Depressive Symptoms Moderate the Association Between the Recent History of Alcohol Use Severity and Suicide Attempt History Among Adults in a Pretrial Jail Diversion Program.

Background: Justice-involved individuals are at elevated risk for suicidal behavior; however, research examining risk for suicidal behavior in pretrial jail diversion programs (pretrial diversion) is limited. Aims: We aimed to test (1) associations between depressive symptoms and alcohol and drug use, and suicide attempt history (SAH), and (2) interactions between depressive symptoms and alcohol and drug use in relation to SAH among adults in an urban pretrial jail diversion program. Method: The design was cross-sectional, including self-report assessments and file reviews of historical information. Adults (N = 274; Mage = 33.72; 73.7% men; 52.6% non-Hispanic Black) completed assessments within two weeks of beginning the pretrial program. Results: Depressive symptoms were positively associated with SAH after adjusting for other covariates. The significant depressive symptoms by alcohol use interaction indicated that adults with low to average depressive symptoms evidenced a similar likelihood of SAH to those with high depressive symptoms when they also had elevated alcohol use scores. Limitations: We used cross-sectional self-report data. Conclusion: It may be important to conduct suicide risk assessments for justice-involved people who use alcohol even when depressive symptoms are low.

A systematic review of the relationship between momentary emotional states and nonsuicidal self-injurious thoughts and behaviours.

BACKGROUND: Nonsuicidal self-injury (NSSI) is associated with high levels of distress, co-morbid mental health issues, and elevated risk of suicide. Previous literature indicates that emotion regulation is the most endorsed function of NSSI. Experience Sampling Methodology (ESM) provides a powerful tool for investigating the moment-to-moment associations between emotional states and NSSI thoughts and behaviours. The aim of the current study was to systematically review and evaluate ESM research concerning the relationship between momentary emotional states and NSSI. METHODS: A systematic search of electronic databases from date of inception to 16th April 2021 was conducted. This was supplemented through backwards citation tracking. A risk of bias assessment was completed prior to data synthesis. RESULTS: Nineteen eligible studies were identified for inclusion in the review. Heightened negative affect was found to typically precede instances of NSSIT thoughts and behaviour. Results were less consistent for positive affect. LIMITATIONS: Sample sizes across studies were often small, meaningful effect sizes were not always reported, and non-validated measures of NSSI thoughts and behaviour were used during ESM assessments. CONCLUSIONS: The results support affect regulation models of NSSI, and demonstrate the value of ESM studies, specifically those sampling more than once per day, in plotting the temporal, "in-the-moment" characteristics of these processes.

A Population-Based Analysis of Interpersonal Trauma, Psychosis, and Suicide: Evidence, Pathways, and Implications.

Subthreshold psychotic experiences (PEs) are known to confer a risk for suicidality. Yet, despite evidence of a strong etiological trauma-psychosis pathway, the coalesced effect of such concurrences on suicide risk is largely discounted. Our aims were to examine the impact of different manifestations of life span trauma and PEs on the risk of suicidal thoughts and attempts, using an exploratory person-centered approach. Data from the Adult Psychiatric Morbidity Survey (N = 7,403) were analyzed. PEs were assessed using the Psychosis Screening Questionnaire (PSQ) alongside items probing childhood and adult trauma, in addition to 12-month suicide thoughts and attempt. A manual three-step latent class analysis elicited four distinct profiles, namely, a socially disconnected/high PE, a sexual victimization/moderate PE, a life span trauma/low PE, and a baseline class. The socially disconnected class, characterized by a moderate likelihood of social disconnection, a high probability of various PE endorsements, yet a low likelihood of other significant trauma, showed the greatest risk of 12-month suicide ideation (odds ratio [OR] = 13.0, 95% confidence interval [CI] = [8.539, 19.021) and attempt (OR = 24.2, 95% CI = [10.349, 56.860). Neither multiple nor recurrent traumatic experiences invariably result in the emergence of PEs. Instead, a sense of social disconnection may be either resultant of PEs or alone sufficient to cultivate such symptom presentations, even in the absence of prior traumas. Moreover, just as traumatic encounters increase the risk of suicidality, so too might seemingly more innocuous adversities, such as poor-quality social relationships, further elevate the risk, particularly when proximal and coupled with the simultaneity of PEs.

