validity. Child-Rated Skin Type Ouestionnaire

A questionnaire created by Johnson (1988) was used to determine the children's skin type, as well as their parents' skin type, for the present study. Four skin types were listed, ranging from very sensitive to pretty




49


insensitive, with a description following each skin type label noting the differences between skin type classifications. For children, the measure was read aloud and they were asked to indicate the skin type that best describes them.

Finally, a demographic questionnaire was completed by subjects' parents. This questionnaire was used to gather information about parents' skin type, education level, employment, skin cancer history, and attitudes toward sun exposure.



Procedure

Two Alachua County elementary schools were selected to participate in the study based on their similar demographic characteristics (socioeconomic status, ethnicity, and geographic distribution of students). The two schools were randomly assigned to the intervention and control conditions. All children in the targeted fifth grade classrooms were asked to participate. Parent consent forms were given to each child to take home to their parent(s), and, only those students returning signed consent forms were allowed to participate in the study. Students not returning signed consent forms worked on class assignments with their teacher in a separate classroom during the intervention.

The study was conducted within each school during their regularly scheduled science classes. Both intervention and control groups were administered all study questionnaires prior to the intervention and again two weeks following the





50


last day of the intervention. The questionnaires were administered by the PI and his undergraduate research assistant. Students were informed that we were interested in children's knowledge of and participation in outdoor activities. To control for variability in reading levels, the scales were administered in a group format and read aloud to participants. Clarifications, if needed, were provided by the administrator. Furthermore, an instructional guide was developed to ensure consistency in administration. Administration of questionnaires took approximately 30-minutes and was completed within classrooms ranging in size from 25 to 40 students.

Following this pre-intervention assessment, children in the intervention group received the comprehensive program and children in the control group received no intervention. The intervention proceeded over three consecutive days, during a 50-minute class period scheduled to cover health related topics. There were four science classes per day with approximately 25 to 35 students per period. Therefore, the intervention was conducted four times per day over the three days. The following is an outline of the intervention:

Day 1: Students received factual information about the sun's effect on the skin in a lecture format. The presentation focused on short-term (i.e., sunburn) as well as long-term (i.e., skin cancer) health complications associated with excessive sun exposure. Risk factors were reviewed and then individualized via a questionnaire




51

targeted at identifying each students' skin type, which is highly related to their susceptibility to the damaging effects of the sun. Prevention behaviors were reviewed, sunscreen application was modeled, and a'10-minute videotape focusing on behavioral changes necessary to reduce the negative effects of sun exposure was shown (Slip, Slop, Slap videotape; ACS, 1988). Positive and negative aspects of preventive behaviors were discussed, and a homework assignment was given. In the homework assignment, the student and their parent were asked to review an informational brochure that highlighted the sun's effects on the skin and identified ways to reduce sun exposure at home (Skin Cancer Foundation, 1992). Finally, children completed the State form of the STAI-C. Children in the intervention group were given a sample of sunscreen with an SPF of 20 at this time, whereas children in the control group were given a sample of sunscreen at the time of the pre-intervention testing.

Day 2: The second class intervention period consisted of reviewing the homework assignment, reiterating behaviors that reduce sun exposure and why it is important, and developing unsafe promotions and slogans to be placed in the classroom. Teachers were instructed to leave the promotions on display in the classrooms for at least two weeks. In addition, the development of a unsafe commercial was initiated, and children were informed that the commercial would be videotaped and shown to classmates. Scripts were developed by the PI emphasizing sun exposure





52

dangers and methods to reduce sun exposure. Children within each class period were divided into two groups for easier management while making the videos.

Homework was assigned for the second day, consisting of the child and their parent reviewing sunsmart behaviors, and completing the unsafe slogan that was initiated in class, or making a new picture with their caretaker emphasizing the importance of using sun protective behaviors. Children were instructed to bring this to the next intervention period.

Day 3: The third and last class intervention period allowed children to "show and tell" their posters with classmates. Most of the class period focused on completing the videotaping of the unsafe commercial and general promotion of the intervention theme. After completion of the commercials, the videos were reviewed. A final task was offering the participants the opportunity to sign a commitment poster indicating their willingness to practice sunsmart behaviors. Departing comments were made encouraging participants to continue practicing sun protective behaviors, but they were not informed of followup testing. Classroom teachers for both conditions were informed of this follow-up testing, but were encouraged not to inform students about this assessment.













CHAPTER IV
RESULTS



Preliminary Analyses

Data were analyzed using the student (vs. school) as the unit of analysis. Although the student may not represent independent observations, the limited number of schools participating in the project does not allow for adequate degrees of freedom, nor power to conduct the most conservative analyses. However, one-way analyses of variance conducted on post-intervention measures showed no differences between classrooms across any of the measures. Therefore, intervention classes were collapsed for all subsequent analyses.

To determine the comparability of the two groups before the intervention, an omnibus between-group's MANOVA across dependent measures (scores from the knowledge, beliefs and attitudes, intentions, and sun protective behaviors scales) was conducted. Results of the MANOVA were not significant,

(4,166) = 2.36, R >.05, suggesting that, at pre-testing, the means for the intervention and control groups across scales were comparable.

Intervention Effectiveness

To determine the intervention's effectiveness compared to the control group (hypothesis 1), a 2 (group) x 2 (prepost-assessments) repeated measures MANOVA across the four 53





54


dependent measures was conducted. Results of these analyses are listed in Table 2. As predicted, results suggested a significant group by time of assessment interaction effect,

(4,166) = 19.79, R <-001To examine group differences at the post-intervention assessment period, an omnibus between-group's MANOVA across the four dependent measures was conducted. Results indicated a significant group effect, F (4,165) 7.13, 2 <.001. Subsequent univariate tests for each scale were conducted. Results indicated that the intervention group scored significantly higher on the Knowledge Scale postintervention compared to the control group E (1,180) 17.44, p <.0001. Furthermore, the intervention group demonstrated significantly healthier attitudes and beliefs about sun exposure dangers and the importance of sun protection compared to the control group, as indicated by their scores on the Attitudes and Beliefs Scale, E (1,167)

4.39, R <.05. The intervention group reported significantly higher intentions to practice sun protective behaviors on the Intentions Scale compared to the control group, I (1,180) = 11.62, R <.001. Finally, the intervention group reported significantly more sunscreen use on the Behavior Scale compared to the control group, Y (1,179) = 5.77, R <.05.

Intervention Group: Pre-Post Differences

To determine the intervention's effectiveness within the intervention group (hypothesis 1), an omnibus withinsubject's MANOVA across the four dependent measures was





55


Table 2

Means and Standard Deviations of Knowledge Score. Attitudes and Beliefs Score. Intentions Score. and-Behavior Score for Intervention and Control Groups at Pre- and PostIntervention Assessments



Intervention Group Control Group (n=99) (n=82)

Variable M s.d. M. s.d.

Pro-Intervention

Knowledge 8.45a 2.19 8.86 2.06

Attitudes & Beliefs* 26.00 6.31 26.55 6.68

Intentions* 14. 90a 4.19 15.00 5.17

Behavior 12.542 24.00 18.77 29.23



Post-Intervention

Knowledge 10.24 b 1.55 9.220 1.72

Attitudes & Beliefs* 25.7 9b 7.02 28.03c 6.86

Intentions* 13.13 b 5.17 15.74c 5.12

Behavior 33.23 b 32.62 21.830 30.79





Lower scores = more positive attitudes/beliefs and
intentions

Note: In each row and each column, means with different
superscripts are significantly different from each
other.




56


conducted. Results of these analyses are listed in Table 2. Consistent with the hypothesis, a significant effect for time across questionnaires was found, E (4,76) = 25.58, 2 <.001. Subsequent dependent sample's univariate tests for each of the dependent measures were conducted. The hypothesis that the intervention subjects would score higher on the Knowledge Scale post-intervention compared to their pre-intervention score was supported, Jt (1,93) 9.20, R <.001. Also supported were the hypotheses that intervention subjects would report higher intentions to wear sunscreen, (1,92) = 3.47, R <.001, and report more sunscreen use, (1,92) = -6.32, p <.001, at post-intervention compared to their pre-intervention responses. The only hypothesis not supported was the prediction that intervention subjects would report healthier attitudes and beliefs toward sun protective behaviors at post-intervention compared to preintervention, :t (1,81) = -.37, R >.05.

The result of the permanent products index was that 302 packets of sunscreen were removed from a sunscreen container at the intervention school compared to 45 at the control school. Moreover, 60 empty packets of sunscreen were returned at the intervention school, whereas only 8 empty sunscreen packets were returned at the control school. Multiple Regression Analyses
Examination of the predictive utility of the conceptual model (hypothesis 2) was conducted using two sets of identical hierarchical multiple regression analyses (MRAs), one set of MRAs for the intervention group and one set for




57


the control group. Results of these analyses can be found in Tables 3 through 6. Both sets of hierarchical MRAs were computed by entering, first, either the pre-intervention Intentions Score (when predicting the post-intervention Intentions Score) or pre-intervention Behavior Score (when predicting the post-intervention Behavior Score), then entering each of the demographic variables separately in the following order: gender, skin type, SES, and STAI-C score. Next, the post-intervention assessment Knowledge Score was entered into the equation, followed by the Attitudes and Beliefs Score to predict behavioral intentions to practice sun protective behaviors post-intervention. Intentions to practice sun protective behaviors at the post-evaluation was then added into the model to predict practice of sunscreen use, as indicated by the score on the Behavior Scale at the post-intervention assessment.

Results of the hierarchical MRA using the Intentions Scale as the dependent measure for the intervention group indicated that the pre-intervention Intentions Score significantly predicted 29% of the variance associated with intentions to wear sunscreen F = 24.20, 2 m-0001- The Attitudes and Beliefs score uniquely accounted for an additional 8% of the variance associated with intentions to practice sun protective behaviors F = 7.99, 2 =.007. Overall, 47% of the variance associated with the Intentions Scale was captured by all of the variables in the model for the intervention group, F = 5.70, p <.0001.




58


Table 3

Hierarchical Multiple Regression Analyses Evaluating the Contribution of Demographic Variables and Sun Protection Measures in Predicting the Intentions Score for the Intervention GrouR

Predictor Beta Increase p value

Variables Weight in R2

Pre-Intervention

Intentions Score .54 .29 .0001

Child Gender -.23 .04 .07

Child Skin Type -.07 .00 .61

SES Status -.16 .02 .21

STAI-C State Score .25 .04 .06

Knowledge Score .04 .00 .78

Attitudes and

Beliefs Score .36 .08 .01

Total .47 .0001




59


Table 4

Hierarchical Multiple Regrression Analyses Evaluating the Contribution of Demographic Variables and Sun Protection Measures in Predicting the Behavior Score for the Intervention Group



Predictor Beta Increase p value

Variables Weiciht in R2

Pre-Intervent ion

Behavior Score .30 .09 .02

Child Gender .17 .03 .19

Child Skin Type .18 .03 .16

SES Status -.06 .00 .67

STAI-C State Score .20 .00 .97

Knowledge Score .16 .02 .23

Attitudes and

Beliefs Score -.35 .10 .01

Intentions Score -.10 .01 .44

Total .29 .02





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Table 5

Hierarchical Multiple Regression Analyses Evaluating the Contribution of Demographic Variables and Sun Protection Measures in Predicting the Intentions Score for the Control GrOuR

Predictor Beta Increase value

Variables Weight in R

Pre-Intervention

Intentions Score .67 .45 .0001

Child Gender -.20 .02 .10

Child Skin Type .06 .00 .60

SES Status -.03 .00 .80

STAI-C State Score .21 .02 .08

Knowledge Score -.01 .00 .92

Attitudes and

Beliefs Score .62 .20 .0001

Total .70 .0001




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Table 6

Hierarchical Multiple Regression Analyses Evaluating the Contribution of Demographic variables and Sun Protection Measures in Predicting the Behavior Score for the Control




Predictor Beta Increase 2 value

Variables Weiaht in R2

Pre-Intervention

Behavior Score .57 .33 .0001

Child Gender -.04 .00 .71

Child Skin Type -.16 .02 .18

SES Status .19 .02 .12

STAI-C State Score -.10 .01 .41

Knowledge Score .02 .00 .89

Attitudes and

Beliefs Score -.10 .00 .42

Intentions Score -.13 .01 .31

Total .40 .0001




62

Results of the second hierarchical MRA using the postintervention Behavior Scale as the dependent measure showed that pre-intervention sunscreen use predicted 9% of the variance associated with post-intervention sunscreen use, JE = 5.83, p =.02. In addition, the Attitudes and Beliefs Scale uniquely accounted for 10% of the variance associated with reported use of sunscreen, F = 7.86, R =.007. Overall, 29% of the variance was accounted for by all of the variables in the model for the intervention group, F 2.58,

2 =.019.
Results of the hierarchical MRA using the postintervention Intentions Scale as the dependent measure for the control group indicated that the pre-intervention Intentions Score predicted 45% of the variance associated with the post-intervention Intentions Score f 55.52, p <.0001. In addition, the Attitudes and Beliefs Score uniquely accounted for 20% of the variance associated with intentions to practice sun protective behaviors F 39.92, R <.0001. Overall, 70% of the variance associated with the Intentions Scale was captured by all of the predictor variables for the control group, f = 20.20, p <.0001.

Results of the second hierarchical MRA using the postintervention Behavior Score as the dependent measure showed the pre-intervention Behavior Score was the only variable significantly contributing to this equation, accounting for 33% of the variance associated with reported use of sunscreen, f = 32.77, R <.0001- Overall, 40% of the




63


variance was accounted for by all of the predictor variables in this model, F 4.91, R <.0001.













CHAPTER V
DISCUSSION



The present study provided evidence for the

effectiveness of a school-based intervention program for increasing sun protective behaviors among fifth-grade children. Children receiving a three-day intervention demonstrated more skin cancer knowledge, higher intentions to practice unsafe behaviors, and more frequent use of sunscreen compared to children in the control group, as well as to their pre-intervention scores. It is important to note that these effects may be more "statistically" significant than "clinically" significant. It is uncertain whether the scores would be "clinically" significant if measures with better psychometric properties were used, and it is likely that the large sample size contributed to the robustness of the findings.

Children in the intervention and control groups

demonstrated comparably high levels of skin cancer and sun protection knowledge (70% correct) prior to the intervention. However, children in the intervention group, on average, answered 10 of the 12 questions correctly (84% correct); a full question better than children in the control group at the post-intervention assessment. Although children are knowledgeable about this topic, the intervention appears to have contributed to increasing skin

64





65


cancer and sun protection knowledge. This finding is consistent with other intervention research demonstrating modest increases in skin cancer and sun protection knowledge (Fork et al., 1992; Hughes et al., 1993; Katz & Jernigan, 1991).

Children in the intervention group reported

significantly stronger intentions to wear sunscreen compared to both the control group and their pre-intervention scores. The intervention and control groups differed by three points on the Intentions Scale, and the mean pre-post assessment difference score for the Intentions Scale was two points,, suggesting a modest increase in plans to wear sunscreen for children in the intervention group. Although a modest difference, this finding is an improvement over the findings by Mermelstein and Riesenberg (1992), in which no change in the likelihood of practicing sun protective behaviors was noted. It may be that the intervention designed for the present study, being more comprehensive than those reported in most other studies, was more effective at changing intentions to practice sun protective behaviors. Specifically, the children's "hands on" involvement in the project (i.e., making sunsafe posters and videos), as well as their signing a commitment poster likely contributed to the increase in intentions to wear sunscreen.

it is important to note that the definition of

intentions to practice sun protective behaviors differed between our study and Mermelstein and Riesenberg's study. Mermelstein and Riesenberg (1992) used a broad-band




66


definition, examining all sun protectivebehaviors (i.e., wearing sunscreen, long-sleeved shirt, etc.), whereas the present study focused solely on intentions to use sunscreen. It may be that sun protection interventions have a selective impact on increasing behaviors most saliently associated with sun protection (i.e., sunscreen use), and less effect on behaviors that children are less likely to associate with sun protection (i.e., wearing a hat). These findings suggest that a common measurement ground is needed for intentions to practice sun protective behaviors.

Findings also showed that children in the intervention group reported wearing sunscreen significantly more often than children in the control group following the intervention. children in the intervention group reported using sunscreen 33% more often than the control group, suggesting a modest impact of the intervention on practicing this sun protective behavior. Further support for the effectiveness of the intervention was evident in the significant within-intervention group comparison over time for sunscreen use. While the control group's sunscreen use at pre- and post-intervention assessment periods was very comparable, children in the intervention group increased sunscreen use by 100% from pre- to post-intervention. Although both between and within group improvements were evident, children in the intervention group were using sunscreen, on average, only a third of the time during outdoor activities.




67


The present study is one of the first to demonstrate a significant increase in sunscreen use following a sun protection intervention. For instance, Hughes et al. (1993) and Mermelstein and Riesenberg (1992) were unable to demonstrate a significant increase in sunscreen use or in other sun protective behaviors following their interventions. Only Lombard et al. (1991) and Girgis et al. (1991) demonstrated increases in sun protective behaviors (i.e., staying in the shade) post-intervention; however, there was no change in sunscreen use in the Lombard et al. study. The primary difference between studies demonstrating a change in sun protective behavior and those not producing such a change appears to be the complexity of the intervention, with longer-term and more intensive interventions producing greater behavioral change.

