Abstract
Promoting sun-protective behaviors is important because decreased exposure to ultraviolet radiation (UVR) reduces the risk of skin cancer. However, many individuals deliberately engage in overexposure to UVR for cosmetic purposes. Due to this and other factors, the need for prevention programs is clear. Several efficacious prevention strategies have been developed for the health care setting.
Exposure to ultraviolet radiation (UVR) through the sun is the most preventable cause of skin cancer, 1 and more than 2 million cases of nonmelanoma skin cancer are diagnosed in the United States each year. 2 As discussed in this issue by Morganroth et al, 3 multiple steps can and should be taken to protect oneself from UVR. Although these protection strategies are clear and many instances of skin cancer are preventable, the incidence of skin cancer is on the rise.4-7 This increase in incidence is likely due to many factors including deliberate UVR exposure. 8 Although there is a relatively high level of knowledge of skin cancer risk associated with UVR exposure, 9 deliberate exposure remains popular because tanned skin is viewed as attractive and desirable.10-12 Trends in the United States indicate that minimal changes in sun-protective behavior have been made over the past 10 years and that only a small percentage of people engage in multiple sun-protection strategies. 13
Exposure to ultraviolet radiation (UVR) through the sun is the most preventable cause of skin cancer.
To increase the use of sun-protection strategies, many programs have been developed to address the knowledge, attitudes, and beliefs around this issue.13,14 These interventions typically focus on high-risk individuals or small groups within an organizational context (eg, school, worksite, or recreation program) and are provided in a variety of ways, including printed materials, lectures, and multimedia programs. 14 Some evidence supports the need for multilevel or comprehensive interventions that include public health campaigns and legislation (eg, tax-free sunscreen and limits to occupational UV exposure). 13 Although it is difficult to assess the overall effectiveness of these programs due to the inconsistencies in evaluated outcomes, variability in interventions, and limited studies that measure actual behavior change, 14 multiple randomized controlled trials have been conducted in this area.15-25
Interventions for the Primary Care Setting
Counseling in the primary care setting has been shown to promote sun-protective behaviors for adults, adolescents, and children. 26 Considerable variability is found for interventions used between these age groups, with several interventions showing considerable promise. Specifically, appearance-based interventions and brief counseling with adults, and integrated counseling during well-child visits for children have been used with success. The importance of providing feedback regarding the impact of UV exposure is a consistent component in interventions with adults, whereas interventions with young children are more likely to focus on parental behaviors.
Appearance-Based Interventions
These interventions are intended to highlight the link between UVR exposure and the possible negative appearance consequences that exposure may have (eg, wrinkles and age spots). To provide this type of individualized feedback, UV photography is used. This type of photography captures uneven pigmentation, which appears as brown splotches. 27 Viewing a photograph with brown areas on a patient’s face may make the message of sun protection more salient and immediate. In turn, saliency and immediacy affect the level of awareness in patients. This type of feedback also is likely to be more effective than messaging about long-term cancer risk because it provides feedback about events that occur more frequently than cancer (eg, wrinkles). Appearance-based interventions have been shown to decrease indoor tanning, 28 improve sun-protection intentions, 27 and improve objective assessments of sun-protective behaviors long term in young adults. 21 Because UV photography is both brief and inexpensive, it appears to be a viable intervention to promote sun-protection behaviors. 21
Brief Counseling
Although there is considerable variability in the topics to be covered to promote sun-protection behaviors, health care providers are encouraged to include basic information on ways to protect skin from the sun, characteristics of skin that may be at risk, and the removal of barriers associated with engaging in sun-protective behaviors.15,16 Providing tailored feedback based on individual characteristics such as complexion and family history may be beneficial as well. 15 Informing patients in the highest risk groups for skin cancer has been shown to significantly increase skin self-exams. 16 Computer programs have been developed as one way to provide this information in an effective manner. 15 Overall, interventions that use behavioral counseling appear to increase sun-protective behaviors and decrease indoor tanning. 26
Well-Child Visits
Promoting sun-protective behaviors in children is important for several reasons. For example, a single severe sunburn in childhood significantly increases the risk of developing skin cancer. 29 Additionally, the establishment of childhood routines for these behaviors has been shown to promote life-long habits. 30 An intervention has been developed that involves parents of young children during well-child visits and may be one way to effectively change sun-protective behaviors for this age group. 31 In this intervention, parents were first provided environmental reminders (eg, refrigerator magnets), sun-protective products (eg, sun screen samples and UV-protective sunglasses), and informational packets containing age-appropriate tips for sun protection. Additionally, messages for sun protection were placed in children’s medical charts as prompts for the health care provider to briefly remind parents of the importance of sun protection during each well-child visit. This program resulted in improvements in providers giving sun-protection advice and parents reporting more sun-protective behaviors compared to a control group. 31
Conclusion
Given the prevalence of skin cancer, 2 there is a clear need for prevention in this area. One prevention strategy is to reduce UVR exposure by engaging in sun-protective behaviors. Although multiple barriers exist for patients to engage in these behaviors (eg, getting a tan is viewed as attractive),10-12 health care providers have been shown to play a critical role in these prevention efforts. 26 Appearance-based interventions and brief behavioral counseling have been shown to be effective for adults,15,16,27 and focusing on parental behaviors has been shown to be effective for children. 31 Although providing sun-protective information to all patients is supported, it may be most important to assign patients a risk score. 16 Not only will this help ensure that those with the highest risk are provided with the most appropriate care, patients with the highest risk have been shown to incorporate these behaviors to a greater degree into their daily lives.