Visual Aids for Sunscreen Application: A mixed methods study.

BACKGROUND: Consumers routinely underapply sunscreen, and this may be because they misinterpret application quantity directions on sunscreen labels. U.S. labels use ambiguous terms such as "apply generously" to communicate application quantity. Visual aids may be helpful to consumers to determine proper application quantity. PURPOSE: To examine sunscreen application practices and sunscreen quantity visual aid preferences. METHODS: Sets of five GIFs and five static images were created corresponding to five quantities of sunscreen. Participants extracted their typical-use sunscreen quantity from a pre-measured tube and answered questions about their estimation process and use of labeled instructions. Participants then identified their typical-use sunscreen quantity in response to three stimuli: teaspoons, images, and GIFs and reported their preferred format. RESULTS: No participants reported using the label directions for application quantity to inform their sunscreen use. The GIF-based visual aid for sunscreen application quantity (44%) was preferred over image-based (40%) or teaspoon-based (16%) versions (p = .0249). Addition of a GIF demonstration to clarify application quantity was reported as highly helpful. CONCLUSION: Consumers have difficulty determining the appropriate quantity of sunscreen to use and labeling does not influence their application quantity. A QR code incorporating an image or GIF demonstration of proper sunscreen quantity could be useful to sunscreen consumers.

Cross-sectional Association between Walking and Sunburn: A Potential Trade-off between Cancer Prevention and Risk Factors.

BACKGROUND: The positive association between physical activity and sunburn is a health behavior trade-off between the health benefits of physical activity and increased risk of skin cancer. PURPOSE: We assessed walking, which is a common source of physical activity, and the prevalence of sunburn. METHODS: This research used the 2015 National Health Interview Survey of adults (N = 26,632), age ≥ 18 years. We defined four exclusive categories of walking: (a) those who reported not walking; (b) only transportation (to get some place, such as work, a store, or public transit stop); (c) only leisure (such as for fun, relaxation, or exercise); and (d) both categories. We estimated the adjusted prevalence of sunburn by walking category and separately for walking duration; we stratified by gender and sun sensitivity. RESULTS: The adjusted sunburn prevalence was not different between walking categories for women, but it was for men. Specifically, prevalence was lower for men who reported not walking, 34.1% (95% confidence interval [CI]: 32.2%-36.1%) compared to 38.8% (95% CI: 36.5%-41.2%) who walked for both purposes (p = .003). Walking duration was not associated with sunburn prevalence. CONCLUSION: We could not determine whether sunburn occurred during walking trips because the questions were not asked as such. However, the results suggest that walking, unlike leisure-time physical activity (such as exercise, sports, or physically active hobbies), may not generally be associated with sunburn, except for the higher sunburn prevalence for men who walked for both leisure and transportation purposes.

Associations between ultraviolet radiation, tree cover and adolescent sunburns.

BACKGROUND: Sunburn is the strongest risk factor for melanoma and non-melanoma skin cancers. Adolescent sunburns are related to higher risk of developing melanoma later in life. Little is known about the association of sunburns and shade, particularly tree cover, around adolescent homes and schools. This linkage study assessed associations of adolescent self-reported sunburns with ambient ultraviolet radiation (UV) and tree cover. METHODS: We analyzed a U.S. national sample of parent-child dyads (n = 1333) from the 2014 Family Life, Activity, Sun, Health, and Eating (FLASHE) study conducted by the National Cancer Institute. The outcome was adolescent sunburns reported for the previous 12 months. GIS buffers around geocoded home and school addresses were used to summarize UV and tree cover. A sensitivity analysis assessed different UV measures and tree cover buffer distances. Logistic regression models estimated the adjusted odds of any sunburns for five models: (1) no environmental variables; (2) spatial variables of latitude and longitude; (3) UV; (4) tree cover; and, (5) a combined model with UV and tree cover. Covariates included common sunburn-related items such as sun protective behaviors, socio-demographics, and latitude. Model residuals were assessed for spatial dependency and clustering. RESULTS: Overall, 44% of adolescents reported any sunburns in the previous 12 months. For the bivariate associations, lower categories of UV were associated with any reported sunburns (p-trend = 0.002). Home tree cover was not associated with any reported sunburns (p-trend = 0.08), whereas schools with lower categories of tree cover were associated with sunburns (p-trend = 0.008). The adjusted odds of any sunburns by UV tertiles, as a linear tread, was 0.89 (0.76-1.05) (p = 0.17); school tree cover was: 0.91 (0.78-1.07) (p = 0.25). Neither UV nor tree cover, in a combined model, were significant. Sensitivity analyses resulted in the optimal buffer size of 200 m for summarizing tree cover. Spatial dependence of residuals was not significant and clustering was significant for about 6% or less of the sample in each model. CONCLUSIONS: We did not find significant relationships between UV or tree cover and adolescent sunburns, when adjusted by sunburn-related covariates. Better contextual data about where sunburns occurred is needed to identify environmental correlates of sunburn.