Of course, the self-report nature of the assessments yields the possibility of demand characteristics artificially inflating ratings and thereby confounding the results. An attempt was made to address this issue by examining, via a permanent products index (Johnson, 1991), actual use of sunscreen by children in both intervention and control conditions. Results demonstrated that children in the intervention group took more sunscreen packets from the classroom, and returned more empty packets, than did children in the control group. In addition, children in the intervention group were observed by teachers and the PI applying sunscreen prior to recess on several days; whereas only a few children in the control school were observed by




.68


teachers to be applying sunscreen. This index or sunscreen use provides evidence to support the findings of the study suggesting children in the intervention group used sunscreen more often than children in the control group.

Although analyses revealed between-groups differences in sun exposure attitudes and beliefs at post-intervention, closer examination of the data shows that this difference was due to an increase in negative attitudes and beliefs among children in the control group. Indeed, there was no significant change in attitudes and beliefs across time for children in the intervention group. This finding was surprising given that previous sun protection interventions (i.e., Hughes, et al., 1993; Mermelstein and Riesenberg, 1992) have demonstrated modest improvements in attitudes towards sun protective behaviors. There'are two possible explanations for this finding. First, the mean score for each item on the Attitudes and Beliefs Scale for both groups at pre-intervention was around 112,11 which corresponded to subjects' perceived "agreement" with the-importance of sun protective behaviors. Therefore, a ceiling effect was being approached, thus making substantial improvements in attitudes toward sun protective behaviors unlikely. Second, as in the case of measuring intentions, there were differences in the definition of attitudes and beliefs related to skin cancer and sun protective behaviors between other studies and the current study. Mermelstein and Riesenberg (1992) developed scales more narrowly focused on specific attitudes (i.e., susceptibility to skin cancer and




69


benefits of sun exposure), with each scale having several items. Further investigation of their data suggested that their intervention had a positive effect on perceived susceptibility, but not for decreasing perceived benefits of sun exposure. Therefore, it appears that Mermelstein and Riesenberg's intervention had a more selective impact on sun exposure attitudes. In contrast, a broad-band approach to studying attitudes and beliefs was used in the present study, primarily for the more comprehensive perspective that it allows, and for its efficiency. It may be that the content of the current study's Attitudes and Beliefs Scale was too broad band, for it incorporates questions related to personal views and perceived social norms of sun protective behaviors, personal susceptibility to skin cancer, and barriers to practicing sun protective behaviors. It will be important for future research to determine if several narrow-band scales may be more sensitive to changes in specific types of attitudes and beliefs related to sun exposure.

The second hypothesis of the study focused on the

predictive utility of the conceptual model proposed for the study. It should be noted that, since demographic variables were entered into the hierarchical MRA first, the predictive utility of the variables within the theoretical model should be considered a more conservative estimate. Results of the two sets of MRAs provided mixed support for the model. It was clear that pre-intervention intentions to use sunscreen was the best predictor of post-intervention sunscreen use,





70


accounting for 29% and 45% of the variance, respectively. Furthermore, in support of the model, healthier attitudes and beliefs towards skin cancer and sun protection in both the intervention and control groups were' significantly predictive of higher intentions to engage in sun protective behaviors, accounting for 8% and 20% of the variance, respectively. This finding is consistent with other studies in which attitudes and beliefs accounted for 25 30% of the variance associated with intentions to practice sun protective behaviors (Cody & Lee, 1990; Mermelstein& Riesenberg, 1992). This suggests that attitudes and beliefs play an important role in shaping intentions to practice sun protective behaviors, and should be a focal point of future interventions promoting sun protection behaviors.

However, in contrast to the model predictions, skin cancer knowledge was not predictive of intentions to wear sunscreen. This finding also is in contrast to Mermelstein and Riesenberg's (1992) results which showed that knowledge of sun protective behaviors predicted a significant, yet minor, amount of variance associated with intentions to practice sun protective behaviors. Research in other areas of health promotion (e.g., Logan, 1991; Pendergrast et al., 1992) has found that knowledge of a particular health problem and ways to manage it is important, yet not a direct predictor of intentions to or actual practice of a targeted behavior. It may be that knowledge serves as an indirect, or diffuse, predictor of a given behavior targeted for




71


change. Future research will need to clarify the role of knowledge in promoting healthy behaviors.

State anxiety showed a consistent trend with the

Intentions Score, accounting for an additional 4% and 2% of the variance in intention scores for the intervention and control groups, respectively. More anxious subjects reported fewer intentions to wear sunscreen. This relationship may reflect the anxiety experienced by subjects who recognize the risks that they may or may not face depending on their intentions to practice sun protective behaviors (i.e., subjects not planning on wearing sunscreen become more anxious because they realize the potential risks of sunburn and skin cancer).

Overall, 47% and 70% of the variance associated with

intentions to wear sunscreen was accounted for by all of the predictor variables for the intervention and control groups, respectively. These figures are comparable to other studies on sun protection behaviors (Cody & Lee, 1990; Mermelstein & Riesenberg, 1992) as well as other health promotion studies (e.g., Abraham et al., 1992). Findings for both intervention and control groups suggested that an individual's attitudes and beliefs are tied to their intentions to practice sun protective behaviors, which supported the theory of reasoned action (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975).

There also was mixed support for the hypothesis that more frequent sunscreen use would be predicted by higher knowledge, more positive attitudes and beliefs, and higher




72


intentions. of these predictor variables from the theoretical model, the only significant predictor of more frequent sunscreen use among children receiving the intervention was more positive attitudes and beliefs, accounting for 10% of the variance. once again, knowledge did not predict behavior. consistent with the Girgis et al. (1993) study, pre-intervention sunscreen use was a significant predictor of post-intervention sunscreen use, accounting for 33% for the control group, but only 9% of the variance for the intervention group. The different findings between MRAs predicting sunscreen use are not easily interpretable. It does appear that the intervention did have some type of impact on the subjects participating in the study. one explanation may be that the intervention had an impact on the subjects' attitudes and beliefs regarding sun protective behaviors, but that the Attitudes and Beliefs Scale did not accurately assess these changes.

Prochaska and DiClemente's transtheoretical model (1984) describes the process in which health behaviors change, and may provide another explanation of these findings. The authors describe how individuals move from practicing an unhealthy behavior without-intending to change their behavior (precontemplation state), to considering changing the behavior (contemplation state), then making the actual behavior change (action state), and finally maintaining the changed behavior (maintenance state). Based on the transtheoretical model, it may be that a considerable number of subjects in the present study moved from the




73


precontemplation and contemplation stages of behavior change to the action stage. Specifically, prior to the intervention, subjects may have been unaware or only mildly developing an awareness of the dissonance between their attitudes and beliefs about sun exposure and their sun exposure behaviors. Therefore, past sunscreen use was the strongest predictor of current sunscreen use. Following the intervention, which encouraged examination of personal attitudes and beliefs towards sun exposure (contemplation stage), subjects may have become more attuned to their opinions related to sun exposure, and seriously consider, or even practice safer sun exposure behaviors. This would not necessarily require changes in attitudes towards sun exposure behaviors, since they already hold fairly healthy attitudes, simply more consistency between these attitudes and the practice of these behaviors. This would also explain the contrast in the predictive utility of preintervention sunscreen use in predicting post-intervention sunscreen use between the intervention and control conditions (9% for the intervention group compared to 33% for the control group).

What remains unclear is the absence, at postintervention, of the direct predictive relationship between intentions and self-reported use of sunscreen. It will be important to determine if this finding (the absence of a direct predictive relationship between intentions and sunscreen use) is replicable or not. If replicable, support





74


for identifying the model underpinning this dynamic process will be warranted.

Overall, 29% and 40% of the variance related to.

sunscreen use was accounted for by the predictor variables for the intervention and control groups, respectively. These figures are consistent with the 32 34% reported in other studies (e.g., Cody & Lee, 1989; Meirmelstein & Riesenberg, 1992). The only common finding among these two studies and the present one is that attitudes towards sun protection consistently accounts for a significant proportion of variance related to practicing sun protection behaviors. Comparison of the results of the present study with the other studies provided little clarity of the issue since the studies have considerable differences in the models and variables used in the predictive equations. obviously, future research is needed to ascertain the variables which best serve to predict sun protection behavior change over time.

In sum, the findings of the intervention-control group comparisons suggested that modest increases in intentions to practice sun protective behaviors, and actual reported increase in sunscreen use following the intervention were achieved. These findings provide promising evidence for the utility of the present sun protection intervention. Moreover, the results are consistent with other health promotion interventions (i.e, Botvin, et al, 1984; Flay et al., 1985; Parcel, et al., 1989) that have demonstrated that





75


multicomponent interventions are effective at increasing healthy behaviors.

The MRAs provided mixed support for the model proposed for the present study. Specifically, the model appeared to be partially supported, with sun exposure attitudes and beliefs predicting intentions to wear sunscreen. However, the intervention appears to have impacted variables within the model making attitudes and beliefs the best predictor for actual practice of sun protective behaviors, instead of pre-intervention sunscreen use. The theoretical model could be improved by incorporating past intentions to use sunscreen, and actual sunscreen use into predictive equations for current and future sunscreen use.



Strengths and Limitations of the Present Study

This study improves upon past studies in several

important ways. First, this was one of only a few studies to use an experimental design, including both pre and posttesting and experimental and control groups. This type of design allowed for adequate evaluation of the intervention's effectiveness, controlling for time and pre-intervention confounds. The current design also included multiple indices of change, and is unique in its inclusion of two behavioral indicators (self-report of sunscreen use and a permanent products index). The multiple dependent measures allowed for a clearer understanding of the impact of the intervention at several levels of change.




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Second, the multimodal, "hands on" design of the

intervention, and its implementation over several days, provided subjects with a continuous, multi-faceted interaction around sun protection issues. Unlike other sun protection interventions, it is likely that the complexity of the current intervention contributed greatly to being the only study to demonstrate a significant increase in sunscreen use. Third, the intervention was model-driven, allowing for the intervention to incorporate several factors considered important for promoting healthy behaviors in children.

Equally important to identify its strengths is

delineating the study's limitations. First, the measures developed for the study, especially the Xnowledge Scale, lacked solid psychometric properties. According to Carmines and Zeller (1979), using instruments with low reliability may result in underestimating the effectiveness of an intervention. Therefore, any significant findings for the dependent measures used in the present study are likely to be a conservative estimate of the intervention's effectiveness, since the same findings using instruments with higher reliability would likely be more robust. Further refinement of the measures used in this study is necessary to capture the breadth of issues related to sun protection in a sensitive, efficient manner.

A second measurement constraint is the reliance on self-report assessments of sunscreen use. Even with the support of the more tangible permanent products index, it is




77

still not a reliable, direct index of sun protective behaviors. Given the nature of sun protective behaviors, it may be difficult to identify truly objective measures of sunscreen use. Lombard et al.'s (1991) direct observation attempt is worthy of praise, yet even this attempt had several flaws. one index that may provide a more objective index of sunscreen use, albeit still having flaws, is to provide subjects with personal containers of sunscreen that are pre-measured. Therefore, at post-testing, the amount of sunscreen left in the container would provide a behavioral index of sunscreen use. With research demonstrating that interventions can actually have an impact on sun protective behaviors, an important next step will be to develop more accurate and reliable measures of sun protective behaviors.

Third, the two weeks between intervention and posttesting may not have allowed for stabilization of attitudes and beliefs, intentions, and behaviors to occur. Although not reported in the present study, a two-month postintervention assessment was conducted for the intervention group to examine the long-term impact of the intervention Analysis of these data has yet to be conducted, but the findings will shed further light on the utility of the intervention.

Finally, although the multicomponent nature of the

intervention is a strength, this type of intervention may also be considered a limitation because it is not possible to determine which component(s) were most important in the intervention's effectiveness. If it is found that this




78

intervention design is able to reliably produce changes in sun protective behaviors, it will be important for future research to employ a dismantling design to identify the salient components of this intervention. Perhaps, a more streamlined intervention will prove equally beneficial and will allow for greater efficiency in its implementation.



Implications of Findings

As one of the first studies to empirically examine the effectiveness of a sun protection intervention, it was pleasing to find that this relatively unrefined intervention produced modest sun exposure-related changes for latency-age children. The results suggest that, with further research, there is considerable potential for increasing sun protective behaviors. If this were to happen, the likelihood of reducing skin cancer rates is promising.

Maintenance of behavior change is certainly a concern for any type of intervention. At the present time, the stability of the changes in sunscreen use, as well as the predictors of sunscreen use, is uncertain. However, if the findings suggesting that attitudes and beliefs towards sun protective behaviors are the best predictors of sunscreen use, then maintenance of sun protective behaviors may be enhanced by incorporating slogans and reminders related to healthy sun exposure attitudes into any long-term intervention strategy. The overall suitability of the model developed for the study has yet to be determined. It will require greater precision of measurement, as well as long-





79

term, post-intervention assessment of the variables in the model to determine how accurately it captures the process of changing sun protective behaviors.

A final implication of the present study is the efficiency in which such an intervention could be incorporated into the science and health curriculum of elementary schools. If research can demonstrate the intervention's long-term effectiveness, it certainly will be considered for implementation on a large-scale basis.

The potential long-term benefits of having an

effective, model-driven sun protection intervention that can be implemented on a large-scale basis (i.e., in schools) are enormous, both in reducing skin cancer incidence rates, and the concomitant financial and emotional costs of the disease to the citizens of all countries. This is certainly a lofty goal, but one worthy of challenge and yet to be determined.













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BIOGRAPHICAL SKETCH

Russell Gilbert Hoffmann III, son of Russell and Jeanne Hoffmann Jr., was born in Cincinnati, Ohio, on January 2, 1968. In 1986, Russell graduated from Northwest High School in Cincinnati, Ohio. Mr. Hoffmann conducted his undergraduate studies at the University of Cincinnati. He graduated summa cum laude with a Bachelor of Arts degree in psychology in June of 1990. In August of 1990, he entered the clinical and health psychology graduate program at the University of Florida. Russell obtained his Master of Science degree in May, 1993. After receiving his doctoral degree in clinical psychology, Russell plans to work with physically and/or mentally ill children and families experiencing psychological distress.























86








I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

Jrmes R. Johnfton, Chairman
r fessor of linical and
ealth Psy ology


I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

Jailms R. RdS dlp ochairman

Astittl prfeclofClinical1
nd Health Psychology


I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.


Stephen R. Boggs
Associate Professor of Clinical and Health Psychology



I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.


Gary A ffken V
Associate Professor of Clinical and Health Psychology







I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.





Education



This dissertation was submitted to the Graduate Faculty of the College of Health Related Professions and to the Graduate School and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy.



August 1995 __ __ __ __ __ __ __
Dean, College of Health Related Professions




Dean, Graduate School




Full Text
62
Results of the second hierarchical MRA using the post
intervention Behavior Scale as the dependent measure showed
that pre-intervention sunscreen use predicted 9% of the
variance associated with post-intervention sunscreen use, F
= 5.83, p =.02. In addition, the Attitudes and Beliefs
Scale uniquely accounted for 10% of the variance associated
with reported use of sunscreen, F = 7.86, p =.007. Overall,
29% of the variance was accounted for by all of the
variables in the model for the intervention group, F = 2.58,
p =.019.
Results of the hierarchical MRA using the post
intervention Intentions Scale as the dependent measure for
the control group indicated that the pre-intervention
Intentions Score predicted 45% of the variance associated
with the post-intervention Intentions Score F = 55.52, e
<0001. In addition, the Attitudes and Beliefs Score
uniquely accounted for 20% of the variance associated with
intentions to practice sun protective behaviors F = 39.92, e
<.0001. Overall, 70% of the variance associated with the
Intentions Scale was captured by all of the predictor
variables for the control group, F = 20.20, e <*0001.
Results of the second hierarchical MRA using the post
intervention Behavior Score as the dependent measure showed
the pre-intervention Behavior Score was the only variable
significantly contributing to this equation, accounting for
33% of the variance associated with reported use of
sunscreen, F = 32.77, p <.0001. Overall, 40% of the


46
sun protective behaviors (i.e., self-efficacy). All of the
items were based on a 5-point likert scale, with the anchor
points being "strongly agree" (1) and "strongly disagree"
(5). The Attitudes and Beliefs Scale score was computed by
summing across items with scores potentially ranging from 13
to 65. A lower score on the Attitudes and Beliefs Scale
indicates more healthy attitudes and beliefs towards sun
exposure and protection. The coefficient alpha for the
scale was .72, and the two-week test-retest reliability
ranged from r =.61 to r =.64.
Intentions Scale
The 6-item Intentions Scale was designed to capture
subjects' reported plans to engage in sunscreen use across
several situations, such as at the beach, while playing
outdoors, and after swimming. Items on this scale were
directly modeled from previous research on intentions to
engage in health-protective behaviors (e.g., Abraham,
Sheeran, Spears, & Abrams, 1992). The Intentions Scale was
also based on a 5-point likert scale, with the anchor points
being "strongly agree" (1) and "strongly disagree" (5). The
Intentions Scale score was computed by summing across items,
and this score ranged from 6 to 30. A lower score on this
measure indicates a stronger intention to use sunscreen.
The coefficient alpha for the scale was .74, and the test-
retest reliability was r =.68.
Behavior Scale
This visual-analog scale was designed to quantify
sunscreen use during all outdoor activities over a two-week


