Randomized trial of a web-based survivor intervention on melanoma prevention behaviors of first-degree relatives.

OBJECTIVES: Melanoma can be prevented through reducing sun exposure and detected early by increasing examination of skin for lesions. First-degree relatives of melanoma cases have higher risk than the general population and, therefore, could be targets of behavioral interventions through families. We tested the effects of a family-based web delivered intervention to melanoma families on the melanoma risk reduction behaviors of first-degree relatives of melanoma cases. METHODS: A total of 313 families that included one first-degree relative were recruited to join this randomized trial. All intervention families received access to the Suntalk website developed to promote family communication and behavioral risk reduction among families of melanoma survivors. RESULTS: First degree relatives in the intervention arm significantly increased their yearly performance of both skin self examination and thorough provider examination from baseline to 12-month follow-up while the control FDRs decreased their yearly performance of both of those behaviors (p's = 0.006 and 0.005, respectively). Several sun protection behaviors increased significantly in FDRs in the intervention arm but not the control arm, including wearing a covering on the head (p = 0.005), staying in available shade (p = 0.008), and avoiding sun exposure during peak hours (p = 0.010). Some of these changes were mediated by perceptions of risk and other process variables. CONCLUSIONS: A web-based intervention can reduce risk of melanoma through changes in relevant behaviors among first-degree relatives of melanoma survivors. Future research should identify methods for making this type of intervention accessible to more families and for broadening the reach to other types of cancer families. PRACTICE IMPLICATIONS: This program can be provided to melanoma families to improve their sun protection and screening behaviors, at the point of diagnosis.

Use of conventional care and complementary/alternative medicine among US adults with arthritis.

OBJECTIVE: Managing arthritis and co-morbid conditions is of public health importance. It is therefore critical to have a comprehensive understanding of healthcare utilization among US adults with arthritis. Thus, the present study identified characteristics associated with using both complementary and alternative medicine (CAM) and conventional healthcare. METHOD: Using 2007 National Health Interview Survey data, multinomial logistic regression was performed to compare four categories of past year healthcare use (both CAM and conventional care vs. conventional care only, CAM only, and no healthcare use) on their potential correlates. RESULTS: The sample (n=3850) was 62.8% female and 80.4% non-Hispanic White. Nearly half were at least 65 years old, and had used both CAM and conventional services in the previous year. The following characteristics were associated with having used neither CAM nor conventional care in the previous year (vs. having used both CAM and conventional care): being from an ethnic and racial minority group (ORs=2.44, 3.26, and 3.91) and being uninsured (OR=4.06), identifying individuals potentially at risk for unmet need. CONCLUSION: To ensure access to comprehensive care, potentially underserved populations should be targeted with outreach (e.g., providing low-cost, accessible care, and education about benefits of various treatments for arthritis and co-morbid conditions).

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers.

OBJECTIVES: We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model. METHODS: The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling. RESULTS: Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US-Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated. CONCLUSIONS: We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.

Adolescents' use of indoor tanning: a large-scale evaluation of psychosocial, environmental, and policy-level correlates.

OBJECTIVES: We evaluated psychosocial, built-environmental, and policy-related correlates of adolescents' indoor tanning use. METHODS: We developed 5 discrete data sets in the 100 most populous US cities, based on interviews of 6125 adolescents (aged 14-17 years) and their parents, analysis of state indoor tanning laws, interviews with enforcement experts, computed density of tanning facilities, and evaluations of these 3399 facilities' practices regarding access by youths. After univariate analyses, we constructed multilevel models with generalized linear mixed models (GLMMs). RESULTS: In the past year, 17.1% of girls and 3.2% of boys had used indoor tanning. The GLMMs indicated that several psychosocial or demographic variables significantly predicted use, including being female, older, and White; having a larger allowance and a parent who used indoor tanning and allowed their adolescent to use it; and holding certain beliefs about indoor tanning's consequences. Living within 2 miles of a tanning facility also was a significant predictor. Residing in a state with youth-access legislation was not significantly associated with use. CONCLUSIONS: Current laws appear ineffective in reducing indoor tanning; bans likely are needed. Parents have an important role in prevention efforts.

Dog walking: its association with physical activity guideline adherence and its correlates.