Adolescent Physical Activity at Public Schools, Private Schools, and Homeschools, United States, 2014.

INTRODUCTION: Physical activity overall and during school-related opportunities among homeschool adolescents are poorly documented. METHODS: We used data from the National Cancer Institute's Family Life, Activity, Sun, Health, and Eating (FLASHE) study, a national sample of parent-child dyads. We examined reported frequency of physical activity in middle-school and high-school respondents (N = 1,333). We compared the overall physical activity by school type (ie, public school, private school, and homeschool), compared school-related contexts (eg, recess, physical education [PE] class), and tested for level of physical activity by school for those reporting PE. RESULTS: Middle-school homeschool adolescents reported less physical activity during school hours compared with public school, but not private school, adolescents. Physical activity was not different by school type for out of school or weekends. Physical activity of high-school homeschool adolescents was not different from that of high-school adolescents at traditional schools; homeschool adolescents in both middle and high school reported less physical activity in PE compared with public and private school adolescents. Other school-related contexts of physical activity were not different by school type. More homeschool students reported not having PE (middle school, 54.8%; high school, 57.5%) compared with public (middle school, 18.7%; high school, 38.0%) or private schools (middle school, 13.5%; high school, 41.5%). CONCLUSION: Homeschool adolescents in middle school reported less physical activity compared with middle-school adolescents in traditional schools during school hours, likely because of having fewer PE classes and less physical activity during PE.

Evaluating the attractiveness of a new light rail extension: Testing simple change and displacement change hypotheses.

Many communities in the United States have been adding new light rail to bus-predominant public transit systems. However, there is disagreement as to whether opening light rail lines attracts new ridership or merely draws ridership from existing transit users. We study a new light rail line in Salt Lake City, Utah, USA, which is part of a complete street redevelopment. We utilize a pre-test post-test control group quasi-experimental design to test two different measures of ridership change. The first measure is calculated from stops along the light rail route; the second assumes that nearby bus stops might be displaced by the rail and calculates ridership change with those stops included as baseline. Both the simple measure (transit use changes on the complete street light rail corridor) and the "displacement" measure (transit use changes in the one-quarter mile catchment areas around new light rail stops) showed significant (p < .01) and substantial (677%) increases in transit passengers compared to pre-light rail bus users. In particular, the displacement analysis discredits a common challenge that when a new light rail line opens, most passengers are simply former bus riders whose routes were canceled in favor of light rail. The study suggests that light rail services can attract additional ridership to public transit systems. In addition, although pre-post control-group designs require time and effort, this project underscores the benefits of such quasi-experimental designs in terms of the strength of the inferences that can be drawn about the impacts of new transit infrastructure and services.

Transit Use, Physical Activity, and Body Mass Index Changes: Objective Measures Associated With Complete Street Light-Rail Construction.

OBJECTIVES: We assessed effects on physical activity (PA) and weight among participants in a complete street intervention that extended a light-rail line in Salt Lake City, Utah. METHODS: Participants in the Moving Across Places Study resided within 2 kilometers of the new line. They wore accelerometers and global positioning system (GPS) loggers for 1 week before and after rail construction. Regression analyses compared change scores of participants who never rode transit with continuing, former, and new riders, after adjustment for control variables (total n = 537). RESULTS: New riders had significantly more accelerometer-measured counts per minute than never-riders (P < .01), and former riders had significantly fewer (P < .01). New riders lost (P < .05) and former riders gained (P < .01) weight. Former riders lost 6.4 minutes of moderate-to-vigorous PA (MVPA) per 10 hours of accelerometer wear (P < .01) and gained 16.4 minutes of sedentary time (P < .01). New riders gained 4.2 MVPA minutes (P < .05) and lost 12.8 (P < .05) sedentary minutes per 10 hours accelerometer wear. CONCLUSIONS: In light of the health benefits of transit ridership in the complete street area, research should address how to encourage more sustained ridership.