16
control subjects receiving the intervention after post
testing of the experimental group. It was noted that high
school participants' skin cancer knowledge was significantly
lower than that of college students, but they perceived
themselves as egually knowledgeable on this topic. Students
receiving the educational intervention significantly
increased their knowledge of targeted aspects of skin cancer
compared to control group, and that the control group, as
well, significantly increased their knowledge following
intervention. Two weeks follow-up testing revealed that
knowledge scores significantly deteriorated for both groups
compared to scores immediately following intervention, but
the follow-up scores were significantly higher than pre
intervention scores. Katz and Jernigan (1991) concluded
that both high school and college students are relatively
uninformed about how to recognize and prevent skin cancer,
and that these knowledge deficits can be improved via a
brief educational intervention.
Knowledge and Attitude-Based Interventions
In addition to increasing knowledge about the dangers
associated with sun exposure and measures to protect oneself
from ultraviolet radiation, a few researchers have attempted
to modify attitudes towards skin cancer prevention.
Mermelstein and Riesenberg (1992) sampled 1703 high school
students regarding their knowledge of skin cancer and
protective measures, sun exposure habits, and intention to
practice sun safe behaviors. In addition, the authors
examined perceived susceptibility to damage caused by


67
The present study is one of the first to demonstrate a
significant increase in sunscreen use following a sun
protection intervention. For instance, Hughes et al. (1993)
and Mermelstein and Riesenberg (1992) were unable to
demonstrate a significant increase in sunscreen use or in
other sun protective behaviors following their
interventions. Only Lombard et al. (1991) and Girgis et al.
(1993) demonstrated increases in sun protective behaviors
(i.e., staying in the shade) post-intervention; however,
there was no change in sunscreen use in the Lombard et al.
study. The primary difference between studies demonstrating
a change in sun protective behavior and those not producing
such a change appears to be the complexity of the
intervention, with longer-term and more intensive
interventions producing greater behavioral change.
Of course, the self-report nature of the assessments
yields the possibility of demand characteristics
artificially inflating ratings and thereby confounding the
results. An attempt was made to address this issue by
examining, via a permanent products index (Johnson, 1991),
actual use of sunscreen by children in both intervention and
control conditions. Results demonstrated that children in
the intervention group took more sunscreen packets from the
classroom, and returned more empty packets, than did
children in the control group. In addition, children in the
intervention group were observed by teachers and the PI
applying sunscreen prior to recess on several days; whereas
only a few children in the control school were observed by


27
children, there have been various health promotion
interventions targeted towards other risky behaviors in
younger populations. It is important to examine other
health promotion interventions used for children and
adolescents to identify salient issues related to reducing
health risks, as well as improving intervention strategies.
The health promotion interventions for children and
adolescents have been characterized by using multiple foci,
including increasing knowledge, changing attitudes and
motivation, and, ultimately, changing behaviors related to a
variety of modifiable health risks. A primary prevention
approach has been taken to target health risks, with a goal
of reducing behaviors associated with diseases and injuries,
thus reducing their incidence and prevalence rates in the
years to come. Some of the specific health behaviors
targeted for intervention have included improving
cardiovascular health, decreasing tobacco and substance use,
increasing use of bicycle helmets, and improving dental
hygiene.
Researchers have focused on increasing knowledge
related to the health risks associated with certain
behaviors in hopes of reducing the frequency of such high
risk behaviors. Initial research on decreasing alcohol and
illicit drug use during adolescence demonstrated substantial
increases in knowledge of the dangers associated with
alcohol/drug use, but failed to change behaviors (see
reviews of this literature by Shaps, Bartalo, Moskowitz,
Palley, & Churgin, 1981; and Logan, 1991). Other studies


50
last day of the intervention. The questionnaires were
administered by the PI and his undergraduate research
assistant. Students were informed that we were interested
in children's knowledge of and participation in outdoor
activities. To control for variability in reading levels,
the scales were administered in a group format and read
aloud to participants. Clarifications, if needed, were
provided by the administrator. Furthermore, an
instructional guide was developed to ensure consistency in
administration. Administration of questionnaires took
approximately 30-minutes and was completed within classrooms
ranging in size from 25 to 40 students.
Following this pre-intervention assessment, children in
the intervention group received the comprehensive program
and children in the control group received no intervention.
The intervention proceeded over three consecutive days,
during a 50-minute class period scheduled to cover health
related topics. There were four science classes per day
with approximately 25 to 35 students per period. Therefore,
the intervention was conducted four times per day over the
three days. The following is an outline of the
intervention:
Dav 1: Students received factual information about the
sun's effect on the skin in a lecture format. The
presentation focused on short-term (i.e., sunburn) as well
as long-term (i.e., skin cancer) health complications
associated with excessive sun exposure. Risk factors were
reviewed and then individualized via a questionnaire


61
Table 6
Hierarchical Multiple Regression Analyses Evaluating the
Contribution of Demographic Variables and Sun Protection
Measures in Predictincr the
Behavior
Score for the Control
Group
Predictor
Variables
Beta
Weiaht
Increase
in R2
P value
Pre-Intervention
Behavior Score
.57
.33
.0001
Child Gender
-.04
.00
.71
Child Skin Type
-.16
.02
.18
SES Status
.19
.02
.12
STAI-C State Score
-.10
.01
.41
Knowledge Score
.02
.00
.89
Attitudes and
Beliefs Score
-.10
.00
.42
Intentions Score
-.13
.01
.31
Total
.40
.0001


79
term, post-intervention assessment of the variables in the
model to determine how accurately it captures the process of
changing sun protective behaviors.
A final implication of the present study is the
efficiency in which such an intervention could be
incorporated into the science and health curriculum of
elementary schools. If research can demonstrate the
intervention's long-term effectiveness, it certainly will be
considered for implementation on a large-scale basis.
The potential long-term benefits of having an
effective, model-driven sun protection intervention that can
be implemented on a large-scale basis (i.e., in schools) are
enormous, both in reducing skin cancer incidence rates, and
the concomitant financial and emotional costs of the disease
to the citizens of all countries. This is certainly a lofty
goal, but one worthy of challenge and yet to be determined.


49
insensitive, with a description following each skin type
label noting the differences between skin type
classifications. For children, the measure was read aloud
and they were asked to indicate the skin type that best
describes them.
Finally, a demographic questionnaire was completed by
subjects' parents. This questionnaire was used to gather
information about parents' skin type, education level,
employment, skin cancer history, and attitudes toward sun
exposure.
Procedure
Two Alachua County elementary schools were selected to
participate in the study based on their similar demographic
characteristics (socioeconomic status, ethnicity, and
geographic distribution of students). The two schools were
randomly assigned to the intervention and control
conditions. All children in the targeted fifth grade
classrooms were asked to participate. Parent consent forms
were given to each child to take home to their parent(s),
and, only those students returning signed consent forms were
allowed to participate in the study. Students not returning
signed consent forms worked on class assignments with their
teacher in a separate classroom during the intervention.
The study was conducted within each school during their
regularly scheduled science classes. Both intervention and
control groups were administered all study questionnaires
prior to the intervention and again two weeks following the


39
behaviors increases self-efficacy, which further promotes
future sun protective behaviors.


37
participate in the targeted behavior. Social learning
theory emphasizes the importance of environmental,
individual, and social aspects of learning, and further
targets key behavioral principles related to modifying
behavior. This theory, therefore, is easily applicable to
health promotion interventions.
It is important to consider how these theoretical
models apply to reducing children's ultraviolet radiation
exposure. First, the CDT model provides a backdrop for
generating an intervention that can be targeted to a
specific developmental level. Abstract issues, such as
health promotion, need to be specified and focused on
distinct health behaviors, such as reducing exposure to
sunlight. Also, the concrete, short-term dangers associated
with sun exposure (i.e., sunburn) should be emphasized given
that the concept of skin cancer in adulthood may be too
long-term and vague for children below the formal
operational stage of development. Moreover, specific,
concrete techniques to reduce sun exposure need to be
accentuated for children below the formal operational stage.
Within the constraints defined by cognitive
development, components of the TRA model can be implemented.
One of the particular limitations that the CDT places on the
TRA model is that children must be at least at the concrete
operational stage due to the assumption that the individual
can reason logically. The TRA model provides a framework to
consider the process of changing sun exposure practices.
Specifically, children need to be informed of the


84
Murray, D. M., Perry, C. L., & Davis-Hearn, M. A. (1987).
Cardiovascular risk reduction in children. Special
Issue: Health promotion in children: A behavior
analysis and public health perspective: II. Education
and Treatment of Children. 10. 48-57.
National Cancer Institute. (1990). What vou need to know
about melanoma.
Oei, T. P., & Fea, A. (1987). Smoking prevention program
for children: A review. Journal of Drug Education.
17, 11-42.
Olson, C. M. (1989). Childhood nutrition education in health
promotion and disease prevention. Bulletin of the New
York Academy of Medicine. 10, 1143-1153.
Parcel, G. S. (1984). Theoretical models for application in
school health research. Journal of School Health. 54,
39-49.
Parcel, G. S., Simmons-Morton, B., O'Hara, N. M.,
Baranowski, T., & Wilson, B. (1989). School promotion
of healthful diet and physical activity: Impact on
learning outcomes and self-reported behavior. Health
Education Quarterly. 16, 181-199.
Pendergrast, R. A., Seymore-Ashworth, C. S., DuRant, R. H.,
& Litaker, M. (1992). Correlates of children's bicycle
helmet use and short-term failure of school-level
interventions. Pediatrics, 90, 354-358.
Perry, C. L., Luepker, R. V., Murray, D. M., Kurth, C.,
Mullis, R., Crockett, S., & Jacobs, D. R. (1988).
Parent involvement with children's health promotion:
The Minnesota home team. American Journal of Public
Health. 78, 1156-1160.
Prochaska, J. 0. & Diclemente, C. C. (1983). Stages and
processes of self-change of smoking: Toward an
integrative model of change. Journal of Consulting and
Clinical Psychology. 51. 390-395.
Pupo, R. A., Sherertz, E. F., & Flowers, F. P. (1986). Sun
protection in well-child care: Results of a survey of
Florida pediatricians. Pediatric Dermatology. 3.,
390-394.
Roberts, M. C. (1985). The future of children's health
care: What do we do? Journal of Pediatric Psychology.
11. 3-13.


63
variance was accounted for by all of the predictor variables
in this model, F = 4.91, p <.0001.


7
Skin cancers develop on all areas of the skin (Council
on Scientific Affairs, 1989). In addition, skin cancer
sites differ by gender, with women having more skin cancers
on the arms and lower legs, and men developing more skin
cancers between the hips and shoulders and on the head and
neck (NCI, 1990). Skin cancers are usually detected by
either physicians, or by individuals educated on the ABCD's
of skin cancer detection. The ABCD of skin cancer detection
stands for: A-asymmetry, meaning that one part of the nevi
does not match the other; B-border, meaning that the border
is uneven; C-color, meaning that the color of the nevi is
uneven; and D-diameter, denoting the change in size of the
nevi (NCI, 1990). Detection of skin cancer at its earliest
stages is crucial for minimizing long-term health problems.
Treatment of skin cancer depends on malignancy type and
stage of development. Most skin carcinomas at early stages
of development can be removed via surgical resection, with
minimal complications (NCI, 1990). However, more advanced
stages of skin cancer may require a combination of nevi
resection and chemotherapy or radiation therapy. Overall, a
considerable amount of health care resources is being spent
on a disease whose prevalence could be dramatically reduced
if a primary prevention approach was taken instead of the
traditional tertiary care approach.
Prevention of skin cancer consists of educating people
regarding endogenous and exogenous risk factors, and making
specific behavioral changes to reduce exposure to risk
factors. Education consists of reviewing the previously


38
consequences associated with sun exposure so that they can
evaluate whether it is worth engaging in sun protective
behaviors. Successful change in beliefs towards sun
protective behaviors increases the probability of enhancing
one's attitude towards reducing sun exposure. Moreover, the
social norm regarding important others' view of sun exposure
and taking protective measures to avoid ultraviolet
radiation need to be addressed. This may be accomplished by
incorporating SLM into the child's environment to promote
healthy sun behavior. The combination of a supportive
environment and a positive attitude towards using sun
protective measures increases the likelihood of one
expressing the intention to engage in these behaviors,
which, in turn, raises the probability of increasing the
frequency and prevalence of sun protective behaviors.
The role of SLM in reducing sun exposure is that
consequences for engaging in targeted behaviors can be
manipulated by environmental agents (i.e., teacher, parents,
peers), as well as avoiding the negative consequences
associated with overexposure to the sun (i.e., sunburn, skin
cancer). Moreover, emphasis on the short-term and long-term
physical health benefits of sun protective behaviors is
likely to shape positive expectancies for engaging in these
behaviors. Also, modeling of sun protective behaviors by
salient others provides the opportunity for vicarious
learning. Finally, practicing specific sun protective
behaviors and enhancing their competency to carry out these


5
contributing factor is increased ultraviolet radiation
exposure.
The What. Who. When, and Where of Skin Cancer
Several factors are believed to be related to the
etiology of skin cancer. There are endogenous factors, such
as family history of skin cancer, and the prevalence of
moles (i.e., nevi), that appear to increase vulnerability
for some individuals (these will be covered in next
section). Exogenous, or environmental factors, appear to
play a primary role in the development of skin cancer.
Exposure to toxins, such as caustic materials found in
factories, appears to play a minor role in the development
of skin malignancies (DeLeo, 1988). However, the major
exogenous factor increasing skin cancer risk is sun exposure
(Council on Scientific Affairs, 1989; MacKie, Freudenberger,
& Aitchison, 1989; Sober, 1986; Truhn, 1991). Ultraviolet
radiation exposure can cause erythema and sunburn, which are
short-term insults to the skin, or more long-term damage,
such as photoaging, alteration of the immune system, and
skin cancer (Council on Scientific Affairs, 1989). Leading
exogenous risk factors for developing skin cancer include
childhood sunburns, primary indoor work with frequent
outdoor exposure (i.e., outdoor recreation), and overall
frequency of sun exposure (MacKie et al., 1989). The
effects of solar radiation on the skin are well documented,
and their role in damaging the skin and in the development
of skin cancer is becoming increasingly apparent.


35
models selected were the Cognitive Development Theory (CDT),
the Health Belief Model (HBM), the Social Learning Model
(SLM) and the Theory of Reasoned Action (TRA). It was
determined that aspects of these models captured the
variables believed to be pertinent in the health behaviors
of children, and further research would identify the
validity of these models in research on children's health
behaviors. After further empirical research, it appears
that the Health Belief Model added little to explaining
children's health behaviors and, therefore, will not be
included in this study (Bush & Iannotti, 1985). A brief
review of the three models used in this study will be
presented next.
The importance of Cognitive Development Theory for
guiding health promotion interventions with children is that
intervention material must be presented at a level
consistent with the child's cognitive development for it to
be meaningful and optimally useful.
The Theory of Reasoned Action (TRA; Ajzen & Fishbein,
1980; Fishbein & Ajzen, 1975) also provides a theoretical
framework within which to consider children's health
behavior change. This conceptual approach suggests that the
best predictor of a given behavior is the individual's
intention to engage in that behavior. Moreover, behavioral
intention is defined by the individual's attitude (positive
or negative) towards performing the behavior and their
subjective norms regarding the targeted behavior. Attitudes
toward a given behavior are based on one's belief about the


78
intervention design is able to reliably produce changes in
sun protective behaviors, it will be important for future
research to employ a dismantling design to identify the
salient components of this intervention. Perhaps, a more
streamlined intervention will prove equally beneficial and
will allow for greater efficiency in its implementation.
Implications of Findings
As one of the first studies to empirically examine the
effectiveness of a sun protection intervention, it was
pleasing to find that this relatively unrefined intervention
produced modest sun exposure-related changes for latency-age
children. The results suggest that, with further research,
there is considerable potential for increasing sun
protective behaviors. If this were to happen, the
likelihood of reducing skin cancer rates is promising.
Maintenance of behavior change is certainly a concern
for any type of intervention. At the present time, the
stability of the changes in sunscreen use, as well as the
predictors of sunscreen use, is uncertain. However, if the
findings suggesting that attitudes and beliefs towards sun
protective behaviors are the best predictors of sunscreen
use, then maintenance of sun protective behaviors may be
enhanced by incorporating slogans and reminders related to
healthy sun exposure attitudes into any long-term
intervention strategy. The overall suitability of the model
developed for the study has yet to be determined. It will
require greater precision of measurement, as well as long-


18
To address issues related to motivation and perceived
negative aspects of sun exposure, Jones and Leary (1992)
exposed 128 college students to one of three conditions: 1)
a health-based intervention consisting of an essay
discussing skin cancer and health risks associated with
tanning; 2) an appearance-based essay focusing on the
negative effects of tanning on appearance (i.e. photoaging,
sunburn); and 3) a control group. Following the
intervention, subjects were asked questions regarding their
concern about sun exposure effects, their intentions to work
on a suntan during the upcoming summer, and their intention
to use sunscreen. Results showed that subjects were
significantly more influenced by the appearance-based essay
compared to the health-based essay, as indicated by their
higher rate of concern regarding the effects of sun exposure
and their higher intentions to use sunscreen. In the
appearance-based intervention, subjects with high appearance
motivation endorsed higher intentions to work on their tan
compared to low appearance motivated subjects. There were
no differences in intentions between high and low appearance
motivated subjects in the health-based essay condition. The
authors concluded that providing information related to the
negative aspects of sun exposure appears to be more
effective in communicating ultraviolet radiation dangers
than simply providing health-related information. Moreover,
focusing on the harmful sun exposure effects and its impact
on appearance appears to increase intentions to practice sun
safe behaviors.