Moderating Factors in Culpability Ratings and Rape Proclivity in Stranger and Acquaintance Rape: Validation of Rape Vignettes in a Community Sample.

Rape is a serious concern globally. Past research has identified Ambivalent Sexism (AS), Rape Myth Acceptance (RMA), and the victim-perpetrator relationship as key constructs influencing rape blame attributions and rape proclivity. Limitations with methodologies have, however, limited the practical implications of past research, particularly in the context of underpowered samples and a lack of transparency in vignette development and implementation. In the current research, three studies aimed to validate material to be used in research into rape perceptions and to examine the impact of victim-perpetrator relationship, AS, and RMA on victim and perpetrator culpability, and rape proclivity, using an experimental design. On 563 participants, this research developed and validated six rape vignettes which accounted for methodological limitations of past research (Study One) and were found to be believable and realistic by participants; it further found that aggressively sexist attitudes were associated with increased victim culpability and decreased perpetrator culpability (Study Two), and increased rape proclivity (Study Three). Scenarios of a casual acquaintance produced the highest levels of victim culpability and the lowest levels of perpetrator culpability. Victims were ascribed more control than blame, or responsibility. Men reported the highest levels of rape proclivity in scenarios of casual acquaintance, and intimate partner relationships. Contrary to past research, Benevolent Sexism (BS) did not directly impact attributions in rape cases but may maintain and legitimize the attitudes, which do. As some of our findings contradict past research, we suggest that the need for standardized rape vignettes is evident, along with greater transparency and methodological rigor in sexual assault research, as this will improve the practical implications of findings. Reproducible research practices may be useful for this. While limited in diversity, this research has important implications for policy and research practice, particularly in producing validated material that can be reused by future researchers.

Attributions of Blame in Stranger and Acquaintance Rape: A Multilevel Meta-Analysis and Systematic Review.

BACKGROUND: Victim blame, particularly in cases of acquaintance rape, presents an obstacle to criminal justice. Past research indicates that acquaintance rape results in more blame than stranger rape. However, there are inconsistencies in these findings (e.g., whether there is a linear relationship between victim blame and relationship closeness), partly due to methodological variation. OBJECTIVES: To examine the effect of victim-perpetrator relationship on victim blame, how this effect is impacted by rape myth acceptance (RMA) and ambivalent sexism (AS), and to establish what the methodological quality is of studies. SYNTHESIS METHOD: Studies were synthesized through a multilevel meta-analysis using the Metafor package in R (version 2.4-0), synthesizing findings from 47 individual studies. Studies compared victim blame between stranger and acquaintance rape, in isolation or in conjunction with RMA and AS, and were identified through a database search. RESULTS: The review found higher levels of blame in acquaintance as compared to stranger rape, with a medium effect size. This effect was not moderated by RMA. AS was not included as a moderator in the meta-analysis, but the review indicated that benevolent sexism may be a particularly relevant variable. IMPLICATIONS: Future research should examine the relationship between AS and victim blame. The current review contributes to the evidence base on victim blame in rape cases by suggesting that methodological limitations can account for some of the past mixed findings in this area, particularly in a lack of consistency in vignette details. It is recommended that future sexual assault research uses rigorous methodology and increases transparency of research processes.

BRIEF MOTIVATIONAL INTERVENTION FOR SUBSTANCE USE MAY DECREASE VIOLENCE AMONG HEAVY ALCOHOL USERS IN A JAIL DIVERSION PROGRAM.

Rates of harmful alcohol use are high among justice-involved individuals and may contribute to violent recidivism. Robust treatments for alcohol-related violence in criminal justice systems are thus a public health priority. In this analysis of existing randomized controlled trial data (N = 105), we examined the impact of a brief motivational intervention (BMI) for harmful substance use on violent recidivism among individuals in a pretrial jail diversion program. Results indicated that, after controlling for violence history, the intervention's impact on violent recidivism was moderated by baseline harmful alcohol use. Specifically, among people with severe alcohol problems at baseline, the BMI + standard care group had less violent recidivism at a 1-year follow-up than participants randomized to standard care alone. This finding was unchanged when we accounted for psychopathic traits. Our study provides preliminary evidence that a BMI may be useful for decreasing violent recidivism among heavy drinkers in criminal justice systems.