OBJECTIVE: We examined the prevalence and correlates of dog walking among dog owners, and whether dog walking is associated with meeting the American College of Sports Medicine/American Heart Association physical activity guidelines. METHODS: In March 2008, we mailed a survey to dog-owning clients from two San Diego County veterinary clinics. Useable data were obtained from 984 respondents, and 75 of these completed retest surveys. We assessed associations between potential correlates and dog walking (i.e., yes/no dog walking for at least 10 min in past week). RESULTS: Test-retest reliability of measures was generally high. Approximately one-third of the sample (31.5%) were not dog walkers. Proportions of dog walkers versus non-dog walkers meeting United States guidelines were 64.3% and 55.0%, respectively. Dog walking was independently associated with meeting guidelines in a multivariate model (odds ratio=1.59, p=0.004). Three variables were independently associated with dog walking in a multivariate model: dog encouragement of dog walking, dog-walking obligation, and dog-walking self-efficacy. CONCLUSION: Dog walking was associated with meeting physical activity guidelines, making it a viable method for promoting physical activity. Dog-walking obligation and self-efficacy may be important mediators of dog walking and may need to be targeted if interventions are to be successful.

Measuring skin cancer risk in African Americans: is the Fitzpatrick Skin Type Classification Scale culturally sensitive?

OBJECTIVE: Fitzpatrick's Skin Type Classification Scale often is used to assess sun sensitivity and skin cancer risk. Because the scale was developed with Whites, its utility and validity with Blacks may be limited by its reliance on the European-cultural terms suntan and sunburn. We tested the hypothesis that most Blacks would be unable to classify their skin into the four Fitzpatrick skin types. DESIGN, SETTING, PARTICIPANTS: A random, statewide sample of 2085 California Black adults were administered a survey to categorize their skin into the Fitzpatrick types of always burn/never tan (I), usually burn/rarely tan (II), rarely burn/usually tan (III), and never burn/always tan (IV). We also added a response option not available in the scale, "none of the above describes me." Questions on sunscreen use and demographics were included. MAIN OUTCOME MEASURE: Self-reported skin type. RESULTS: 1231 (59%) selected none of the above, and only 559 (26.8%) categorized themselves as type IV. When the none option is removed and the 59% who chose it were excluded as non-responders, the 559 who selected type IV constitute 65.5% of the remaining sample. Those who selected none were significantly less likely than all others to use sunscreen, and income and residential segregation were the strongest predictors of type I/II skin. CONCLUSION: Standard administration of the Fitzpatrick Scale excludes the majority of Blacks, yields data that overestimate Black population prevalence of type IV skin, and excludes the Blacks who are least likely to use sunscreen. Suggestions are provided for improving the cultural sensitivity of the skin-type assessment.

Season of interview and self-report of summer sun protection behaviors.

Self-report of past behavior may be affected by recall biases that result in over- or under-reporting. This study explored whether the season an interview was conducted affected individuals' self-reported frequency of past summer sun protection behaviors, including the use of sunscreen, hats, long sleeves, and shade. We examined two existing datasets--National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS) with sample sizes of 31,428 and 21,122, respectively. Weighted logistic regression models adjusting for survey design estimated the influence of interview season on the odds of consistent summer sun protection behaviors, while controlling for age, sex, sun sensitivity, and geographic region. For NHIS, significant seasonal differences were found for all protection behaviors that were measured. For the BRFSS items, significant seasonal differences were found only for staying in the shade. Based on these findings, when interviewing adults about summer sun safety behavior, we recommend conducting the interviews during the summer season or shortly thereafter to reduce potential recall biases.

Use of sunglasses in public outdoor recreation settings in Honolulu, Hawaii.