PRIMARY SCHOOL-BASED HEALTH PROMOTION PROGRAM
FOR INCREASING SUN PROTECTION BEHAVIORS
By
RUSSELL G. HOFFMANN III
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTORATE OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1995


85
Shaps, E., Bartalo, R.D., Moskowitz, J., Palley, C.S., &
Churgin, S.A. (1981). A review of 127 drug abuse
prevention program evaluations. Journal of Drug
Issues. 11, 17-43.
Siegler, R. S. (1991). Children's thinking (2nd Ed.).
Englewood Cliffs, NJ: Prentice Hall.
Skin Cancer Foundation (1992). Simple steps to sun safety.
Skolnick, A. A. (1991). Sunscreen protection controversy
heats up. Journal of the American Medical Association.
265. 3217- 3220.
Sober, A. J. (1986). Solar exposure in the etiology of
cutaneous melanoma. Photodermatoloov. 4., 23-31.
Spielberger, C. (1973). Manual for the State-Trait Anxiety
Inventory for Children. Palo Alto, CA: Consulting
Psychologists Press, Inc..
Stern, R. S., Weinstein, M. C., & Baker, G. (1986). Risk
reduction for nonmelanoma skin cancer with childhood
sunscreen use. Archives of Dermatology. 122. 537-545.
Tones, K. (1987). Devising strategies for preventing drug
misuse: The role of the Health Action Model. Health
Education Research. 2, 305-317.
Truhn, A. P. (1991). Sun protection in childhood. Clinical
Pediatrics. 30. 676-681.
Weinstock, M. A. (1992). Assessment of sun sensitivity by
guestionnaire: Validity of items and formulation of a
prediction rule. Journal of Clinical Epidemiology. 45,
547-552.
Williams, M. C., & Pennella, R. (1994). Melanoma,
melanocytic nevi, and other melanoma risk factors in
children. Journal of Pediatrics. 124, 833-845.
Wright, L. (1967). The pediatric psychologist: A role
model. American Psychologist. 22. 323-325.


68
teachers to be applying sunscreen. This index of sunscreen
use provides evidence to support the findings of the study
suggesting children in the intervention group used sunscreen
more often than children in the control group.
Although analyses revealed between-groups differences
in sun exposure attitudes and beliefs at post-intervention,
closer examination of the data shows that this difference
was due to an increase in negative attitudes and beliefs
among children in the control group. Indeed, there was no
significant change in attitudes and beliefs across time for
children in the intervention group. This finding was
surprising given that previous sun protection interventions
(i.e., Hughes, et al., 1993; Mermelstein and Riesenberg,
1992) have demonstrated modest improvements in attitudes
towards sun protective behaviors. There are two possible
explanations for this finding. First, the mean score for
each item on the Attitudes and Beliefs Scale for both groups
at pre-intervention was around "2," which corresponded to
subjects' perceived "agreement" with the importance of sun
protective behaviors. Therefore, a ceiling effect was being
approached, thus making substantial improvements in
attitudes toward sun protective behaviors unlikely. Second,
as in the case of measuring intentions, there were
differences in the definition of attitudes and beliefs
related to skin cancer and sun protective behaviors between
other studies and the current study. Mermelstein and
Riesenberg (1992) developed scales more narrowly focused on
specific attitudes (i.e., susceptibility to skin cancer and


26
peer educators, can effectively increase skin cancer
knowledge and awareness of sun exposure dangers. Moreover,
many of these intervention approaches have a positive effect
on increasing one's awareness of their susceptibility to
skin cancer, and changing attitudes towards risky sun-
exposure behaviors. However, interventions that have
effectively changed intentions to practice sun protective
behaviors as well as the behaviors themselves remain
relatively elusive. Possible reasons for the limited
success of these interventions are the lack of
methodological sophistication and restricted
generalizability.
Although the few interventions focusing on increasing
sun protective behaviors in children and adolescents have
had limited success, further empirical research is needed.
Given the potential detrimental impact of sun exposure
during childhood, and the ability to avoid most, if not all,
of these dangers via modification of sun practices, it would
appear that further research would likely have significant
implications for reducing skin cancer rates. It is not
often that psychologists have the opportunity to make such a
unique contribution to the physical health of the
population, as well as averting the psychological sequela
following physical illness (e.g., skin cancer).
School-Based Health Promotion Interventions
Although there has been a relative dearth of
interventions promoting sun protective behaviors in


best and most difficult times of graduate school; boy, did
we grow up!
Finally, I thank my wife, Beth, for her love,
friendship, and commitment to our relationship. Together,
we tackled the graduate school Mmonster," and I look forward
to reaping the rewards and experiences of life with her.
I am a fortunate individual for having so many
generous, caring people in my life.
iii


82
Fork, H. E., Wagner, R. F., & Wagner, K. D. (1992). The
Texas peer education sun awareness project for
children: Primary prevention of malignant melanoma and
nonmelanocytic skin cancers. CUTIS, 5fi, 363-364.
Friedman, R. J., Rigel, D. S., Silverman, M. K., Kopf, A.
W., & Vossaert, K. A. (1991). Malignant melanoma in
the 1990s: The continued importance of early detection
and the role of physician examination and self-
examination of the skin. CA-A Cancer Journal for
Clinicians. 41, 201-209.
Girgis, A., Sanson-Fisher, R. W., Tripodi, D. A., & Golding,
T. (1993). Evaluation of interventions to improve
solar protection in primary schools. Health Education
Quarterly. 20. 275-287.
Glass, A. G. & Hoover, R. N. (1989). The emerging epidemic
of melanoma and squamous cell skin cancer. Journal of
the American Medical Association. 262. 2097-2100.
Grob, J. J., Guglielmina, C., Gouvernet, J., Zarour, H.,
Noe, C., & Bonerandi, J. J. (1993). Study of sunbathing
habits in children and adolescents: Application to the
prevention of melanoma. Dermatology. 186, 94-98.
Hill, D., White, V., Marks, R., Theobald, T., Borland, R., &
Roy, C. (1992). Melanoma prevention: Behavioral and
nonbehavioral factors in sunburn among an Australian
urban population. Preventive Medicine. 21. 654-669.
Hollingshead, A. B. (1975). Four Factor Index of Social
Status. New Haven, CT: Yale University
Hughes, B. R., Altman, D. G., & Newton, J. A. (1993).
Melanoma and skin cancer: Evaluation of a health
education programme for secondary schools. British
Journal of Dermatology. 128. 412-417.
Hurwitz, S. (1988). The sun and sunscreen protection:
Recommendations for children. Journal of Dermatologic
Surgery and Oncology. 14. 657-660.
Johnson, C. C., Nicklas, T. A., Arbeit, M. L., Franklin, F.
A., & Berenson, G. S. (1988). A comprehensive model for
maintenance of family health behaviors: The "heart
smart" family health promotion program. Family and
Community Health. 11. 1-7.
Johnson, E. Y., & Lookingbill, D. P. (1984). Sunscreen use
and sun exposure: Trends in a white population.
Archives of Dermatology. 120. 727-731.


BIOGRAPHICAL SKETCH
Russell Gilbert Hoffmann III, son of Russell and Jeanne
Hoffmann Jr., was born in Cincinnati, Ohio, on January 2,
1968. In 1986, Russell graduated from Northwest High School
in Cincinnati, Ohio. Mr. Hoffmann conducted his
undergraduate studies at the University of Cincinnati. He
graduated summa cum laude with a Bachelor of Arts degree in
psychology in June of 1990. In August of 1990, he entered
the clinical and health psychology graduate program at the
University of Florida. Russell obtained his Master of
Science degree in May, 1993. After receiving his doctoral
degree in clinical psychology, Russell plans to work with
physically and/or mentally ill children and families
experiencing psychological distress.
86


73
precontemplation and contemplation stages of behavior change
to the action stage. Specifically, prior to the
intervention, subjects may have been unaware or only mildly
developing an awareness of the dissonance between their
attitudes and beliefs about sun exposure and their sun
exposure behaviors. Therefore, past sunscreen use was the
strongest predictor of current sunscreen use. Following the
intervention, which encouraged examination of personal
attitudes and beliefs towards sun exposure (contemplation
stage), subjects may have become more attuned to their
opinions related to sun exposure, and seriously consider, or
even practice safer sun exposure behaviors. This would not
necessarily require changes in attitudes towards sun
exposure behaviors, since they already hold fairly healthy
attitudes, simply more consistency between these attitudes
and the practice of these behaviors. This would also
explain the contrast in the predictive utility of pre
intervention sunscreen use in predicting post-intervention
sunscreen use between the intervention and control
conditions (9% for the intervention group compared to 33%
for the control group).
What remains unclear is the absence, at post
intervention, of the direct predictive relationship between
intentions and self-reported use of sunscreen. It will be
important to determine if this finding (the absence of a
direct predictive relationship between intentions and
sunscreen use) is replicable or not. If replicable, support


15
to skin cancer knowledge and sun-exposure behaviors; There
was demonstrated a 17% increase in skin cancer awareness
post education campaign, with a 23% increase in the number
of respondents reporting that they had heard or seen
something related to skin cancer in the media. A 7%
increase was noted in correctly identifying melanoma as the
most serious type of skin cancer. Also, a slight increase
(8%) was noted in adults who perceived having a sunburn as
an adult was a serious cancer risk, but a 14% elevation was
observed post-intervention in the number of respondents
identifying sunburn during childhood as a serious skin
cancer risk. A salient finding was that, in general, the
respondents polled post-intervention had not changed their
sun-exposure behaviors, with the exception of a slight
change in those reporting avoidance of the sun (10% increase
from pre-intervention). The authors concluded that, once
again, educational interventions are effective in increasing
knowledge of skin cancer and sun-exposure preventive
behaviors, but do not necessarily translate into behavior
change.
Katz and Jernigan (1991) identified deficiencies in
skin cancer knowledge among high school and college students
and designed an educational intervention to modify these
deficiencies. Their educational intervention focused on
increasing awareness of skin cancer risk factors, preventive
measures, and warning signs for early detection. A wait
list education control group design was used, with 40
subjects receiving the intervention immediately and 31


ACKNOWLEDGEMENTS
This dissertation, as well as the work I have
accomplished over the past several years, has been greatly
influenced by the two chairmen of my dissertation, Jim
Rodrigue and Jim Johnson. I would like to thank Dr.
Rodrigue for his support, motivating enthusiasm, and
friendship, both on and off the professional "court." I
thank Dr. Johnson for his thought-provoking supervision and
encouragement to go well beyond mediocrity. Both of these
gentlemen have invested their time and resources in me and
have fostered my development as a clinical psychologist, as
well as a person, for which I am deeply indebted. Also, I
wish to acknowledge and thank my supervisory committee, Drs.
Stephen Boggs, Gary Geffken, and John Newell for their
helpful comments and suggestions.
Few worthwhile tasks are accomplished in life without
the help of family and friends. First, I wish to thank my
mother, Jeanne Hoffmann, whose personal sacrifices and love
provided me with a bounty of opportunities and experiences
from which to grow. Moreover, my sisters, in-laws, and
life-long friends have each contributed, via encouragement
and support, to the successes which I have experienced.
Also noteworthy is the friendship and support of my fellow
graduate students. In particular, I wish to thank Sam F.
Sears Jr. for his comraderie and support in weathering the
ii


69
benefits of sun exposure), with each scale having several
items. Further investigation of their data suggested that
their intervention had a positive effect on perceived
susceptibility, but not for decreasing perceived benefits of
sun exposure. Therefore, it appears that Mermelstein and
Riesenberg's intervention had a more selective impact on sun
exposure attitudes. In contrast, a broad-band approach to
studying attitudes and beliefs was used in the present
study, primarily for the more comprehensive perspective that
it allows, and for its efficiency. It may be that the
content of the current study's Attitudes and Beliefs Scale
was too broad band, for it incorporates questions related to
personal views and perceived social norms of sun protective
behaviors, personal susceptibility to skin cancer, and
barriers to practicing sun protective behaviors. It will be
important for future research to determine if several
narrow-band scales may be more sensitive to changes in
specific types of attitudes and beliefs related to sun
exposure.
The second hypothesis of the study focused on the
predictive utility of the conceptual model proposed for the
study. It should be noted that, since demographic variables
were entered into the hierarchical MRA first, the predictive
utility of the variables within the theoretical model should
be considered a more conservative estimate. Results of the
two sets of MRAs provided mixed support for the model. It
was clear that pre-intervention intentions to use sunscreen
was the best predictor of post-intervention sunscreen use,


CHAPTER II
PURPOSE OF STUDY AND HYPOTHESES
Purposes
As noted previously, several researchers have designed
sun protection interventions for children and/or
adolescents. However, these studies have had limited
success in changing sun protection behaviors. Findings of
these studies are constrained by the lack of methodological
rigor and limited generalizability. The present study
attempted to improve upon previous sun protection
interventions. Specifically, the objectives of the present
study were:
1. To make a significant contribution to the scientific
literature regarding the effectiveness of sun protection
interventions on knowledge, beliefs, attitudes, intentions,
and behavior change of elementary school children.
2. To develop and evaluate skin cancer and sun protection
questionnaires for children.
3. To examine the effectiveness of a theory-based
intervention on enhancing knowledge, beliefs, attitudes,
intentions, and sun protection behaviors of children.
4. To empirically examine the utility of the conceptual
model developed for this project in predicting intention to
engage in sun protective behaviors and actual practice of
sun protective behaviors.
40


75
multicomponent interventions are effective at increasing
healthy behaviors.
The MRAs provided mixed support for the model proposed
for the present study. Specifically, the model appeared to
be partially supported, with sun exposure attitudes and
beliefs predicting intentions to wear sunscreen. However,
the intervention appears to have impacted variables within
the model making attitudes and beliefs the best predictor
for actual practice of sun protective behaviors, instead of
pre-intervention sunscreen use. The theoretical model could
be improved by incorporating past intentions to use
sunscreen, and actual sunscreen use into predictive
equations for current and future sunscreen use.
Strengths and Limitations of the Present Study
This study improves upon past studies in several
important ways. First, this was one of only a few studies
to use an experimental design, including both pre and post
testing and experimental and control groups. This type of
design allowed for adequate evaluation of the intervention's
effectiveness, controlling for time and pre-intervention
confounds. The current design also included multiple
indices of change, and is unique in its inclusion of two
behavioral indicators (self-report of sunscreen use and a
permanent products index). The multiple dependent measures
allowed for a clearer understanding of the impact of the
intervention at several levels of change.


77
still not a reliable, direct index of sun protective
behaviors. Given the nature of sun protective behaviors, it
may be difficult to identify truly objective measures of
sunscreen use. Lombard et al.'s (1991) direct observation
attempt is worthy of praise, yet even this attempt had
several flaws. One index that may provide a more objective
index of sunscreen use, albeit still having flaws, is to
provide subjects with personal containers of sunscreen that
are pre-measured. Therefore, at post-testing, the amount of
sunscreen left in the container would provide a behavioral
index of sunscreen use. With research demonstrating that
interventions can actually have an impact on sun protective
behaviors, an important next step will be to develop more
accurate and reliable measures of sun protective behaviors.
Third, the two weeks between intervention and post
testing may not have allowed for stabilization of attitudes
and beliefs, intentions, and behaviors to occur. Although
not reported in the present study, a two-month post
intervention assessment was conducted for the intervention
group to examine the long-term impact of the intervention.
Analysis of these data has yet to be conducted, but the
findings will shed further light on the utility of the
intervention.
Finally, although the multicomponent nature of the
intervention is a strength, this type of intervention may
also be considered a limitation because it is not possible
to determine which component(s) were most important in the
intervention's effectiveness. If it is found that this


58
Table 3
Hierarchical Multiple Regression Analyses Evaluating the
Contribution of DemoaraDhic Variables and Sun Protection
Measures in Predicting
the Intentions Score for
the
Intervention Group
Predictor
Variables
Beta
Weicrht
Increase
in R2
E value
Pre-Intervention
Intentions Score
.54
.29
.0001
Child Gender
-.23
.04
.07
Child Skin Type
-.07
.00
.61
SES Status
-.16
.02
.21
STAI-C State Score
.25
.04
.06
Knowledge Score
.04
.00
.78
Attitudes and
Beliefs Score
.36
.08
.01
Total
.47
.0001


12
As can be seen, sun exposure has an interesting history
in our society, and is a significant part of leisure
activities for children, adolescents, and adults. Sun
exposure has been viewed as a healthy behavior in the past,
and only recently has information regarding the risks of
ultraviolet radiation been fully determined and
disseminated. It is not surprising that there is only a
moderate knowledge base related to sun exposure and skin
cancer, and many people are unaware of particularly salient
information, such as SPF and effective sun protective
behaviors. Although skin cancer information and its
prevention are important, many researchers have noted that
knowledge is not sufficient for increasing sun protective
behaviors.
A particular subset of the population, Caucasian
children and adolescents, have been identified as the most
likely to engage in risky sun exposure behaviors, and are
most susceptible to skin cancer. This subset is most likely
to benefit from sun protection interventions. Researchers
have concluded that the use of sun protective behaviors
would reduce the probability of sunburning, as well as
longer term dangers of sun-exposure (i.e. skin cancer).
Moreover, many authors have stressed that intervention
programs should be targeted towards younger people since
they engage most often in risky sun-exposure behaviors, and
because reduction in sun exposure rates during childhood are
most likely to reduce rates of skin cancer during adulthood.