Physical activity mediates the relationship between perceived crime safety and obesity.

OBJECTIVE: The current cross-sectional study tests whether low perceived crime safety is associated with body mass index (BMI) and obesity risk and whether less moderate-to-vigorous physical activity (MVPA) accounts for part of this relationship. METHOD: Adults (n=864) from a relatively low-income and ethnically mixed neighborhood in Salt Lake City UT (2012) were assessed for perceived crime safety, objective physical activity, and BMI measures. RESULTS: This neighborhood had lower perceived safety than for other published studies utilizing this safety measure. In a mediation test, lower perceived crime safety was significantly associated with higher BMI and greater risk of obesity, net of control variables. Residents with lower perceived safety had less MVPA. Lower MVPA partially explained the relationship between less safety and both elevated BMI and higher obesity risk, suggesting that perceiving less crime safety limits MVPA which, in turn, increases weight. CONCLUSION: In this neighborhood, with relatively low perceived safety from crime, residents' low perceived safety is related to more obesity and higher BMI; lower MVPA among residents explained part of this relationship. If residents are to become more active in their neighborhood it may be important to address perceived crime safety as part of broader efforts to enhance active living.

Adding maps (GPS) to accelerometry data to improve study participants' recall of physical activity: a methodological advance in physical activity research.

OBJECTIVE: Obtaining the 'when, where and why' of healthy bouts of moderate-to-vigorous physical activity (MVPA) provides insights into natural PA. DESIGN: In Salt Lake City, Utah, adults wore accelerometer and Global Positioning System (GPS) loggers for a week in a cross-sectional study to establish baseline travel and activity patterns near a planned Complete Street intervention involving a new rail line, new sidewalks and a bike path. RESULTS: At the end of the week, research assistants met with the 918 participants who had at least three 10 h days of good accelerometer readings. Accelerometer and GPS data were uploaded and integrated within a custom application, and participants were provided with maps and time information for past MVPA bouts of ≥3 min to help them recall bout details. Participants said that 'getting someplace' was, on average, a more important motivation for their bouts than leisure or exercise. A series of recall tests showed that participants recalled most bouts they were asked about, regardless of the duration of the bout, suggesting that participant perceptions of their shorter lifestyle bouts can be studied with this methodology. Visual prompting with a map depicting where each bout took place yielded more accurate recall than prompting with time cues alone. CONCLUSIONS: These techniques provide a novel way to understand participant memories of the context and subjective assessments associated with healthy bouts of PA. Prompts with time-stamped maps that illustrate places of MVPA offer an effective method to improve understanding of activity and its supportive sociophysical contexts.

Homeschool Student Physical Activity Compared to Public/Private School Students: The 2017 US National Household Travel Survey.

BACKGROUND: School is an important place for physical activity (PA); however, little is known about how homeschool students' PA levels compare with public and private school students. This study estimated the national prevalence of PA levels of homeschool students compared to public and private school students. METHODS: We used the 2017 National Household Travel Survey for school-aged participants (N = 31,486) to compare weekly PA (not active, light or moderate activity, or vigorous activity) by school type (public/private or homeschool) and school level (elementary, middle, and high school). RESULTS: Unadjusted analyses found higher prevalence of physical inactivity for homeschool students, 14.2% (95% CI, 9.7-18.7%), compared to public/private school students, 8.0% (95% CI, 7.1-9.0%). For students who reported any PA, there was no difference in mean number of episodes for light or moderate PA [public/private: 4.2 (95%, CI, 4.1-4.3), homeschool: 4.3 (95% CI, 3.9-4.6)], or vigorous PA [public/private: 5.6 (95% CI, 5.5-5.7); homeschool: 5.5 (95% CI, 4.9-6.0)]. Results were comparable for covariate-adjusted analyses. CONCLUSIONS: A higher percentage of homeschool students report being physically inactive compared to public/private school students. However, data with more specific measures of PA intensity and duration are required to determine the potential magnitude of reported differences in behavior.