PURPOSE: Approximately, 20.5 million Americans (17.2%) older than 40 years have a cataract in at least one eye, and rates are expected to rise to over 30 million by 2020. Wearing sunglasses, especially early in life, may reduce the risk of cataracts. Meanwhile, little is known about the prevalence of wearing sunglasses in the United States, especially in areas with high ultraviolet radiation. The objective of this study was to assess the prevalence and predictors of wearing sunglasses in public outdoor recreation settings. METHODS: Systematic observations were made at beaches, parks and outdoor public swimming pools in Honolulu, Hawaii on sunny days between November 2005 and June 2007. Observations were conducted independently by two trained observers between 10:00 am and 4:00 pm. During each observation period, each individual in the area was coded for gender, age category, clothing coverage, shade use, and use of sunglasses. RESULTS: A total of 5171 people were observed by two independent observers, and the inter-rater reliability use of sunglasses was excellent (Cohen kappa = 0.83). Overall, 33.0% of people wore sunglasses. chi analysis revealed that significantly more people (p < 0.001) wore sunglasses at swimming pools (35.1%) and parks (34.8%) compared to beaches (30.4%). Adults (41.6%) were more likely to wear sunglasses than children (12.3%; p < 0.001). Gender was not significantly associated (p = 0.3) with the use of sunglasses (males = 32.7%; females = 33.3%). Those wearing hats were significantly more likely (p < 0.001) to wear sunglasses (46.6%) than those with bare heads (28.4%). CONCLUSIONS: Direct observation in public outdoor recreation settings revealed that only one third of the population wore sunglasses. Further research should examine the use of sunglasses in other locations and investigate the effectiveness of interventions that promote the wearing of sunglasses in settings with risk for ultraviolet radiation exposure.

The high costs of cheap tanning: pricing and promotional practices of indoor tanning facilities in six cities in the United States.

Few studies have investigated pricing and promotional practices used by the indoor tanning industry, despite their potential to promote indoor UV tanning-a well-established risk factor for melanoma skin cancer. Posing as potential customers, we telephoned 94 indoor tanning businesses in six United States (U.S.) cities and requested pricing information. The price of a single tanning session ranged from $0 to $23, and was lower at facilities that offered indoor tanning as a secondary service (mean $4.82 and free in 35%) than at tanning salons (mean $16.45). Session prices in salons could be as low as $1.50 with daily use of an unlimited monthly plan. Free indoor tanning, monthly packages, and memberships encourage increased use. Policies that limit free indoor tanning or that restrict pricing and advertising for indoor tanning exist in several places in the U.S. and Europe. Future research should evaluate whether those policies are effective in reducing indoor tanning.

Enforcement of state indoor tanning laws in the United States.

INTRODUCTION: Twenty-eight US states have passed legislation for indoor tanning facilities. To our knowledge, whether these state laws are actually enforced has not been evaluated previously in all 28 states. Therefore, we interviewed key informants in these states to assess enforcement practices. METHODS: Two trained interviewers used a structured survey instrument to interview 28 key informants who were knowledgeable about enforcement practices for laws regarding indoor tanning. Respondents provided information specific to the most populous city in their states. RESULTS: Licensure for indoor tanning businesses was required in 22 of the 28 cities. Slightly less than half of the cities gave citations to tanning facilities that violated state law. Approximately 32% of the cities did not inspect indoor tanning facilities for compliance with state law, and another 32% conducted inspections less than annually. Of those cities that inspected at all, most conducted unannounced inspections. CONCLUSION: The relatively low rates of annual inspections and citations are of concern. We recommend that future studies assess whether legislation, enforcement practices, or a combination of the 2 affects the practices of indoor tanning facilities or of consumers.

Promoting sun safety among US Postal Service letter carriers: impact of a 2-year intervention.

OBJECTIVES: We examined whether US Postal Service letter carriers who received a sun safety intervention would wear wide-brim hats and sunscreen significantly more often than those who did not receive the intervention. METHODS: We used a 2-group randomized design with 2662 evaluation cohort participants from 70 US postal stations. Evaluations were conducted at baseline, 3 months, 1 year, and 2 years. Questionnaire items assessed occupational use of sun-screen and wide-brim hats. The 2-year sun safety intervention included the provision of wide-brim hats, accessible sunscreen, reminders, and 6 educational sessions. RESULTS: At the 3-month follow-up evaluations, the odds ratio (OR) for regular sun-screen use was 2.8 times higher among the intervention group than among the control group (95% confidence interval [CI]=2.2, 3.5); at the 2-year follow-up evaluations, the rate was still significantly higher (OR=2.0; 95% CI=1.6, 2.6). Intervention group participants also had significantly higher rates of hat use, with the differences remaining consistent across all follow-ups (OR=2.9; 95% CI=2.3, 3.6). CONCLUSIONS: The intervention should be disseminated to postal stations nationwide and possibly to other occupational groups that work outdoors.

Measuring the stringency of states' indoor tanning regulations: instrument development and outcomes.