41
Sunscreen use was chosen as the targeted sun protection
behavior since engaging in sunscreen use is a selective
behavior, in the sense that it has one purpose: to protect
the skin from sun exposure. Other sun protective behaviors,
such as wearing a hat, or shirt and pants, can be engaged in
for reasons in addition to sun protection, and therefore
were not examined due to this confound. Moreover, sunscreen
use provides the only way to protect areas of the skin at
high risk for skin cancer, such as the face and neck.
Hypotheses
This investigation examined the effects of a
multicomponent intervention on children's sun protection
beliefs, attitudes, intentions, knowledge, and behaviors.
It was predicted that:
1. Following the intervention, children will report: (a)
higher levels of sun exposure knowledge, (b) more positive
sun protection beliefs and attitudes, (c) more intentions
to practice sun protective behaviors, and (d) practicing
more sun protective behaviors compared to their pre
intervention responses as well as compared to children in
the control group post-intervention.
2. Higher knowledge and more positive beliefs and attitudes
will be significantly predictive of higher behavioral
intentions to practice sun protective behaviors post
intervention, and the two predictor variables plus
behavioral intentions will be significantly predictive of
more frequent practice of sun protective behaviors.


13
Issues that have been recognized as particularly
difficult to address in this population have been modifying
positive attitudes towards sun exposure, lack of immediate
cause and effect relationship between sun exposure and skin
cancer, and overall lack of awareness about sun exposure
dangers. Variables that have been described as potentially
useful in overcoming these challenges have been the
inclusion of parents in interventions, altering social
attitudes about sun exposure, and increasing knowledge of
children and their caregivers about ultraviolet radiation
dangers. The following chapter will examine the utility of
these variables, as well as others, in changing the beliefs,
attitudes, and behaviors associated with the practice of sun
protective behaviors.
Skin Cancer Risk Reduction Intervention Studies
Knowledge-Based Interventions
Several researchers have attempted to promote sun
protection behaviors through educational programs. These
programs have focused on increasing knowledge of skin cancer
and the danger of sun exposure, and teaching sun protective
behaviors. Educational interventions have targeted adults,
parents, adolescents, and children.
Johnson and Lookingbill (1984) conducted one of the
first educational studies designed to increase knowledge of
sunscreens and sun-exposure risks by providing subjects with
an informational brochure and free sunscreen samples. One
month following the dissemination of sun exposure


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
mes H. Jo.
fessor
ealth Psy
on, Chairman
linical and
ology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
is R. Rodricfyie, Cochairman
sdistant Professor of Clinical
and Health Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Stephen R. Boggs
Associate Professor of Clinical
and Health Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
/>CL^
try R. Geffken j/lj
Gary
Associate Professor^cTf Clinical
and Health Psychology


23
same intervention as group A but discussed materials on a
second occasion; and group E served as a no information
control group. Within each of the seven schools in the
study, five classes were selected to participate and
randomly assigned to one of the five conditions. Two months
after implementing the interventions in May of 1990, 466
participants completed a questionnaire tapping knowledge and
attitudes related to sun exposure and skin cancer.
Following the participants' summer school break, a second
questionnaire was completed by 266 participants examining
attitudes toward sun exposure and skin cancer and sun-risk
behaviors practiced over the summer break.
Results of the Hughes et al. (1993) study indicated
that mean skin cancer knowledge and sun exposure attitudes
were significantly improved for all intervention groups
compared to the control group. However, no difference in
the practice of sun protective behaviors was found between
experimental and control groups. Findings also suggested
that adolescents with healthier sun exposure attitudes and
higher skin cancer knowledge practiced more sun protective
behaviors. Hughes and colleagues concluded that various
educational intervention formats are equally effective at
increasing both skin cancer knowledge and sun exposure
attitudes, but none of these interventions were effective at
increasing sun protective behaviors. This study is
praiseworthy for its inclusion of multiple indices of change
(e.g., knowledge, attitude, and behavior), as well as the
inclusion of a control group, but the study is hindered by


81
Bruhn, J. G., & Parcel, G. S. (1982). Current knowledge
about health behavior of young children: A conference
summary. Health Education Quarterly. 9, 238-262.
Bush, P. J. & Iannotti, R. J. (1985). The development of
children's health orientations and behaviors: Lessons
for substance use prevention. National Institute on
Drug Abuse Research Monograph Series. 56. 45-74.
Butcher, A. H., Frank, G. C., Harsha, D. W., Serpas, D. C.,
Little, S. D., Nicklas, T. A., Hunter, S. M., &
Berenson, G. S. (1988). Heart smart: A school health
program meeting the 1990 objectives for the nation.
Health Education Quarterly. 5, 17-34.
Carleton, R. A., Sennett, L., Gans, K. M., Levin, S.,
Lefebvre, C., & Lasater, T. M. (1991). The Pawtucket
Heart Health Program: Influencing adolescent eating
patterns. Annals of the New York Academy of Sciences.
623. 322-326.
Carmines, E. G., & Zeller, R. A. (1979). Reliability and
validity assessment. London: Sage Publications.
Cody, R., & Lee, C. (1990). Behaviors, beliefs, and
intentions in skin cancer prevention. Journal of
Behavioral Medicine. 13., 373-389.
Council on Scientific Affairs. (1989). Harmful effects of
ultraviolet radiation. Journal of the American Medical
Association. 262. 380-384.
DeLeo, V. A. (1988). Prevention of skin cancer. Journal of
Dermatological Surgery and Oncology. 14, 902-906.
Fishbein, M. & Ajzen, I. (1975). Belief, attitude.
intention, and behavior: An introduction to theory and
research. Reading, MA: Addison-Wesley Publication
Company.
Fitzpatrick, T.B. (1988). The validity and practicality of
sun-reactive skin types I through IV. Archives of
Dermatology. 124. 869-871.
Flay, B. R. (1985). Psychosocial approach to smoking
prevention: A review of findings. Health Psychology.
4, 449-488.
Flay, B.R., Ryan, K.B., Best, J. A., Brown, K. S., Kersell,
M, W., d'Avernas, J. R., & Zanna, M. P. (1985). Are
social psychological smoking prevention programs
effective? The Waterloo study. Journal of Behavioral
Medicine. 8., 37-59.


skin is susceptible to many diseases, of which skin cancer
is the most dangerous.
Skin cancer is the most common type of cancer, with
over 600,000 new detections per year (ACS, 1988). Cells in
the body undergo normal, controlled processes of growth and
division to replace dying cells and repair damaged areas
(NCI, 1990). However, cells in the body, at times, lose
their ability to regulate the natural process of growth and
division (NCI, 1990). Cells that grow rapidly and/or out of
control produce tumors, or groups of abnormal cells. Tumors
can be either benign or malignant. Benign tumors are not
cancerous, and instead, tend to develop without spreading
throughout the body and seldom pose a serious health threat.
Malignant tumors are cancerous, meaning that they damage
healthy tissues, and tend to spread throughout the body
(i.e., metastasize). Skin cancer, then, refers to
malignant tumors in skin cells. There are several types of
skin cancer that are defined by the cell type which is
affected. Specifically, there are squamous cell and basal
cell cancers, and cancer occurring in the melanocytes,
formally known as malignant melanoma (NCI, 1990).
Basal cell and squamous cell cancers are much more
common than melanoma, and typically are not a serious health
risk because they rarely metastasize. Basal cell
malignancies usually are small, slow growing bumps or
nodules that occur on frequently exposed areas of skin
(i.e., head, neck, hands) (ACS, 1985). Although typically
not life threatening, if this form of cancer is left


20
with postvideo and follow-up intentions to practice skin
protective behaviors. The authors indicated that both
videotape interventions were effective in increasing
knowledge, beliefs and intentions related to skin cancer.
Utilizing skin cancer information, peer modeling, free
sunscreen, risk protection feedback and goals, and a
"written commitment," Lombard, Neubauer, Canfield, and
Winett (1991) attempted to increase the practice of sun
protective behaviors by pool patrons at two neighborhood
pools. After establishing an observed base rate for sun
safe behaviors, the interventions were initiated. Results
indicated that a modest increase in pool patron preventive
behaviors was observed compared to baseline. Primarily,
changes were noted in increased frequency of hats worn in
sun and number of people in the shade. There were several
confounds to this study (e.g., no interrater reliability
index, raters known by pool patrons), but this is the first
study to use behavioral observation of sun protection
behaviors.
In summary, several components have been identified as
essential for interventions focusing on skin cancer
prevention and promotion of sun protective behaviors.
Education is a necessary but not sufficient element in
efforts to reduce sun exposure. Other components, such as
one's attitudes and beliefs regarding the importance of
protecting oneself from the sun, appear to be very important
to enhance the effectiveness of interventions. Also, one's
skin sensitivity and susceptibility to skin cancer appear to


and their appropriateness for the present proposal's focus
on skin cancer prevention will be discussed.
A third commonality of effective health promotion
studies is that they tend to last longer than one class
period. In acknowledging that behavior change is a
complicated, long-term process, several researchers have
implemented interventions that occur over several days to
several months. For example, most of the cardiovascular
health promotion projects and alcohol/drug use interventions
have been conducted in classroom curriculums, at which time
initial knowledge of the health problem is addressed, and
subsequent classes target behaviors to change or reduce
one's health risk (Logan, 1991; Olson, 1989). The goal of
these longer term interventions appears to be merging the
targeted healthy behavior into the participants' daily life,
with the hope of maintaining compliance to the specified
healthy behavior.
A fourth component of successful intervention
strategies has been incorporating parent and/or community
involvement in promoting behavior change. For instance, in
attempting to change dietary behaviors for third grade
students, Perry et al. (1988) devised a classroom
intervention and a separate home-based intervention
involving students' parents. Results showed that the
classroom intervention increased knowledge of healthy diets
compared to the home-based intervention and control group,
but the home-based intervention group demonstrated
significantly more dietary behavior changes compared to the


mentioned information regarding skin cancer, and targeting
specific groups which can maximize their risk reduction.
For example, given that severe sunburn during childhood and
adolescence increases risk for development of skin cancer,
if the sun exposure behaviors of children and adolescents
could be modified so that they avoided getting sunburns,
then it is reasonable to conclude that skin cancer rates
would decline. Furthermore, if exposure time could be
reduced, especially during peak sun hours, then incidence
rates would likely decline further.
Risk reduction has assumed center stage in the battle
against skin cancer. Several cancer institutes and
government health agencies have produced skin cancer
informational brochures. It is generally agreed upon that
several "sunsafe" or "sunsmart" behaviors can be used to
reduce one's ultraviolet radiation exposure. These
preventive behaviors include: 1) wearing protective clothing
(e.g., long-sleeve shirts, pants, and hats); 2) wearing a
sun screen with a sun protection factor (SPF) of at least
15; 3) refraining from sun exposure between 10:00 A.M. and
3:00 P.M.; and 4) reducing overall exposure to sun,
especially during early childhood (ACS, 1992; Council on
Scientific Affairs, 1989; NCI, 1990; Skolnick, 1991).
Reduction in the prevalence and severity of skin cancer,
then, appears to be a function of increasing knowledge about
skin cancer, and decreasing high risk behaviors. Indeed,
Stern, Weinstein, and Baker (1986) found that regular
sunscreen (SPF 15) use during childhood and adolescence


2
In light of the foregoing, interventions designed to
increase healthy sun-exposure behaviors, particularly during
childhood, may prove beneficial in reducing skin cancer
rates. Therefore, the purpose of this study is to examine
the efficacy of an intervention designed to increase sun
exposure knowledge and modify beliefs, intentions, and
behaviors associated with ultraviolet radiation exposure.
The study is designed to address one of Logan Wright's
(1967) founding tenets of pediatric psychology, i.e.,
prevention, and, more recently, Robert's (1985) call for
health promotion studies to promote and improve the quality
of life during childhood and adulthood.
Skin Cancer
Skin Cancer Information
The skin, weighing approximately 6 pounds and comprised
of two layers, is the largest organ in the human body
(National Cancer Institute, 1990). The epidermis is the
outer layer of skin and is composed of squamous cells (top
layer) and basal cells (bottom layer). At the deepest layer
of the epidermis, melanocytes can be found. Melanocytes
produce melanin which gives the skin its color. The dermis
lies under the epidermis, and contains supportive structures
for the skin, such as sweat glands, blood and lymph vessels,
and hair follicles. The function of the skin is to protect
the body from several damaging agents, such as the heat,
infection, and light (1990). In addition, the skin benefits
the body in many ways, such as assisting in regulating body
temperature and gathering vitamin D. Like other organs, the


24
the multiple confounds, such as a high attrition rate and
the lack of pre-intervention testing.
The most successful sun protection intervention to date
was conducted in Australia by Girgis, Sanson-Fisher,
Tripodi, and Golding (1993). This intervention targeted
increasing sun protective behaviors at school for 9-11 year
olds. Over 600 students participated in the study, and
schools were randomly assigned to one of three conditions:
an intensive intervention, a standard intervention, and a
control group. The intensive intervention was developed by
the New South Wales Cancer Council, and it targeted
increasing children's knowledge, and developing attitudes
and skills to reduce their skin cancer risk. The
intervention was implemented over four weeks within several
curriculum areas. The standard intervention consisted of a
30-minute lecture on the dangers of sun exposure and ways to
practice sun protective behaviors, as well as free posters
and sunscreen. The control group received no intervention.
At 5-weeks post-intervention, the intensive intervention was
the only treatment successful at increasing the number of
students practicing frequent sun protective behaviors. The
strongest predictor of sun protective behaviors was
frequency of pre-intervention sun protective behaviors. At
8-months post-intervention, the same predictors of sun
protective behaviors emerged, except that participation in
the intensive intervention group became a stronger predictor
of the targeted behavior then pre-intervention sun
protective behaviors. Also, higher number of opportunities


55
Table 2
iivUii0 cuiu u uaiiucii u uc v ia tiuiio ui ixiiuw ouul u nutituucs
and Beliefs Score. Intentions Score, and Behavior Score for
Intervention and Control
GrouDS
at Pre- and
Post-
Intervention Assessments
Intervention Group
(n=99)
Control
(n=
Group
=82)
Variable
M
s. d.
M
s.d.
Pre-Intervention
Knowledge
8.45a
2.19
8.86
2.06
Attitudes & Beliefs*
26.00
6.31
26.55
6.68
Intentions*
14.90a
4.19
15.00
5.17
Behavior
12.54a
24.00
18.77
29.23
Post-Intervention
Knowledge
10.24b
1.55
9.22c
1.72
Attitudes & Beliefs*
25.79b
7.02
28.03c
6.86
Intentions*
13.13b
5.17
15.74'
5.12
Behavior
33.23b
32.62
21.83'
30.79
* Lower scores = more positive attitudes/beliefs and
intentions
Note: In each row and each column, means with different
superscripts are significantly different from each
other.


intervention (n = 128), while the other served as a no
intervention control group (n = 97). Results indicated that
the intervention significantly increased sun exposure
knowledge, intentions to wear sunscreen, and self-reported
sunscreen use at a two-week post-intervention assessment.
Attitudes and beliefs towards sun protective behaviors
predicted intentions to wear sunscreen for both groups and
reported sunscreen use for the intervention group, only.
Pre-intervention sunscreen use predicted post-intervention
sunscreen use for both groups. Generally, the present study
provides valuable information for directing future
intervention efforts to increase sunscreen use in children.
viii


CHAPTER V
DISCUSSION
The present study provided evidence for the
effectiveness of a school-based intervention program for
increasing sun protective behaviors among fifth-grade
children. Children receiving a three-day intervention
demonstrated more skin cancer knowledge, higher intentions
to practice sunsafe behaviors, and more frequent use of
sunscreen compared to children in the control group, as well
as to their pre-intervention scores. It is important to
note that these effects may be more "statistically"
significant than "clinically" significant. It is uncertain
whether the scores would be "clinically" significant if
measures with better psychometric properties were used, and
it is likely that the large sample size contributed to the
robustness of the findings.
Children in the intervention and control groups
demonstrated comparably high levels of skin cancer and sun
protection knowledge (70% correct) prior to the
intervention. However, children in the intervention group,
on average, answered 10 of the 12 questions correctly (84%
correct); a full question better than children in the
control group at the post-intervention assessment. Although
children are knowledgeable about this topic, the
intervention appears to have contributed to increasing skin
64