Perceived Usefulness and Recall of Sunscreen Label Information by Consumers.

Importance: In February 2019, the US Food and Drug Administration issued a proposed rule (84 FR 6204), an amendment to the Sunscreen Innovation Act of 2014, that would require listing active ingredients on the principal display panel of sunscreens to allow consumers to "more readily compare products and either select or avoid a given product accordingly." Objective: To understand consumers' perceived importance of active ingredients in sunscreen and their ability to recall these ingredients when comparing, avoiding, or selecting sunscreen products. Design, Setting, and Participants: In this qualitative study, participants were recruited from Fors Marsh Group and User Works, Inc consumer panels and interviewed in person in November and December 2019. Eligible participants were 18 years or older, reported sunscreen use in the past 12 months, and were residents of the Washington, DC, area. After viewing 2 mock sunscreen labels (1 that meets current US Food and Drug Administration requirements and 1 designed to meet proposed requirements), participants were asked questions to assess their perceived importance of active ingredients in sunscreen products, whether they could recall any of the active ingredients on the labels, and whether they typically looked for active ingredients on a sunscreen label. Main Outcomes and Measures: The main outcomes were the sunscreen label information used by participants to select a sunscreen and their ability to recall the active ingredients after viewing 2 mock sunscreen labels. Results: The mean (SD) age of the 47 participants was 42.8 (13.6) years, 32 (68%) were women, and 40 (85%) had a bachelor's or graduate degree. Of the total, 13 (28%) participants stated that sunscreen ingredients influenced their sunscreen selection, but only 5 (11%) said it was the most important information. Instead, 34 (72%) participants stated that the sun protection factor rating was the most important information. After viewing the mock sunscreen labels, only 5 (11%) participants recalled any of the active ingredients, although 10 (21%) reported typically looking at active ingredients when choosing a sunscreen. Conclusions and Relevance: This qualitative study investigated the US Food and Drug Administration's proposed new rule requiring that active ingredients be listed on the front of sunscreen labels to facilitate product comparison for consumers. However, active ingredients were not reported to be a primary reason for consumers' sunscreen selection. Recall of active ingredients was low, and few consumers reported typically looking at the active ingredients, which were more commonly used to avoid ingredients rather than to select a sunscreen. Therefore, listing active ingredients on the front label alone may not have the intended usefulness for consumers.

The 2019 Conference on Health and Active Transportation: Research Needs and Opportunities.

Active transportation (AT) is widely viewed as an important target for increasing participation in aerobic physical activity and improving health, while simultaneously addressing pollution and climate change through reductions in motor vehicular emissions. In recent years, progress in increasing AT has stalled in some countries and, furthermore, the coronavirus (COVID-19) pandemic has created new AT opportunities while also exposing the barriers and health inequities related to AT for some populations. This paper describes the results of the December 2019 Conference on Health and Active Transportation (CHAT) which brought together leaders from the transportation and health disciplines. Attendees charted a course for the future around three themes: Reflecting on Innovative Practices, Building Strategic Institutional Relationships, and Identifying Research Needs and Opportunities. This paper focuses on conclusions of the Research Needs and Opportunities theme. We present a conceptual model derived from the conference sessions that considers how economic and systems analysis, evaluation of emerging technologies and policies, efforts to address inclusivity, disparities and equity along with renewed attention to messaging and communication could contribute to overcoming barriers to development and use of AT infrastructure. Specific research gaps concerning these themes are presented. We further discuss the relevance of these themes considering the pandemic. Renewed efforts at research, dissemination and implementation are needed to achieve the potential health and environmental benefits of AT and to preserve positive changes associated with the pandemic while mitigating negative ones.

Walking and Sun Protective Behaviors: Cross-Sectional Associations of Beneficial Health Factors.