OBJECTIVES: We sought to describe the development of an instrument to quantify the stringency of state indoor tanning legislation in the United States, and the instrument's psychometric properties. The instrument was then used to rate the stringency of state laws. METHODS: A 35-item instrument was developed. An overall stringency measure and 9 stringency subscales were developed, including one measuring minors' access to indoor tanning. Stringency measures showed good internal consistency and interrater reliability. RESULTS: In all, 55% of the 50 states and the District of Columbia had any indoor tanning law, and 41% had any law addressing minors' access. Oregon, Illinois, South Carolina, Florida, Indiana, Iowa, and Rhode Island had high overall stringency scores, and Texas and New Hampshire were the most restrictive with regard to minors' access. LIMITATIONS: Measurement of actual enforcement of the laws was not included in this study. CONCLUSIONS: The instrument appears to be an easy-to-use, reliable, and valid methodology. Application of the instrument to actual laws showed that, in general, state laws are relatively weak, although there was considerable variability by state.

The influence of parents and peers on adolescent indoor tanning behavior: findings from a multi-city sample.

BACKGROUND: Indoor tanning is common among adolescents. OBJECTIVE: Our purpose was to examine the influence of parents and peers on adolescent indoor tanning. METHODS: Telephone interviews were conducted with 5274 teen-parent pairs in the 100 largest US cities. Random coefficient regression analyses were conducted to examine the relationship between parental and peer factors and adolescent indoor tanning. RESULTS: Teens' report of whether their parents allow them to tan indoors was the strongest predictor (adjusted odds ratio [aOR]: 5.6), whereas parents' modeling (aOR: 1.2), attitudes (aOR: 1.1), and concern about teen tanning (aOR: 1.9) were significantly but less strongly associated. Teens thinking most of their peers like to be tan (aOR: 1.7) and perceived percentage of peers who tan indoors (aOR: 1.0) also were significantly associated. LIMITATIONS: The cross-sectional design was a limitation of this study. CONCLUSION: Interventions targeting adolescent indoor tanning should address both family- and peer-related factors.

Sun sensitivity in 5 US ethnoracial groups.

Some sun safety activities have included only non-Hispanic white individuals, even though individuals in other ethnoracial groups may be at risk for skin cancer. The objectives of this study were to investigate distributions of self-reported Fitzpatrick skin type within 5 ethnoracial groups and substantiate each group's self-report with an objective measure. The study used a cross-sectional design. The research was conducted at 70 postal stations in Southern California. Participants were US Postal Service letter carriers and included 115 Pacific Islanders, 222 black individuals, 329 Asians, 513 Hispanics, and 1364 non-Hispanic white individuals. Participants self-reported skin type and had skin color measurements taken with colorimeters. Some individuals in each ethnoracial group reported having sun-sensitive skin. Correlation tests assessing the relationship between skin type and colorimeter data showed substantial associations for each group except Asians. Future sun safety research and educational messages should include all potentially high-risk individuals, irrespective of ethnoracial identity.

Comparing two methods of measuring legislation compliance among indoor tanning facilities.

BACKGROUND: Accurate measurement of compliance by tanning facilities to indoor tanning legislation is important. OBJECTIVE: This study compared a telephone-based measurement procedure with a face-to-face visit. METHODS: Indoor tanning facilities (N = 115) in San Diego County, California, were contacted by two adolescents posing as prospective customers using each method. Two compliance variables were assessed: number of times one can tan during 1 week and written parental consent for minors. RESULTS: Facility compliance with the frequency variable by face-to-face and telephone was 25.5% and 17.5%, respectively. These rates for the parental consent variable were 73.3% and 80.8%, respectively. Percent agreement between data collection methods was 71.3% for compliance with the frequency recommendation and 76.3% for parental consent regulation. Although traditional statistical tests indicated poor concordance, an alternative test indicated good concordance. LIMITATIONS: Levels of concordance for the confederates differed. CONCLUSION: Telephone assessment of compliance is fairly comparable with the more labor-intensive, face-to-face assessment.

Effects of an introductory letter on response rates to a teen/parent telephone health survey.