51
targeted at identifying each students' skin type, which is
highly related to their susceptibility to the damaging
effects of the sun. Prevention behaviors were reviewed,
sunscreen application was modeled, and a 10-minute videotape
focusing on behavioral changes necessary to reduce the
negative effects of sun exposure was shown (Slip, Slop, Slap
videotape; ACS, 1988) Positive and negative aspects of
preventive behaviors were discussed, and a homework
assignment was given. In the homework assignment, the
student and their parent were asked to review an
informational brochure that highlighted the sun's effects on
the skin and identified ways to reduce sun exposure at home
(Skin Cancer Foundation, 1992). Finally, children completed
the State form of the STAI-C. Children in the intervention
group were given a sample of sunscreen with an SPF of 20 at
this time, whereas children in the control group were given
a sample of sunscreen at the time of the pre-intervention
testing.
Dav 2: The second class intervention period consisted
of reviewing the homework assignment, reiterating behaviors
that reduce sun exposure and why it is important, and
developing sunsafe promotions and slogans to be placed in
the classroom. Teachers were instructed to leave the
promotions on display in the classrooms for at least two
weeks. In addition, the development of a sunsafe commercial
was initiated, and children were informed that the
commercial would be videotaped and shown to classmates.
Scripts were developed by the PI emphasizing sun exposure


change. Future research will need to clarify the role of
knowledge in promoting healthy behaviors.
State anxiety showed a consistent trend with the
Intentions Score, accounting for an additional 4% and 2% of
the variance in intention scores for the intervention and
control groups, respectively. More anxious subjects
reported fewer intentions to wear sunscreen. This
relationship may reflect the anxiety experienced by subjects
who recognize the risks that they may or may not face
depending on their intentions to practice sun protective
behaviors (i.e., subjects not planning on wearing sunscreen
become more anxious because they realize the potential risks
of sunburn and skin cancer).
Overall, 47% and 70% of the variance associated with
intentions to wear sunscreen was accounted for by all of the
predictor variables for the intervention and control groups,
respectively. These figures are comparable to other
studies on sun protection behaviors (Cody & Lee, 1990;
Mermelstein & Riesenberg, 1992) as well as other health
promotion studies (e.g., Abraham et al., 1992). Findings
for both intervention and control groups suggested that an
individual's attitudes and beliefs are tied to their
intentions to practice sun protective behaviors, which
supported the theory of reasoned action (Ajzen & Fishbein,
1980; Fishbein & Ajzen, 1975).
There also was mixed support for the hypothesis that
more frequent sunscreen use would be predicted by higher
knowledge, more positive attitudes and beliefs, and higher


4
untreated, it often continues to grow, damaging adjacent
tissue. The second most common form of skin cancer,
squamous cell carcinoma, also occurs on frequently exposed
areas of the skin and appears as red blotches. Although not
typically life threatening, this form of cancer differs from
basal cell carcinoma in that it can spread to other areas of
the skin.
The most dangerous form of skin cancer is malignant
melanoma which accounts for 75% of skin cancer deaths (ACS,
1992). The American Cancer Society (1992) estimated that
21% of the 32,000 new cases of melanoma in 1992 would be
fatal. What makes malignant melanoma more lethal than the
two other forms of skin cancer is the abnormal cell's
tendency to break away from the original tumor, travel
through the lymphatic system and bloodstream, and spread
throughout the body (NCI, 1990). The spread of melanoma
usually results in damage to other vital organs, often
resulting in death.
Changes in the prevalence rate of malignant melanoma
over the past decade have been staggering. In the United
States, malignant melanoma has increased 1500% over the past
50 years (ACS, 1992; Williams & Pennella, 1994). During the
1930's 1 in 1,500 persons developed malignant melanoma
during their lifetime, and now the current estimate is about
1 in 120 (Hurwitz, 1988). By the year 2000, it is estimated
that 1 in 90 persons will develop skin cancer during their
life (ACS, 1992). The reason for this dramatic rise in
melanoma is only starting to be understood, but one known


60
Table 5
Hierarchical Multiple Regression Analyses Evaluating the
Contribution of Demographic Variables and Sun Protection
Measures in Predicting the Intentions Score for the Control
Group
Predictor
Variables
Beta
Weicrht
Increase
in R2
E value
Pre-Intervention
Intentions Score
.67
.45
.0001
Child Gender
-.20
.02
.10
Child Skin Type
VO
o

.00
.60
SES Status
-.03
.00
.80
STAI-C State Score
.21
.02
.08
Knowledge Score
-.01
.00
.92
Attitudes and
Beliefs Score
.62
.20
.0001
Total
.70
0001


CHAPTER IV
RESULTS
Preliminary Analyses
Data were analyzed using the student (vs. school) as
the unit of analysis. Although the student may not
represent independent observations, the limited number of
schools participating in the project does not allow for
adequate degrees of freedom, nor power to conduct the most
conservative analyses. However, one-way analyses of
variance conducted on post-intervention measures showed
no differences between classrooms across any of the
measures. Therefore, intervention classes were collapsed
for all subsequent analyses.
To determine the comparability of the two groups before
the intervention, an omnibus between-groups MANOVA across
dependent measures (scores from the knowledge, beliefs and
attitudes, intentions, and sun protective behaviors scales)
was conducted. Results of the MANOVA were not significant,
F (4,166) = 2.36, g >.05, suggesting that, at pre-testing,
the means for the intervention and control groups across
scales were comparable.
Intervention Effectiveness
To determine the intervention's effectiveness compared
to the control group (hypothesis 1), a 2 (group) x 2 (pre
post-assessments) repeated measures MANOVA across the four
53


47
period. Subjects were asked to consider outdoor activities
in which they had participated during the past two weeks and
to write these activities on the questionnaire. Then,
subjects were asked to keep these activities in mind when
they responded to a visual-analogue scale asking how often
they used sunscreen during the past two-week period. Anchor
points for the 0 mm. to 100 mm. scale were "did not use
sunscreen" to "used sunscreen every time," and subjects were
asked to place an "X" along the line. In addition to the
anchor points, two drawings, one of a full sunscreen bottle
and one of an empty sunscreen bottle, accompanied the verbal
description. Subjects' responses were measured in
millimeters, with higher measurement indicating more
sunscreen use. Test-retest reliability of the Behavior
scale ranged from r =.59 to r =.85.
Permanent Products Index
As a behavioral index of sunscreen use, a permanent
products index was used in the present study. According to
Johnson (1991), a permanent product is a tangible item that
can be quantified, and is an indirect indicator of the
occurrence of a given behavior. An example of a permanent
product index often used in compliance research is the pill
count, which consists of counting the number of pills left
in a bottle at time two, and subtracting this amount from
the number of pills at time one. For the present study, the
permanent product was packets of sunscreen (.5 oz., SPF 20).
Specifically, two containers filled with several packets of
sunscreen (equal amounts in each school) were placed in both


associated with overall good health. Second, the upper
classes' reaction to the Industrial Revolution was to
10
embrace tanned skin as an index of one's higher social
status and ability to spend outdoor leisure time in sports.
A final influence was the work of a French fashion designer
who promoted tanned skin and a sunburn as a fashion
statement.
Although only a few decades passed before the healthy
benefits of sun exposure were debunked, and some physicians
spoke out that sunbathing was actually a health danger, the
social climate still promoted suntanning (Keesling &
Friedman, 1987). Only over the past three decades have
sunscreens been developed, and the general public has only
recently started to recognize the risks associated with sun
exposure. However, millions of people around the world
still continue to engage in behaviors that increase their
exposure to the harmful effects of ultraviolet radiation.
The following section will review research examining factors
related to sunbathing, and variables related to sunsmart
behavior, or sun protective behaviors.
Research on Sun Exposure Practices
Several recent studies suggest that knowledge of sun
exposure dangers is fairly high among adults (Johnson &
Lookingbill, 1984; Hill et al., 1992) as well as adolescents
(Hill et al., 1992). Despite these rapidly expanding
educational efforts, unhealthy attitudes towards the effects
of sun exposure (i.e., suntans look good) are commonplace
(e.g., Grob et al., 1993; Keesling & Friedman, 1987).


56
conducted. Results of these analyses are listed in Table 2.
Consistent with the hypothesis, a significant effect for
time across questionnaires was found, F (4,76) = 25.58, e
<.001. Subsequent dependent sample's univariate tests for
each of the dependent measures were conducted. The
hypothesis that the intervention subjects would score higher
on the Knowledge Scale post-intervention compared to their
pre-intervention score was supported, t (1,93) = 9.20, e
<001. Also supported were the hypotheses that intervention
subjects would report higher intentions to wear sunscreen, t
(1,92) = 3.47, e <.001, and report more sunscreen use, £
(1,92) = -6.32, e <.001, at post-intervention compared to
their pre-intervention responses. The only hypothesis not
supported was the prediction that intervention subjects
would report healthier attitudes and beliefs toward sun
protective behaviors at post-intervention compared to pre
intervention, t (1,81) = -.37, e >.05.
The result of the permanent products index was that 302
packets of sunscreen were removed from a sunscreen container
at the intervention school compared to 45 at the control
school. Moreover, 60 empty packets of sunscreen were
returned at the intervention school, whereas only 8 empty
sunscreen packets were returned at the control school.
Multiple Regression Analyses
Examination of the predictive utility of the conceptual
model (hypothesis 2) was conducted using two sets of
identical hierarchical multiple regression analyses (MRAs),
one set of MRAs for the intervention group and one set for


Second, the multimodal, "hands on" design of the
intervention, and its implementation over several days,
provided subjects with a continuous, multi-faceted
interaction around sun protection issues. Unlike other sun
protection interventions, it is likely that the complexity
of the current intervention contributed greatly to being the
only study to demonstrate a significant increase in
sunscreen use. Third, the intervention was model-driven,
allowing for the intervention to incorporate several factors
considered important for promoting healthy behaviors in
children.
Equally important to identify its strengths is
delineating the study's limitations. First, the measures
developed for the study, especially the Knowledge Scale,
lacked solid psychometric properties. According to Carmines
and Zeller (1979), using instruments with low reliability
may result in underestimating the effectiveness of an
intervention. Therefore, any significant findings for the
dependent measures used in the present study are likely to
be a conservative estimate of the intervention's
effectiveness, since the same findings using instruments
with higher reliability would likely be more robust.
Further refinement of the measures used in this study is
necessary to capture the breadth of issues related to sun
protection in a sensitive, efficient manner.
A second measurement constraint is the reliance on
self-report assessments of sunscreen use. Even with the
support of the more tangible permanent products index, it is


In a similar research vein, Cody and Lee (1990)
examined the effects of an information-based intervention
versus an emotional-appealing intervention on skin cancer
19
knowledge and intentions to practice sun protective
behaviors. Three hundred and twelve Australian college
students were randomly assigned to one of three conditions:
1) seeing an informational video on skin cancer and its
prevention; 2) seeing an emotional video which portrayed one
adult dying from skin cancer and another who was
successfully treated for skin cancer, and reviewed skin
cancer causes and preventive behaviors; and 3) control video
group. Knowledge of skin cancer, perceived susceptibility
to skin cancer, perceived benefits of sun protective
behaviors, and perceived barriers to skin cancer prevention
were assessed pre-intervention, immediately following the
video, and 10 months following the intervention. Analyses
revealed that immediate postvideo skin cancer knowledge and
intentions to practice sun safe behaviors significantly
increased for both experimental groups compared to the
control group, but that the positive intentions were
maintained only for the emotional video group at long-term
follow-up. Moreover, scores on measures of perceived
susceptibility, severity and barriers to skin cancer
increased from prevideo to postvideo. Regression analyses
revealed that perceived susceptibility, severity, benefits
and barriers accounted for 32% of the variance associated
with prevideo skin protection behaviors. These four
variables also accounted for 30% of the variance associated


65
cancer and sun protection knowledge. This finding is
consistent with other intervention research demonstrating
modest increases in skin cancer and sun protection knowledge
(Fork et al., 1992; Hughes et al., 1993; Katz & Jernigan,
1991).
Children in the intervention group reported
significantly stronger intentions to wear sunscreen compared
to both the control group and their pre-intervention scores.
The intervention and control groups differed by three points
on the Intentions Scale, and the mean pre-post assessment
difference score for the Intentions Scale was two points,
suggesting a modest increase in plans to wear sunscreen for
children in the intervention group. Although a modest
difference, this finding is an improvement over the findings
by Mermelstein and Riesenberg (1992), in which no change in
the likelihood of practicing sun protective behaviors was
noted. It may be that the intervention designed for the
present study, being more comprehensive than those reported
in most other studies, was more effective at changing
intentions to practice sun protective behaviors.
Specifically, the children's "hands on" involvement in the
project (i.e., making sunsafe posters and videos), as well
as their signing a commitment poster likely contributed to
the increase in intentions to wear sunscreen.
It is important to note that the definition of
intentions to practice sun protective behaviors differed
between our study and Mermelstein and Riesenberg's study.
Mermelstein and Riesenberg (1992) used a broad-band


As noted previously, there are several endogenous
factors that place individuals at risk for developing skin
6
cancer. For instance, a family history of malignant
melanoma combined with atypical moles, i.e., dysplastic
nevi, increases one's risk of skin cancer (Friedman et al.,
1991; MacKie et al., 1989) and accounts for approximately.
5% of melanomas (Mackie et al., 1989). Other more common
risk factors that account for a greater percentage of skin
cancer cases include increased number of nevi and presence
of freckles, ethnic characteristics (e.g., fair skin, blond
or red hair, and blue eyes), and living close to the equator
(MacKie et al., 1989). Thus, many individuals are at risk
for developing skin cancer due to biological variables, over
which they have no control. However, many individuals
choose to place themselves at even higher risk for skin
cancer by engaging in behaviors that expose them to a
primary cause of skin cancer: the sun.
Although most people are exposed to exogenous risk
factors, such as the sun, throughout their life, the
majority of sun exposure primarily occurs during childhood
and adolescence. However, skin cancer may not present
itself for several decades following exposure to exogenous
risk factors. The majority of detected skin cancers occur
after age 30, and more commonly after age 50 (Kirkpatrick,
Lee, and White, 1990). This time-lag between the cause (sun
exposure) and effect (skin cancer) interferes with the
association between the two, thus making prevention
difficult.


54
dependent measures was conducted. Results of these analyses
are listed in Table 2. As predicted, results suggested a
significant group by time of assessment interaction effect,
F (4,166) 19.79, p <.001.
To examine group differences at the post-intervention
assessment period, an omnibus between-group's MANOVA across
the four dependent measures was conducted. Results
indicated a significant group effect, F (4,165) = 7.13, p
<.001. Subsequent univariate tests for each scale were
conducted. Results indicated that the intervention group
scored significantly higher on the Knowledge Scale post
intervention compared to the control group £ (1,180) =
17.44, p <.0001. Furthermore, the intervention group
demonstrated significantly healthier attitudes and beliefs
about sun exposure dangers and the importance of sun
protection compared to the control group, as indicated by
their scores on the Attitudes and Beliefs Scale, £ (1,167) =
4.39, p <.05. The intervention group reported significantly
higher intentions to practice sun protective behaviors on
the Intentions Scale compared to the control group, £
(1,180) = 11.62, p <.001. Finally, the intervention group
reported significantly more sunscreen use on the Behavior
Scale compared to the control group, £ (1,179) = 5.77, p
<.05.
Intervention Group: Pre-Post Differences
To determine the intervention's effectiveness within
the intervention group (hypothesis 1), an omnibus within-
subject's MANOVA across the four dependent measures was


74
for identifying the model underpinning this dynamic process
will be warranted.
Overall, 29% and 40% of the variance related to
sunscreen use was accounted for by the predictor variables
for the intervention and control groups, respectively.
These figures are consistent with the 32 34% reported in
other studies (e.g., Cody & Lee, 1989; Mermelstein &
Riesenberg, 1992). The only common finding among these two
studies and the present one is that attitudes towards sun
protection consistently accounts for a significant
proportion of variance related to practicing sun protection
behaviors. Comparison of the results of the present study
with the other studies provided little clarity of the issue
since the studies have considerable differences in the
models and variables used in the predictive equations.
Obviously, future research is needed to ascertain the
variables which best serve to predict sun protection
behavior change over time.
In sum, the findings of the intervention-control group
comparisons suggested that modest increases in intentions to
practice sun protective behaviors, and actual reported
increase in sunscreen use following the intervention were
achieved. These findings provide promising evidence for the
utility of the present sun protection intervention.
Moreover, the results are consistent with other health
promotion interventions (i.e, Botvin, et al, 1984; Flay et
al., 1985; Parcel, et al., 1989) that have demonstrated that


could reduce the lifetime nonmelanoma incidence rates by 78
percent.
9
As has been reviewed in this section, skin cancer is a
formidable health problem that no one is immune to, and some
are at high risk. Its human and economic costs are
increasing exponentially. Fortunately, skin cancer is
preventable if sun exposure behaviors are modified,
especially during childhood and adolescence. Next, research
related to sun exposure and sun protection interventions
will be reviewed.
Knowledge and Attitudes Toward Sun Exposure
and Sun Protection Behaviors
History of Sun Exposure
Society's interest in exposing themselves to the sun
has a fascinating and colorful past (see review by Keesling
& Friedman, 1987). Before the 1900s, the more pale a
person's skin, the higher their perceived social standing.
Pale skin was an indicator of higher social status because
members of the lower class were more likely to work
outdoors and, consequently, be tanned. However, beginning
with the Industrial Revolution, members of the lower class
began to work indoors, and degree of tanning no longer
served to differentiate the social classes. Keesling and
Friedman (1987) identified three factors that changed
society's view towards skin color. First, in the early
1900's, pale skin became associated with poor health and
physical illness (e.g., tuberculosis), whereas a tan was