Sun protective behaviors and physical activity have the potential to reduce cancer risk. Walking is the most common type of physical activity in the United States, but it is unclear whether sun protective behaviors differ by categories of walking, such as leisure versus transportation walking. We examined whether sun protective behaviors varied by category or duration of walking in the 2015 National Health Interview Survey (N = 26,632), age ≥ 18 years. We used logistic regression to estimate sunscreen use, sun avoidance, and sun protective clothing use by four categories of walking (no reported walking, transportation only, leisure only, or walking for both) and separately for walking duration for the general population and sun-sensitive individuals. Prevalence of sunscreen use varied across walking categories and the odds of use were higher with longer walking duration for transportation and leisure compared to those who reported no walking. Sun avoidance varied across walking categories and the odds of avoidance were lower with longer duration leisure but not transportation walking. Sun protective clothing varied across walking categories and the odds of use were higher for longer duration transportation, but not leisure walking. Data on the concurrence of walking and sun protection is needed to further understand the relationship between these health behaviors. By examining leisure and transportation walking, we found variations in sun protective behaviors that may provide important insight into strategies to increase sun protection while promoting physical activity.

Geographic regions for assessing built environmental correlates with walking trips: A comparison using different metrics and model designs.

There is growing international evidence that supportive built environments encourage active travel such as walking. An unsettled question is the role of geographic regions for analyzing the relationship between the built environment and active travel. This paper examines the geographic region question by assessing walking trip models that use two different regions: walking activity spaces and self-defined neighborhoods. We also use two types of built environment metrics, perceived and audit data, and two types of study design, cross-sectional and longitudinal, to assess these regions. We find that the built environment associations with walking are dependent on the type of metric and the type of model. Audit measures summarized within walking activity spaces better explain walking trips compared to audit measures within self-defined neighborhoods. Perceived measures summarized within self-defined neighborhoods have mixed results. Finally, results differ based on study design. This suggests that results may not be comparable among different regions, metrics and designs; researchers need to consider carefully these choices when assessing active travel correlates.

Analyzing Walking Route Choice through Built Environments using Random Forests and Discrete Choice Techniques.

Walking is a form of active transportation with numerous benefits, including better health outcomes, lower environmental impacts and stronger communities. Understanding built environmental associations with walking behavior is a key step towards identifying design features that support walking. Human mobility data available through GPS receivers and cell phones, combined with high resolution walkability data, provide a rich source of georeferenced data for analyzing environmental associations with walking behavior. However, traditional techniques such as route choice models have difficulty with highly dimensioned data. This paper develops a novel combination of a data-driven technique with route choice modeling for leveraging walkability audits. Using data from a study in Salt Lake City, Utah, USA, we apply the data-driven technique of random forests to select variables for use in walking route choice models. We estimate data-driven route choice models and theory-driven models based on predefined walkability dimensions. Results indicate that the random forest technique selects variables that dramatically improve goodness of fit of walking route choice models relative to models based on predefined walkability dimensions. We compare the theory-driven and data-driven walking route choice models based on interpretability and policy relevance.

Changes in bicycling over time associated with a new bike lane: relations with kilocalories energy expenditure and body mass index.

Although bicycling has been related to positive health indicators, few studies examine health-related measures associated with non-competitive community cycling before and after cycling infrastructure improvements. This study examined cycling changes in a neighborhood receiving a bike lane, light rail, and other "complete street" improvements. Participants wore accelerometers and global positioning system (GPS) data loggers for one week in both 2012 and 2013, pre- and post- construction completion. Participants sampled within 2 km of the complete street improvements had the following patterns of cycling: never cyclists (n=434), continuing cyclists (n= 29), former cyclists (n=33, who bicycled in 2012 but not 2013), and new cyclists (n=40, who bicycled in 2013 but not 2012). Results show that all three cycling groups, as identified by GPS/accelerometry data, expended more estimated kilocalories (kcal) of energy per minute during the monitoring week than those who were never detected cycling, net of control variables. Similar but attenuated results emerged when cycling self-report measures were used. BMI was not related to cycling group but those who cycled longer on the new path had lower BMI. Although cyclists burn more calories than non-cyclists across the week, among cyclists, their cycling days involved more calories expended than their non-cycling days. The new cyclists account for 39% of the cyclists identified in this study and former cyclists account for 32% of cyclists. These results suggest that cycling is healthy, but that sustaining rates of cycling will be an important goal for future policy and research.

Assessing Built Environment Walkability using Activity-Space Summary Measures.