Examining the factor structure of ICD-11 posttraumatic stress disorder (PTSD) and complex-PTSD among prison staff exposed to potentially traumatic experiences.

The recently released 11th edition of the International Classification of Diseases (ICD-11) classifies posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as distinct, yet related, disorders within the spectrum of trauma and stress-related disorders. This study aimed to explore the construct validity of the International Trauma Questionnaire (ITQ), a measure of ICD-11 PTSD and CPTSD symptoms among prison governors (i.e., wardens in the U.S. and Canada). Trauma-exposed prison governors (N = 409) aged 26 to 82 years (M = 50.04, SD = 7.97) provided their data online anonymously. Confirmatory factor analyses were performed to evaluate the construct validity of ITQ scores. When using the five-point item response scale, our five first-order factor model produced the best fit to the data; however, when using a dichotomous item scale, the first-order two-factor PTSD and disturbances of self-organization (DSO) model produced the best fit to the data. These results indicate that item-coding and estimation methods can significantly impact conclusions about the best-fitting model for this measure among trauma-exposed prison governors.

Suicide Ideation Among Male Prisoners: Preliminary Evidence That Psychopathic Traits are Indirectly Linked to Suicide Ideation Through Thwarted Interpersonal Needs.

BACKGROUND: The relation between psychopathic traits and suicide ideation (SI) is frequently discussed but little research has examined potential mechanisms underlying this association. The interpersonal theory of suicide (ITS) proposes two mechanisms in the pathogenesis of suicidal desire: thwarted belongingness (TB) and perceived burdensomeness (PB). This study cross-sectionally tested TB and PB as possible explanatory links in the relation between psychopathic traits and SI. METHOD: Archival data from 784 male U.K. prisoners (Mage  = 37.21, SD = 9.97) were analyzed using structural equation modeling. RESULTS: Psychopathic traits were indirectly associated with SI through more specific suicide-promoting processes - namely TB and PB. More specifically, results indicated that Egocentricity and Stimulus Seeking were indirectly associated with SI through PB and TB in combination. However, results indicated specific indirect effects of TB in the relations between the Antisocial Behavior, Egocentricity, and Stimulus Seeking facets, and SI, whereas specific indirect effects for PB were only significant in the relations between Egocentricity and Stimulus Seeking facets and SI. CONCLUSION: Preliminary results are consistent with the ITS and suggest that psychopathic traits may be distal risk markers for SI and provide direction for future research that could inform suicide prevention efforts among male prisoners high in such traits.

Psychological Correlates of Self-Harm within Gay, Lesbian and Bisexual UK University Students.

This study explores the association between lesbian, gay or bisexual (LGB) status and self-harm in UK higher education students. There is currently limited data on this association, and the role psychological variables have in potentially explaining this link, in UK students. We examine whether LGB status is associated with self-harm (both non-suicidal self-injury [NSSI] and suicide attempts [SA]), and whether 4 psychological variables (depression, anxiety, belongingness, self-esteem) mediate this association. A cross-sectional survey was used. UK university students (n = 707) completed an online survey including measures of self-harm, affective symptoms, belongingness, and self-esteem. Latent Variable Modelling (LVM) was used to test our hypotheses. LGB status remained associated with an elevated risk of NSSI and SA even after accounting for mediating factors. Self-esteem and (in the case of SA but not NSSI) thwarted belongingness, did, however, explain some of this association and were correlated with self-harm risk. The findings suggest that psychological factors may account for the association between LGB status and self-harm and, as such, prevention and intervention efforts directed at these psychological mediators may help to reduce self-harm risk in this population.

Awareness and knowledge of human papilloma virus in UK women aged 25 years and over: Results from a cross-sectional internet-based survey.