22
limited scope) results indicated that the peer educational
interventions were effective in increasing knowledge of skin
cancer prevention behaviors.
Mermelstein and Reisenberg (1992) conducted an
intervention study examining the effectiveness of a brief
sun exposure educational presentation on increasing skin
cancer knowledge, personal susceptibility to skin cancer,
and intentions to practice sunsafe behaviors. The
experimental group demonstrated significantly higher skin
cancer knowledge and increased perceived susceptibility
compared to control group, but no differences were noted in
intentions to practice sun protective behaviors. Although
this educational intervention demonstrated some
effectiveness, the authors noted that additional content is
needed addressing sun exposure attitudes for an intervention
to effectively increase intentions to practice sun
protective behaviors.
Hughes, Altman, and Newton (1993) developed a
comprehensive intervention program to increase sun exposure
knowledge and to improve attitudes and behaviors associated
with practicing sunsafe behaviors. Five hundred and forty-
three students from 7 schools participated in the study.
Design of the study included 5 groups: group A read a text
related to sun protection and received an informational
leaflet; group B received the same intervention as group A
with the addition of a video on sun exposure risks; group C
received the same intervention as group A with the addition
of designing a public education poster; group D received the


TABLE OF CONTENTS
PAGE
ACKNOWLEDGEMENTS ii
LIST OF TABLES vi
ABSTRACT V
CHAPTERS
I REVIEW OF LITERATURE 1
Skin Cancer 2
Skin Cancer Information 2
The What, Who, When, and Where of Skin
Cancer 5
Knowledge and Attitudes Toward Sun Exposure
and Sun Protection Behavior 9
History of Sun Exposure 9
Research on Sun Exposure Habits 10
Skin Cancer Risk Reduction Intervention
Studies 13
Knowledge-Based Interventions 13
Knowledge and Attitude-Based
Interventions 16
Sun Protection Interventions Targeting
Children and Adolescents 21
School-Based Health Promotion Interventions.. 26
Theories of Behavior Change 34
II PURPOSE OF STUDY AND HYPOTHESES 40
Purpose 40
Hypotheses 41
III METHODS 42
Subjects 42
Measures 42
Knowledge Scale 45
Attitudes and Beliefs Scale 45
Intentions Scale 46
Behavior Scale 46
Permanent Products Index 47
State-Trait Anxiety Inventory for
Children 48


to practice sun protective behaviors was negatively
predictive of actual practice.
25
The Girgis et al. (1993) study provides an excellent
example of how purely information-based interventions yield
little results in actual behavior change. Although the
content of the intensive intervention was unclear, it did
appear to incorporate a multimodal design, which was likely
a salient factor in increasing sun protective behaviors.
Overall, this study sets forth a foundation for future
efforts in this area. In particular, it will be important
to determine if the increase in sun protective behaviors
generalizes to nonschool settings (e.g., after school,
weekends). Also, it will be important to study variations
in intervention length and intensity to identify the most
efficient and effective intervention design. Finally, it is
uncertain whether the findings of the Girgis et al. (1993)
study are directly applicable to studies conducted in other
countries, given that sun protection issues are likely to be
more salient, and more widely known by individuals in
Australia versus other, less tropical locations in the
world.
In summary, few studies have been conducted on sun
protection interventions, especially for children and
adolescents. A review of the literature suggests that the
school system may be an ideal location for sun protection
interventions. Preliminary findings of the sun protection
interventions suggest that a wide variety of intervention
techniques, such as using multimedia, discussion groups, and


30
et al., 1991). Moreover, interventions incorporating
several modalities have been successful in positively
changing other health behaviors, including seat belt use,
drug and alcohol use, and tobacco use (Botvin, Baker,
Renick, Filazzola, & Botvin, 1984; Flay et al., 1985;
Morrow, 1989).
A second commonality of child health promotion studies
is that they are model driven. Although a variety of health
models have been used, many consist of similar health
variables, and all provide an integrated structure to carry
out the research projects. For instance, many primary
prevention studies to reduce smoking behaviors have used a
psychosocial prevention model which incorporates several
common variables (Flay, 1985). Specifically, the
psychosocial prevention model emphasizes the negative
physical effects of smoking, negative social norms related
to smoking, social pressures to smoke, and behavioral skills
needed to resist social influences to smoke (Flay, 1985).
Other research programs have emphasized the social learning
model, such as the Heart Smart cardiovascular health
promotion project, and rational based theories utilized in
several drug use prevention projects (Johnson, Nicklas,
Arbeit, Franklin, & Berenson, 1988; see Tones, 1987 for
review of drug use prevention). The above mentioned models
are just two of the approaches taken towards health
promotion in children. In the following chapter, other
theoretical models of health promotion will be introduced


CHAPTER III
METHOD
Subjects
Subjects in the study were 225 5th-grade students (128
in the intervention group and 97 in the control group) from
8 5th-grade classes in two elementary schools in Alachua
County, Florida. Students in four classes from one school
were randomly assigned to receive the intervention and
students in the other school were assigned to the control
group. Of the 225 students agreeing to participate in the
study, 46 students (29 intervention, 17 control) were absent
during either pre-or post-testing or during the intervention
itself and subsequently dropped from the analyses.
Pertinent demographic characteristics of the
intervention and control groups are listed in Table 1. Chi-
Square indicated that there were no significant between-
groups differences, X2(l, 198) =.02, p >.05, child-rated
skin type, X2(3, 186) =.46, p >.05, ethnicity, X2(6, 167) =
7.74, p >.05, and SES X2(3, 167) = 4.90, p >.05.
Measures
Since sun exposure research with children is scarce,
several questionnaires were developed to tap the variables
of interest for the study. A 10-item questionnaire
developed by Johnson (1988) was used to test 5th-grader's
42


29
education components and improving the quality of school
lunches. The authors found that subjects in the
experimental group demonstrated increased knowledge of
healthy foods and higher rates of behavioral expectancies
towards healthy foods compared to a control group. In
addition, the intervention contributed to positive changes
in behavior. Health promotion interventions have
demonstrated that attitudes, beliefs and intentions are open
to modification and play a critical role in actual behavior
change.
The most salient goal for most health promotion/disease
prevention interventions is actual positive change in health
risk behaviors. However, for many studies, this goal has
been elusive. For studies that have successfully achieved
behavior change, several common factors have emerged.
First, studies have focused on more broad-band approaches,
using multimodal interventions. For instance, Parcel et
al. (1989) demonstrated that they were successfully able to
change elementary school students' diet and exercise by
intervening at multiple levels. The authors targeted
students and emphasized the importance of a healthy diet and
exercise, utilized peer support by communicating information
and practicing behaviors in the classroom and school
environment, and changed environmental factors such as the
nutrition of school lunches. Other interventions targeting
cardiovascular health promotion have adopted similar
multimodal intervention strategies and have produced
comparable behavior changes (Arbeit et al., 1992; Carleton


14
information, phone interviews were conducted with 342 of the
original 489 subjects to evaluate their current knowledge of
sunscreen and sun exposure risks. Results indicated that
89% of subjects reported reading the informational brochure,
and there was a significant increase in participants'
knowledge of SPF and sun exposure risks (i.e., skin cancer
and wrinkling) compared to initial subject report.
Moreover, 41% of the participants reported using the free
sunscreen sample, but only 10% bought a sunscreen over the
four week time period. Of the identified sun-exposed
sunscreen nonusers during the initial contact, only 35%
tried the free sample of sunscreen and a minimal number of
participants (7%) bought sunscreen. Overall, this
educational intervention was successful in increasing
knowledge of sunscreens and sun-exposure risks, but was
minimally effective in promoting sunsafe behaviors.
In a broader, community-based public health education
program, Kelley (1991) focused on educating adults, children
(preschool through 6th grade), and their parents using a
statewide skin cancer awareness campaign. The education
program used a multimedia approach (brochures, videotapes,
public service announcements, informative news reports,
billboards, artwork, and posters) in Texas, and provided
some participants with sun protective devices (i.e.,
sunscreen and hats). The efficacy of this broad, 6-month
intervention was assessed by an independent survey agency,
who polled over 1000 randomly selected Texans pre- and post
intervention, and asked participants 23 questions pertaining


Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of
the
Requirements for the Degree of Doctor of Philosophy
PRIMARY SCHOOL-BASED HEALTH PROMOTION PROGRAM
FOR INCREASING SUN PROTECTION BEHAVIORS
By
RUSSELL G. HOFFMANN III
August 1995
Chairman: James H. Johnson
Cochairman: James R. Rodrigue
Major Department: Clinical and Health Psychology
The rate of newly diagnosed skin cancer malignancies
has increased dramatically over the past several decades.
This increase is largely attributed to ultraviolet radiation
exposure. Moreover, sun exposure during childhood has been
linked to higher incidence rates of skin cancer in
adulthood. Sun exposure throughout life, especially during
childhood, is primarily a behavior individuals choose to
engage in. Therefore, it is reasonable to conclude that
promoting healthy sun-exposure habits will likely result in
a reduction of skin cancer rates, particularly if the
intervention is introduced during childhood.
The present study examined the effectiveness of a
theory-driven, multimodal intervention to promote safe sun-
exposure behaviors in elementary school students. One of
two schools was randomly assigned to receive the
vii


Child-Rated Skin Type Questionnaire 48
Procedures 49
IV RESULTS 53
Preliminary Analyses 53
Intervention Effectiveness 53
Intervention Group: Pre-Post Differences.... 54
Multiple Regression Analyses 56
V DISCUSSION 64
Strengths and Limitations of the Present
Study 75
Implications of Findings 78
REFERENCES 86
BIOGRAPHICAL SKETCH 95
V


43
Table 1
Demographic Data
Variable
Intervention Group
(n=99)
Control Group
(n=82)
Gender
Male
49%
47%
Female
51%
53%
Ethnicitv
Caucasian
85%
77%
Afric. Amer.
9%
10%
Hispanic
1%
3%
Other
6%
10%
Skin Tvoe
Very Sensitive
10%
10%
Moderately Sensitive
39%
40%
Moderately Insensitive
30%
34%
Insensitive
19%
16%
SES Strata*
1
0%
0%
2
6%
7%
3
21%
14%
4
31%
47%
5
42%
32%
a Hollingshead (1975) 4-factor index of social status


72
intentions. Of these predictor variables from the
theoretical model, the only significant predictor of more
frequent sunscreen use among children receiving the
intervention was more positive attitudes and beliefs,
accounting for 10% of the variance. Once again, knowledge
did not predict behavior. Consistent with the Girgis et al.
(1993) study, pre-intervention sunscreen use was a
significant predictor of post-intervention sunscreen use,
accounting for 33% for the control group, but only 9% of the
variance for the intervention group. The different findings
between MRAs predicting sunscreen use ar not easily
interpretable. It does appear that the intervention did
have some type of impact on the subjects participating in
the study. One explanation may be that the intervention had
an impact on the subjects' attitudes and beliefs regarding
sun protective behaviors, but that the Attitudes and Beliefs
Scale did not accurately assess these changes.
Prochaska and DiClemente's transtheoretical model
(1984) describes the process in which health behaviors
change, and may provide another explanation of these
findings. The authors describe how individuals move from
practicing an unhealthy behavior without intending to change
their behavior (precontemplation state), to considering
changing the behavior (contemplation state), then making the
actual behavior change (action state), and finally
maintaining the changed behavior (maintenance state). Based
on the transtheoretical model, it may be that a considerable
number of subjects in the present study moved from the


36
consequences of engaging in the behavior and evaluation of
these consequences. The subjective norm consists of
perceived beliefs of what important others think about
performing the targeted behavior and motivation to comply
with the behavior. In summary, TRA is defined by how
beliefs, attitudes, and the social norm combine in a
hierarchical manner to predict intention, which in turn,
predicts behavior. For the present study, TRA provides a
conceptual backdrop to structure the sequencing of
intervention components and the interrelationships between
key variables related to change.
The Social Learning Model (SLM), according to Bandura
(1977, 1986), suggests that behaviors can be changed in a
gradual process by the influence of both positive and
negative consequences of the behavior. It is postulated
that individuals in a child's environment, such as
classmates, teachers, and parents, provide both positive and
negative feedback to the child, as well as occasions for
vicarious learning, which serve to shape the child's
behavior. In addition, perceiving that the changes in one's
behavior will be beneficial to oneself is important for
increasing the frequency of a given behavior. Furthermore,
SLM emphasizes the importance of self efficacy, or one's
perception that they are capable of engaging in the targeted
behavior, to increase the probability of behavior change.
Therefore, by increasing awareness and belief in the healthy
aspects of behavior change, one's expectancies for personal
benefits are enhanced, thus increasing motivation to


17
ultraviolet radiation, perceived benefits of sun exposure,
and awareness of changing attitudes towards the use of sun
protective measures. Results of pre-intervention skin
cancer knowledge tests demonstrated that females and
students with high sensitivity skin types answered
significantly more items correct than males and those with
low skin sensitivity. In addition, females and high
sensitivity subjects perceived themselves as more
susceptible to skin cancer, practiced more sun protective
behaviors, and were more aware of changing attitudes
compared to their counterparts. However, both females and
high skin sensitivity students perceived significantly more
benefits to sun exposure than males and low skin sensitivity
participants.
Mermelstein and Reisenberg (1992) examined factors
which predicted behavioral intention to practice sunsafe
behaviors. The authors found that perceived susceptibility
accounted for the largest proportion (25%) of the variance
associated with intentions, with benefits, gender,
awareness, skin type, and knowledge providing unique, yet
minor contributions. Additional analysis of factors
predicting sunscreen use found that behavioral intention to
use sunscreen accounted for 27% of the variance, with
susceptibility and skin type accounting for an additional 5%
and 2%, respectively. The authors concluded that multiple
factors are associated with sunscreen use, but further
research is needed to examine beliefs that promote sun
protective behavior.


66
definition, examining all sun protective behaviors (i.e.,
wearing sunscreen, long-sleeved shirt, etc.) whereas the
present study focused solely on intentions to use sunscreen.
It may be that sun protection interventions have a selective
impact on increasing behaviors most saliently associated
with sun protection (i.e., sunscreen use), and less effect
on behaviors that children are less likely to associate with
sun protection (i.e., wearing a hat). These findings
suggest that a common measurement ground is needed for
intentions to practice sun protective behaviors.
Findings also showed that children in the intervention
group reported wearing sunscreen significantly more often
than children in the control group following the
intervention. Children in the intervention group reported
using sunscreen 33% more often than the control group,
suggesting a modest impact of the intervention on practicing
this sun protective behavior. Further support for the
effectiveness of the intervention was evident in the
significant within-intervention group comparison over time
for sunscreen use. While the control group's sunscreen use
at pre- and post-intervention assessment periods was very
comparable, children in the intervention group increased
sunscreen use by 100% from pre- to post-intervention.
Although both between and within group improvements were
evident, children in the intervention group were using
sunscreen, on average, only a third of the time during
outdoor activities.


11
Moreover, adults, adolescents and young children continue to
spend considerable amounts of time outdoors during peak sun
hours (e.g., Grob et al., 1993; Hill et al., 1992; Johnson &
Lookingbill, 1984). While outdoors, children do not use
sunscreen regularly (e.g., Banks, Silverman, Schwartz, &
Tunnessen, 1992; Hill et al., 1992;), and most children and
adolescents have experienced at least one, if not more,
sunburns (e.g., Banks et al., 1992; Johnson & Lookingbill,
1984). Even those who routinely use sunscreen often do not
reapply it when it is recommended (e.g., after swimming;
Banks et al., 1992).
Several factors appear to be related to children and
adolescent sunscreen use. Females tend to practice sun
protective behaviors more frequently than males (e.g., Banks
et al., 1992; Johnson & Lookingbill, 1984; Mermelstein &
Reisenberg, 1992), as do individuals whose friends use
sunscreen (e.g., Banks et al., 1992; Keesling & Friedman,
1987). Moreover, parents of children having negative sun
exposure experiences (e.g., sunburns) were more likely to
put sunscreen on their children (Maducoc, Wagner, & Wagner,
1992). Finally, children and adolescents having high
sensitivity skin types (i.e. lighter skin tone that burns
easily; Weinstock, 1992) used sunscreen more often than
children and adolescents with low sensitivity skin types
(e.g., Banks et al., 1992; Grob et al., 1993; Mermelstein &
Reisenberg, 1992). However, it should be noted that
individuals tend to underrate their skin sensitivity (Grob
et al., 1992).


52
dangers and methods to reduce sun exposure. Children within
each class period were divided into two groups for easier
management while making the videos.
Homework was assigned for the second day, consisting of
the child and their parent reviewing sunsmart behaviors, and
completing the sunsafe slogan that was initiated in class,
or making a new picture with their caretaker emphasizing the
importance of using sun protective behaviors. Children were
instructed to bring this to the next intervention period.
Dav 3; The third and last class intervention period
allowed children to "show and tell" their posters with
classmates. Most of the class period focused on completing
the videotaping of the sunsafe commercial and general
promotion of the intervention theme. After completion of
the commercials, the videos were reviewed. A final task was
offering the participants the opportunity to sign a
commitment poster indicating their willingness to practice
sunsmart behaviors. Departing comments were made
encouraging participants to continue practicing sun
protective behaviors, but they were not informed of follow
up testing. Classroom teachers for both conditions were
informed of this follow-up testing, but were encouraged not
to inform students about this assessment.