There is increasing emphasis on active transportation, such as walking, in transportation planning as a sustainable form of mobility and in public health as a means of achieving recommended physical activity and better health outcomes. A research focus is the influence of the built environment on walking, with the ultimate goal of identifying environmental modifications that invite more walking. However, assessments of the built environment for walkability are typically at a spatially disaggregate level (such as street blocks) or at a spatially aggregate level (such as census block groups). A key issue is determining the spatial units for walkability measures so that they reflect potential walking behavior. This paper develops methods for assessing walkability within individual activity spaces: the geographic region accessible to an individual during a given walking trip. We first estimate street network-based activity spaces using the shortest path between known trip starting/ending points and a travel time budget that reflects potential alternative paths. Based on objective walkability measures of the street blocks, we use three summary measures for walkability within activity spaces: i) the average walkability score across block segments (representing the general level of walkability in the activity space); ii) the standard deviation (representing the walkability variation), and; iii) the network autocorrelation (representing the spatial coherence of the walkability pattern). We assess the method using data from an empirical study of built environment walkability and walking behavior in Salt Lake City, Utah, USA. We visualize and map these activity space summary measures to compare walkability among individuals' trips within their neighborhoods. We also compare summary measures for activity spaces versus census block groups, with the result that they agree less than half of the time.

Environmental, behavioral, and psychological predictors of transit ridership: Evidence from a community intervention.

Understanding who takes advantage of new transit (public transportation) interventions is important for personal and environmental health. We examine transit ridership for residents living near a new light rail construction as part of "complete street," pedestrian-friendly improvements. Adult residents (n=536) completed surveys and wore accelerometer and GPS units that tracked ridership before and after new transit service started. Transit riders were more physically active. Those from environments rated as more walkable were likely to be continuing transit riders. Place attachment, but not perceived physical incivilities on the path to transit, was associated with those who continued to ride or became new riders of transit. This effect was mediated through pro-city attitudes, which emphasize how the new service makes residents eager to explore areas around transit. Thus, place attachment, along with physical and health conditions, may be important predictors and promoters of transit use.

A Complete Street Intervention for Walking to Transit, Nontransit Walking, and Bicycling: A Quasi-Experimental Demonstration of Increased Use.

BACKGROUND: Complete streets require evaluation to determine if they encourage active transportation. METHODS: Data were collected before and after a street intervention provided new light rail, bike lanes, and better sidewalks in Salt Lake City, Utah. Residents living near (<800 m) and far (≥801 to 2000 m) from the street were compared, with sensitivity tests for alternative definitions of near (<600 and <1000 m). Dependent variables were accelerometer/global positioning system (GPS) measures of transit trips, nontransit walking trips, and biking trips that included the complete street corridor. RESULTS: Active travel trips for Near-Time 2 residents, the group hypothesized to be the most active, were compared with the other 3 groups (Near-Time 1, Far-Time 1, and Far-Time 2), net of control variables. Near-Time 2 residents were more likely to engage in complete street transit walking trips (35%, adjusted) and nontransit walking trips (50%) than the other 3 groups (24% to 25% and 13% to 36%, respectively). Bicycling was less prevalent, with only 1 of 3 contrasts significant (10% of Near-Time 2 residents had complete street bicycle trips compared with 5% of Far-Time 1 residents). CONCLUSIONS: Living near the complete street intervention supported more pedestrian use and possibly bicycling, suggesting complete streets are also public health interventions.

Public transit generates new physical activity: Evidence from individual GPS and accelerometer data before and after light rail construction in a neighborhood of Salt Lake City, Utah, USA.

Poor health outcomes from insufficient physical activity (PA) are a persistent public health issue. Public transit is often promoted for positive influence on PA. Although there is cross-sectional evidence that transit users have higher PA levels, this may be coincidental or shifted from activities such as recreational walking. We use a quasi-experimental design to test if light rail transit (LRT) generated new PA in a neighborhood of Salt Lake City, Utah, USA. Participants (n=536) wore Global Positioning System (GPS) receivers and accelerometers before (2012) and after (2013) LRT construction. We test within-person differences in individuals' PA time based on changes in transit usage pre- versus post-intervention. We map transit-related PA to detect spatial clustering of PA around the new transit stops. We analyze within-person differences in PA time based on daily transit use and estimate the effect of daily transit use on PA time controlling for socio-demographic variables. Results suggest that transit use directly generates new PA that is not shifted from other PA. This supports the public health benefits from new high quality public transit such as LRT.