OBJECTIVE: The expanding use of human papilloma virus (HPV) testing within cervical screening requires an evaluation of public understanding of HPV. This study aimed to explore HPV awareness and knowledge using a previously psychometrically validated measure in a sample of UK women aged 25 years and over. METHODS: An anonymous web-based cross-sectional survey design was used, and responses were recorded for 246 women (mean age = 37.59, SD = 9.20). RESULTS: Findings indicated limits to women's understanding of HPV, its transmission, treatment and link with cancer. The mean HPV knowledge score was 9.35 (4.43), and the mean HPV testing score was 3.34 (1.91). Multivariate analyses revealed that information seeking following cervical screening and being a student is associated with higher HPV knowledge and that having a positive HPV test result and having university education is associated with higher HPV testing knowledge. CONCLUSIONS: These results highlight that there is a lack of knowledge and misunderstanding relating to HPV and its link with cancer in adult women in the UK. The findings suggest that public health HPV information campaigns are urgently needed, especially with a drop in UK cervical screening attendance rates, and with the upcoming change to HPV primary testing within the UK NHS cervical screening programme.

An examination of the relationship between shame, guilt and self-harm: A systematic review and meta-analysis.

Self-harm is a major public health concern associated with suicide risk and significant psychological distress. Theories suggest that aversive emotional states are an important process that drives self-harm. Shame and guilt may, in particular, be important emotions in self-harm. This review therefore sought to provide a systematic review and meta-analysis of the relationship between shame, guilt, and self-harm. A systematic search of electronic databases (PsycINFO; Medline; CINAHL Plus; Web of Science and ProQuest) was undertaken to identify studies measuring shame, guilt and self-harm (including suicidal and non-suicidal behaviour). Meta-analysis was undertaken where papers focused on the same subtype of shame or guilt and shared a common outcome. Thirty studies were identified for inclusion. Most forms of shame were associated with non-suicidal self-injury (NSSI), but research was sparse concerning suicidal behaviour. Fewer studies examined guilt and findings were more varied. Methodological issues included a paucity of longitudinal designs and lack of justification for sample sizes. Results of this review support the link between shame and self-harm, particularly NSSI. The direction of this relationship is yet to be established. Clinically, consideration should be given to the role of shame amongst individuals who present with NSSI. This review was pre-registered on PROSPERO (CRD42017056165).

"I don't mind being ugly but I don't wanna have skin cancer": A qualitative study of attitudes to UV exposure and a facial morphing intervention in men 35 years and older.

Objectives: Skin cancer is a growing problem globally. Older men have been largely ignored in previous research, even though men may generally be prone to riskier exposure to the sun than women. Past research suggests that appearance-focused techniques such as facial morphing can increase motivations to use sun protection among women of all ages, and younger men.Design: was qualitative, consisting of individual interviews.Methods: were semi-structured interviews with 25 older men, to examine attitudes to UV exposure and reactions to a facial morphing intervention. Interviews were subjected to thematic analysis.Results: Three themes were constructed: masculine UV exposure; appearance that's accepted; personal responsibility. The men did not identify gaps in their sun protection behaviour and demonstrated a lack of concern about ageing and appearance. These attitudes translated into a lack of motivation for behaviour change due to ageing acceptance. However, motivation to change behaviour came from health concerns resulting from the intervention.Conclusions: The men experienced different motivations and barriers for sun protection use than women of similar ages. Facial morphing can be effective with older men but may need to be reframed to focus on health implications and personal choice.

An Empirical Test of the Three-Step Theory of Suicide in U.K. University Students.

The purpose of this study was to further our understanding of how individuals move down the pathway from first thinking about suicide to ultimately attempting to take their own lives by empirically testing the Three-Step Theory (3ST) in a sample of university students (n = 665). Results largely support the theory's central propositions. First, an interactive model of pain and hopelessness accounted for substantial variance in suicidal desire. This result replicated in both men and women, and across age groups (i.e., below 35 and at or above 35). Also, as predicted, connectedness was protective against ideation in those high on both pain and hopelessness. However, contrary to our prediction, connectedness was similarly protective among everyone else. Finally, suicide capacity predicted suicide attempt history over and above current and lifetime suicide ideation. These findings provide further support to the 3ST.

Psychopathy and Suicidal Thoughts and Behaviors Revisited: Results From a Statewide Population of Institutionalized Youth.