The authors conducted a pilot study in preparation for a larger investigation that will rely on telephone surveys to assess select health behaviors of teens and their parents, with a focus on indoor tanning. This study used a randomized design to assess the impact of a presurvey letter on response rates to a telephone survey, as well as prevalence estimates of ever having used an indoor tanning facility. The letter did not have a significant effect on response rates or prevalence estimates in the two cities under study. Findings suggest that researchers should not assume that a letter sent in advance of a telephone survey will necessarily increase response rates enough to justify their use.

Indoor tanning promotions on social media in six US cities #UVTanning #tanning.

There is no research investigating indoor tanning advertising on social media. We assessed the use of social media to promote indoor tanning. We subscribed to social media platforms in six US cities and content-analyzed promotional messages received. We captured 662 messages on Twitter and Facebook, through salon emails, and in daily deal coupons. Salon postings were most frequent on Twitter and Facebook, with an average of 2-3 postings per week. National chains posted more frequently than local businesses. Forty percent of messages were devoid of tanning content and included photos, jokes, or popular references. Thirty percent mentioned price reductions, and 28 % referenced an upcoming holiday. Sunless tanning (17 %) was promoted more often than ultraviolet tanning (9 %). Tanning salons actively use social media as a strategy for maintaining relationships with customers and offer pricing deals that promote loyalty and high-frequency tanning.

Reducing ultraviolet radiation exposure to prevent skin cancer methodology and measurement.

Skin cancer is the most common type of cancer, and is also one of the most preventable. This paper builds on an evidence review of skin cancer prevention interventions that was conducted for the Guide to Community Preventive Services (n=85 studies), and summarizes the state of knowledge about research methodology and measurement in studies of the effectiveness of interventions to reduce ultraviolet radiation (UVR) exposure. As this field advances, researchers should strive to minimize threats to validity in their study designs, as well as to consider the balance between internal and external validity. There is a need for more longer-duration interventions, and follow-up periods that make possible conclusions about the potential of these interventions to affect intermediate markers of skin cancer or at least sustained behavior change. Also, more work is needed to minimize attrition and characterize nonresponders and study dropouts. Verbal report measures of behavior are the most widely used measures of solar protection behavior. Given their limitations, investigators should routinely collect data about reliability and validity of those measures. They should also increase efforts to complement verbal data with objective measures including observations, skin reflectance, personal dosimetry, skin swabbing, and inspection of moles. Measures of environments and policies should incorporate observations, documentation, and direct measures of ambient UVR and shade. This article places the data derived from the evidence review in the context of needs and recommendations for future research in skin cancer prevention.

Ethnoracial differences among outdoor workers in key sun-safety behaviors.

BACKGROUND: Few sun-safety studies have included ethnoracially diverse groups. Comparison across such groups of sun-safety behaviors was the main objective of this analysis. METHODS: Postal workers (n =2543) self-reported frequency of sunscreen, wide-brim hat, and sunglasses use during the last 5 workdays on 5-point Likert-type scales ranging from "never" to "always." Responses were dichotomized by "always" versus all other responses. Generalized estimating equations were used to assess the association between ethnicity/race and frequency of each sun safety behavior. The baseline data reported in this paper were collected in the summer of 2001, and the randomized trial was completed in the summer of 2004. RESULTS: Ethnicity/race was significantly related to sunscreen and sunglasses use. For both sunscreen and sunglasses, the white group had significantly higher "always" rates than the other four groups (30% vs 14% to 23% and 63% vs 44% to 52%, respectively). CONCLUSIONS: The results of this study indicated that although non-Latino white employees tended to have higher rates of sun-safety behaviors, the rates of adequate protection of all groups were low.

Disseminating a sun safety program to zoological parks: the effects of tailoring.

Previous research found that a sun safety program for visitors at 1 zoo increased sun safety behaviors. This randomized study compared the effects of tailored dissemination materials plus 2 brief follow-up phone calls (tailored group) versus generic materials (basic group) on implementation by other zoos of the previously evaluated sun safety program. Education directors of 126 zoos completed surveys several months following initial dissemination and 1 year later. During Summer 1, 40% of tailored group zoos and 24% of basic group zoos offered visitors at least 1 sun safety activity (odds ratio=2.2, 95% confidence interval=1.0-4.8). During Summer 2, these rates were 34% and 44%, respectively (ns). The pattern of findings suggests that tailoring had no incremental long-term impact and that the generic materials produced a good level of dissemination.