59
Table 4
Hierarchical Multiple Regression Analyses Evaluating the
Contribution of Demographic Variables and Sun Protection
Measures in Predicting the Behavior Score for the
Intervention Group
Predictor
Variables
Beta
Weiaht
Increase
in R2
g value
Pre-Intervention
Behavior Score
.30
.09
.02
Child Gender
.17
.03
.19
Child Skin Type
.18
.03
.16
SES Status
-.06
.00
.67
STAI-C State Score
.20
.00
.97
Knowledge Score
.16
.02
.23
Attitudes and
Beliefs Score
-.35
.10
.01
Intentions Score
-.10
.01
.44
.29 .02
Total


44
skin cancer and sun protection knowledge. An additional
three items were rationally generated to tap areas of
knowledge not included in the ACS questionnaire. Three
other questionnaires were rationally derived and targeted at
the following aspects of the study: (a) personal and
perceived beliefs and attitudes towards skin cancer and sun
protective behaviors, (b) intentions to practice sun
protective behaviors, and (c) self-report of practicing sun
protective behaviors. The four sections are referred to as
the Knowledge Scale, Attitudes and Beliefs Scale, Intentions
Scale, and the Behaviors Scale. In addition, several items
were included in the multicomponent questionnaire to
investigate reasons for not using sunscreen.
Questionnaire items were developed with the cognitive
development of the targeted population in mind. Reading
level of the four scales were estimated by two fifth grade
teachers to be within the ability of the average 5th grade
student. In addition, the measures were analyzed for their
readability via a computer program. Multiple indicators of
the readability of the questionnaires suggested that they
are all questionnaires are within the reading level of the
targeted sample.
Initially, a pilot study was conducted to examine the
internal consistency and test-retest reliability of the four
scales. Subjects in the pilot study were 52 5th-grade
students from P.K. Yonge Developmental School, a University
of Florida laboratory school with an ethically and
socioeconomically diverse student body. Results of the


33
behaviors. Parcel et al. (1989) successfully increased
elementary students' self-efficacy for healthful eating and
physical activity by modeling healthy behaviors for
students, focusing on knowledge and skill development
related to eating and physical activity, self-monitoring of
these behaviors, and providing awards for appropriate
behaviors. Moreover, Basen-Engquist and Parcel (1992) found
that self-efficacy regarding condom use predicted a
significant proportion of the variance associated with
intention to use condoms in a 9th grade sample. Overall,
research on self-efficacy in health behaviors has
demonstrated that this variable is a key component for an
effective intervention.
Overall, health promotion studies have demonstrated
their effectiveness in increasing knowledge related to a
variety of health risks, and promoting positive changes in
attitudes, beliefs, and, most importantly, behaviors
associated with health risks. Components of health
promotion interventions that appear to be essential for
increasing knowledge and changing attitudes and beliefs
related to health risks include: a) providing information
about the specific health risk, b) discussing the benefits
of engaging in risk reducing behaviors, c) altering
perceived social norms regarding behaviors, and d) providing
specific instructions on how to practice healthy behaviors.
Several factors appear to be influential in changing health
risk behaviors, including a multimodal, model driven,
school-based intervention which occurs over more than one


70
accounting for 29% and 45% of the variance, respectively.
Furthermore, in support of the model, healthier attitudes
and beliefs towards skin cancer and sun protection in both
the intervention and control groups were significantly
predictive of higher intentions to engage in sun protective
behaviors, accounting for 8% and 20% of the variance,
respectively. This finding is consistent with other studies
in which attitudes and beliefs accounted for 25 30% of the
variance associated with intentions to practice sun
protective behaviors (Cody & Lee, 1990; Mermelstein &
Riesenberg, 1992). This suggests that attitudes and beliefs
play an important role in shaping intentions to practice sun
protective behaviors, and should be a focal point of future
interventions promoting sun protection behaviors.
However, in contrast to the model predictions, skin
cancer knowledge was not predictive of intentions to wear
sunscreen. This finding also is in contrast to Mermelstein
and Riesenberg1s (1992) results which showed that knowledge
of sun protective behaviors predicted a significant, yet
minor, amount of variance associated with intentions to
practice sun protective behaviors. Research in other areas
of health promotion (e.g., Logan, 1991; Pendergrast et al.,
1992) has found that knowledge of a particular health
problem and ways to manage it is important, yet not a direct
predictor of intentions to or actual practice of a targeted
behavior. It may be that knowledge serves as an indirect,
or diffuse, predictor of a given behavior targeted for


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
This dissertation was submitted to the Graduate Faculty
of the College of Health Related Professions and to the
Graduate School and was accepted as partial fulfillment of
the requirements for the degree of Doctor of Philosophy.
August 1995
Dean, College of Health Related
Professions
Dean, Graduate School


57
the control group. Results of these analyses can be found
in Tables 3 through 6. Both sets of hierarchical MRAs were
computed by entering, first, either the pre-intervention
Intentions Score (when predicting the post-intervention
Intentions Score) or pre-intervention Behavior Score (when
predicting the post-intervention Behavior Score), then
entering each of the demographic variables separately in the
following order: gender, skin type, SES, and STAI-C score.
Next, the post-intervention assessment Knowledge Score was
entered into the equation, followed by the Attitudes and
Beliefs Score to predict behavioral intentions to practice
sun protective behaviors post-intervention. Intentions to
practice sun protective behaviors at the post-evaluation was
then added into the model to predict practice of sunscreen
use, as indicated by the score on the Behavior Scale at the
post-intervention assessment.
Results of the hierarchical MRA using the Intentions
Scale as the dependent measure for the intervention group
indicated that the pre-intervention Intentions Score
significantly predicted 29% of the variance associated with
intentions to wear sunscreen F = 24.20, p =.0001. The
Attitudes and Beliefs score uniquely accounted for an
additional 8% of the variance associated with intentions to
practice sun protective behaviors £ = 7.99, p =.007.
Overall, 47% of the variance associated with the Intentions
Scale was captured by all of the variables in the model for
the intervention group, F = 5.70, p <.0001.


21
be important variables. Moreover, highlighting negative
aspects of sun exposure and use of video presentation appear
to positively change intentions to practice sun protective
behaviors. Finally, community interventions focusing on
reducing sun exposure are an area worthy of further
exploration. It must be noted that sun protection research
is relatively scarce, and further research in this area is
desperately needed if true reduction in skin cancer
prevalence is to occur.
Sun Protection Interventions Targeting Children and
Adolescents
Several interventions promoting reduction of sun
exposure have been examined. However, these studies have
been focused primarily on young adults or the entire age
span. In this section, sun protection interventions
focusing on children and adolescents will be critically
reviewed, and direction for future research will be
highlighted.
In a study by Fork, Wagner, and Wagner (1992), a
focused educational intervention was conducted with peers of
elementary school students. The authors educated 7 third
through fifth graders on skin cancer prevention, and trained
them to present information to a group of 9 first grade
students. Both the trained presenters and the first grade
students were pretested on their skin cancer prevention
knowledge, and post-tested one week after the 5-one hour
intervention sessions. Despite methodological limitations,
(e.g., lack of a control group, small sample size, and


LIST OF TABLES
Table Page
1 Demographic Data 43
2 Means and Standard Deviations of Knowledge
Score, Attitudes and Beliefs Score,
Intentions Score, and Behavior Score for
Intervention and Control Groups and Pre-
and Post-Intervention Assessments 55
3 Hierarchical Multiple Regression Analyses
Evaluating the Contribution of Demographic
Variables and Sun Protection Measures in
Predicting Intentions Score for the
Intervention Group 58
4 Hierarchical Multiple Regression Analyses
Evaluating the Contribution of Demographic
Variables and Sun Protection Measures in
Predicting Behavior Score for the
Intervention Group 59
5 Hierarchical Multiple Regression Analyses
Evaluating the Contribution of Demographic
Variables and Sun Protection Measures in
Predicting Intentions Score for the Control
Group 60
6 Hierarchical Multiple Regression Analyses
Evaluating the Contribution of Demographic
Variables and Sun Protection Measures in
Predicting Behavior Score for the Control
Group 61


45
pilot study suggested that all of the questionnaires had
internal consistencies (Cronbach's alpha) above .60 (range
.60 to .82) and two-week test-retest reliability above .64
(range .64 to .89). Psychometric analyses were also
conducted on the full sample following data collection.
These analyses revealed that one item on the Knowledge scale
(item 7) and two items on the Attitudes and Beliefs scale
(items 7 and 9) significantly lowered the internal
consistency of the measure (as indicated by the corrected
item-to-total correlation and overall alpha if item
deleted). Therefore, these items were dropped from the
measures and all subsequent analyses were conducted without
inclusion of these items.
Knowledge Scale
The revised 12-item (6 items multiple choice, 6 items
true-false) Knowledge Scale assessed children's knowledge of
sun exposure risks and sun protection. A total score was
derived for the measure by summing up the number of correct
items, with a higher score indicating more knowledge. A
score of 12 was the highest attainable score. The
coefficient alpha for the scale was .63, and the two-week
test-retest reliability ranged from r=.59 to r =.61.
Attitudes and Beliefs Scale
The 13-item Attitudes and Beliefs Scale was rationally
derived and was primarily targeted at tapping subjects'
perceptions of sun exposure risks and the costs/benefits of
engaging in sun protective behaviors. In addition, two
items were aimed at subjects' perceived ability to engage in


28
have been effective in increasing children's knowledge
related to the health dangers associated with behaviors,
such as tobacco use, not wearing a bicycle helmet, and poor
dietary and exercise habits, but all have noted the
necessity of other intervention strategies to change
attitudes, beliefs, and behaviors (Butcher et al., 1988;
Flay, 1985; Pendergrast, Seymore-Ashworth, DuRant, &
Litaker, 1992). Overall, interventions focusing solely on
increasing children's knowledge of specific health risks and
behaviors known to reduce risks have been effective only in
increasing knowledge, and have not demonstrated notable
increases in frequency of risk reducing behaviors.
Attempts to modify attitudes, health beliefs, and
intentions have also received attention in the
child/adolescent health promotion literature. For example,
Pendergrast et al. (1992) provided elementary school
students and their parents with information about bicycle
safety. Although students reported that they felt helmets
provided important protection, there was no difference in
the number of students intending to wear a helmet on their
next bike ride compared to pretest data. Children's
intention to wear a helmet was predicted by having lower
parental perceptions of social barriers to use, sibling
ownership of a helmet, and having a positive attitude
towards the use of a helmet. Parcel, Simons-Morton, O'Hara,
Baranowski, and Wilson (1989) conducted an extensive health
promotion campaign to change dietary behaviors in children.
The intervention consisted of education and physical


48
intervention and control schools. Students in both groups
were informed of the availability of the free sunscreen,
with the stipulation that they take only one packet at a
time. Also, they were encouraged to return the empty packet
before taking another full packet. The Permanent Products
Index was the number of full packets remaining, as well as
number of empty packets returned for both intervention and
control groups, at the end of a one-week period beginning on
first day of intervention.
State-Trait Anxiety Inventory for Children
To determine if the intervention had any impact on
subjects' level of anxiety, the 20-item State form of the
State-Trait Anxiety Inventory for Children (STAI-C;
Spielberger, 1973) was completed by all participants at pre
testing. Subjects in the intervention group completed the
State form of the STAI-C for a second time at the end of the
first day of the intervention. This was done to determine
the impact of the primarily educational session on
children's anxiety. Subjects in the control group completed
the State form of the STAI-C for a second time during the
post-assessment testing. The STAI-C has demonstrated good
internal reliability, ranging from .90 to .92, and has
established adequate validity.
Child-Rated Skin Type Questionnaire
A questionnaire created by Johnson (1988) was used to
determine the children's skin type, as well as their
parents' skin type, for the present study. Four skin types
were listed, ranging from very sensitive to pretty


83
Johnson, L. (1988). Living with sunshine; Skin education
activities and ideas for primary teachers. Australia:
Anti-Cancer Foundation of South Australia.
Johnson, S. B. (1991). Methodological considerations in
pediatric behavioral research: Measurement. Journal
of Developmental and Behavioral Pediatrics. 12, 361-
369.
Jones, J. L. & Leary, M. R. Promoting safe-sun practices bv
emphasizing the negative effects of ultraviolet
exposure on physical appearance. Presented at the
American Psychological Association, Washington, D.C.,
August, 1992.
Katz, R. C., & Jernigan, S. (1991). Brief report: An
empirically derived educational program for detecting
and preventing skin cancer. Journal of Behavioral
Medicine. 14., 421-428.
Keesling, B., & Friedman, H. S. (1987). Psychosocial factors
in sunbathing and sunscreen use. Health Psychology. j>,
477-493.
Kelley, P. K. (1991). Skin cancer and melanoma awareness
campaign. Oncology Nursing Forum. 18, 927-931.
Kirkpatrick, C. S., Lee, J. A. H., & White, E. (1990).
Melanoma risk by age and socioeconomic status.
International Journal of Cancer. 46. 1-4.
Logan, B. N. (1991). Adolescent substance abuse prevention:
An overview of the literature. Family and Community
Health. 13, 25-36.
Lombard, D., Neubauer, T. E., Canfield, D., & Winett, R. A.
(1991). Behavioral community intervention to reduce
the risk of skin cancer. Journal of Applied Behavioral
Analysis. 24. 677-686.
MacKie, R. M., Freudenberger, T., & Aitchison, T. C. (1989).
Personal risk-factor chart for cutaneous melanoma.
Lancet. 487-490.
Maducdoc, L. R., Wagner, R. F., & Wagner, K. D. (1992).
Parents' use of sunscreen on beach-going children.
Archives of Dermatology. 128. 628-629.
Mermelstein, R. J., & Riesenberg, L. A. (1992). Changing
knowledge and attitudes about skin cancer risk factors
in adolescents. Health Psychology. 11. 371-376.
Morrow, R. (1989). A school-based program to increase
seatbelt use. Journal of Family Practice. 29., 517-520.


32
classroom intervention and control groups. Perry and her
colleagues suggest that education regarding health risks and
ways of preventing health problems is important, but that
parental involvement plays a key role in actual behavior
change. A review of smoking prevention programs for
children also concluded that parent involvement in promoting
healthy behaviors was most effective in reducing the rate
and onset of smoking in children (Oei & Fea, 1987). In an
attempt to promote cardiovascular risk reduction behaviors
in children, Murray, Perry, and Davis-Hearn (1987)
emphasized that the inclusion of community factors in an
intervention is essential in individual, health promoting
behaviors. Overall, it appears that inclusion of salient
others in intervention programs promotes behavior change.
The involvement of family and the community likely improves
perceived social norms towards the targeted behavior, as
well as capitalizes on reinforcement paradigms already
established within the family and community for engaging in
the targeted healthy behaviors.
A fifth similarity of successful health promotion
studies is the practicing of targeted healthy behaviors. In
his work on social learning theory, Bandura (1986)
emphasized the importance of developing self-efficacy.
Self-efficacy is a component of the social learning theory,
and, for health promotion studies, consists of increasing
participants' knowledge of a given health issue, developing
mastery of behaviors associated with prevention of the
disease, and providing positive role-modeling of healthy


CHAPTER I
REVIEW OF LITERATURE
Skin cancer is now the most common malignancy in the
United States (American Cancer Society, 1988; Glass &
Hoover, 1989; Williams & Pennella, 1994). The deadliest
form of skin cancer, malignant melanoma, is increasing at a
rate higher than any other form of cancer (Friedman, Rigel,
Silverman, Kopf, & Vossaert, 1991). Of the 600,000
individuals who are diagnosed with skin cancer each year,
most can be treated successfully; however, several thousand
cases are terminal (American Cancer Society, 1988). In
addition to the human cost, there is an exorbitant financial
cost in treating individuals with skin cancer (Keesling &
Friedman, 1987).
Ninety-five percent of skin cancers are attributed to
ultraviolet radiation exposure (Skolnick, 1991), both
intentional (e.g., sun tanning) and unintentional (e.g.,
outdoor occupation). Moreover, sun exposure during
childhood has been linked to higher skin cancer incidence
rates (Truhn, 1991). Of increasing concern are recent
scientific findings suggesting that the intensity of
ultraviolet radiation exposure may be increasing due to
ozone depletion (Amron & Moy, 1991). If the ozone layer is
thinning, skin cancer rates and deaths with this disease are
estimated to skyrocket (Skolnick, 1991).
1



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34
class period. These successful interventions include the
participation of parents, and consist of modeling healthy
behaviors for children and assisting them in the development
of these health promoting behaviors. This "formula" has
demonstrated its effectiveness in making initial changes in
behavior, and increasing the likelihood of incorporating
these behaviors into the child's "lifestyle." It appears
that many aspects of this "formula" for successful health
promotion interventions can be used in the promotion of sun
protective behaviors, with the short-term goal of reducing
sunburns in children and a long-term goal of reducing the
rate of skin cancer in the population.
Theories of Behavior Change
As previously mentioned, an essential element of an
effective intervention is the use of a theoretical
conceptualization to provide the necessary guidance and
infrastructure to the project. Several theories have been
used to guide research in the area of health promotion, yet
no one theory has come to dominate health promotion
interventions, especially those used in the school systems
(Parcel, 1984). In the following section, a select number
of these health theories will be reviewed, and their
application to increasing sun protective behaviors will be
highlighted.
During a Child Health Conference in 1981, several
models were identified as germane to guiding future research
on children's health behaviors (Bruhn & Parcel, 1982). The