Suicide is the leading cause of death for incarcerated youth, and up to half of all juveniles in confinement experience suicidal ideation in addition to other psychopathology, including psychopathic personality features. Unfortunately, limited research has investigated the psychopathy-suicidality link among juvenile delinquents and using newer psychopathy measures. Based upon a statewide population of incarcerated juvenile offenders, we found that psychopathy was a significant risk factor for suicidal ideation and lifetime suicide attempts, but the latter relationship was attenuated by lifetime depression diagnosis. In addition, certain affective psychopathic features such as Stress Immunity conferred protection against suicidality, whereas behavioral and lifestyle components including Carefree Nonplanfulness, Blame Externalization, and Rebellious Nonconformity were positively linked to suicidal thoughts among the youth offenders. As these risk factors are routinely screened for in juvenile justice settings, this study's findings have considerable implications to applied practice and prevention among juvenile justice involved youth.

Childhood maltreatment and psychotic experiences: Exploring the specificity of early maladaptive schemas.

OBJECTIVE: One potential mechanism that has received limited attention in psychosis research is early maladaptive schemas (EMS). Our aim was to examine whether EMS acts as a potential mediating pathway between early trauma and psychotic symptomology. METHODS: A quantitative survey was conducted online. N = 302 participants took part. The analysis used a multiple mediation framework. RESULTS: Analysis demonstrated significant specificity effects. Different forms of child maltreatment were significantly associated with psychosis experiences through specific dimensions of maladaptive schemas. CONCLUSIONS: Results indicated specificity effects in that specific types of maltreatment are associated with specific maladaptive schemas. From a practitioner's perspective, these findings offer credence to cognitive theories of psychopathology, and support the validity of EMS identification and modification among clients with psychotic symptomology both as a fundamental component of traditional CBT and within specialized schema-focused therapy.

A meta-analysis of the prevalence of different functions of non-suicidal self-injury.

BACKGROUND: A broad variety of different functions can underlie acts of Non-suicidal self-injury (NSSI). Whilst research so far has identified many of the commonly reported functions, no reliable estimates of prevalence currently exist for these different NSSI functions. Understanding the prevalence of NSSI functions represents a key to better understanding the phenomenology of NSSI and addressing the differing needs of the NSSI population. We conducted a systematic review and meta-analysis of the prevalence of NSSI functions in community and clinical samples. METHOD: A literature search of electronic databases PsycINFO, Medline, and Web of Science from date of inception to March 2017 was undertaken. A pre-specified framework for categorising different functions of NSSI was used to collate data from across studies. A random-effects meta-analysis of prevalence was then undertaken on these data. RESULTS: Intrapersonal functions (66-81%), and especially those concerning emotion regulation were most commonly reported by individuals who engage in NSSI (63-78%). Interpersonal functions (e.g., expressing distress) were less common (33-56%). LIMITATIONS: The review was limited to English-language articles. Reviewed articles were inconsistent in their measurement of NSSI. Inconsistency within pooled prevalence estimates was high when moderators were not accounted for. CONCLUSIONS: Findings indicate that intrapersonal functions of NSSI are most common and are present for the majority of participants. This finding supports dominant emotion-regulation models of NSSI, and the use of interventions that work to improve emotion-regulation ability. However, interpersonal functions remain endorsed by a substantial portion of participants.

This corrosion: A systematic review of the association between alternative subcultures and the risk of self-harm and suicide.

BACKGROUND: Rates of self-harm and suicide are increasing in young people. The literature suggests that individuals who identify with alternative subcultures (e.g., Goth) may be at a greater risk. OBJECTIVE: To explore the prevalence of self-harm and suicide in alternative subcultures and the factors that might contribute to this increased risk. METHOD: Using a systematic strategy, the databases PsycINFO, Scopus, MEDLINE and Web of Science, and the E-Thesis online service (ETHOS) were searched for English language only papers, with no restrictions in terms of date of publication. Papers were selected that included data on the relationship between either alternative subculture identity (e.g., Goth) or preference for alternative music (e.g., Heavy Metal) and self-harm or suicide. Ten quantitative papers were included: seven cross-sectional, two longitudinal and one cross-sectional state-level comparison study. Two qualitative papers were also included. Studies were assessed by two reviewers for risk of bias. RESULTS: The findings indicated that individuals who associated with alternative subcultures were at a greater risk of self-harm and suicide. Whilst qualitative papers identified potential mechanisms (e.g., exposure to self-harm and the way self-harm is presented or normalized), there remains limited support for these mechanisms. CONCLUSIONS: More research is required to understand the association between self-harm, suicide and alternative subculture affiliation, and the factors underlying it. Longitudinal studies and studies focusing on mechanism are particularly important. PRACTITIONER POINTS: The review supports the suggestion that those who identify as belonging to an alternative subculture may be at a higher risk of self-harm and suicidal behaviour. It also presents preliminary evidence that alternative affiliation predicts self-harm over time, and that this effect holds whilst adjusting for a number of likely confounders. The findings highlight the importance of increasing the awareness of the victimization and potential risk that these groups hold and suggests areas for intervention in health, educational, and social services. The review does not, however, indicate specifically what it is about alternative subculture affiliation (or alternative music preference) that could contribute to the risk of self-harm. Consequently, studies with a greater focus on mechanisms are needed. Methodological limitations (e.g., cross-sectional studies, small sample of 'alternative' participants, westernized samples) restricted the reliability and validity of the results which impacted on the extent to which the findings could be generalized more widely.

Attributions of victim blame in stranger and acquaintance rape: A quantitative study.

AIMS AND OBJECTIVES: To, on a sample of nurses and the general public, examine whether victim blame varies according to level of familiarly between victim and perpetrator. It also examines how Ambivalent Sexism and Rape Myth Acceptance impact on this. BACKGROUND: Around one in five women will be victims of sexual assault during their lifetime. The majority are acquaintance rapes, and these victims are generally attributed more blame than victims of stranger rape. Research indicates that nurses hold similar attitudes on gender roles and victim blame as do the general public. METHODS: Eighty-one participants read a story depicting a sexual assault of a woman by either a stranger or an acquaintance and completed scales measuring victim blame, Ambivalent Sexism and Rape Myth Acceptance. RESULTS: The results of this study indicated that victim-perpetrator relationship, Benevolent Sexism, Hostile Sexism and whether the participant was a nurse contributed to the variance in attributed victim blame. Hierarchical regressions revealed that whether or not the participant was a nurse contributed to the variance in victim blame in the acquaintance rape condition, and Hostile Sexism and Benevolent Sexism contributed to the variance in victim blame in the stranger rape condition. CONCLUSIONS: This paper gives a novel insight into attitudes involved in victim blame in rape cases and makes a unique comparison between nurses and the general public. Findings suggest that victim blame correlates primarily with aggressively sexist attitudes and that nurses generally attribute more blame to the victim of acquaintance rape. RELEVANCE TO CLINICAL PRACTICE: This study has practical implications for the provision of medical services for victims of sexual assault, as it highlights problems in identifying and accessing rape victims, as well as recommending the sexual assault training of all practicing nurses.

Appearance-based interventions to reduce UV exposure: A systematic review.

PURPOSE: As a majority of skin cancer cases are behaviourally preventable, it is crucial to develop effective strategies to reduce UV exposure. Health-focused interventions have not proved to be sufficiently effective, and it has been suggested that people might be more susceptible to information about the negative effects of the sun on their appearance. METHOD: This systematic review of 30 separate papers, reporting 33 individual studies published between 2005 and 2017, assesses the overall effectiveness of appearance interventions on participants' UV exposure and sun protection behaviour. RESULTS: Appearance-based interventions have positive effects on sun exposure and sun protection, immediately after the intervention as well as up to 12 months afterwards. The meta-analysis found a medium effect size on sun protection intentions for interventions which combined UV photography and photoageing information: r+  = .424; k = 3, N = 319, CI = 0.279-0.568, p = .023. CONCLUSIONS: This review provides a current perspective on the effectiveness of appearance-based interventions to reduce UV exposure, and also highlights methodological issues. It recommends that practitioners administer a UV photo intervention in combination with photoageing information to reduce UV exposure. Furthermore, the review specifically recommends that future research focuses on the use of theoretical constructs to enhance photoageing information and is conducted with older participants and in countries where people have less opportunity for sun exposure. Statement of contribution What is already known on this subject? Appearance-focused interventions may in some cases be more effective than health-focused interventions in reducing UV exposure, as the underlying motivations for tanning are associated with appearance concerns. Previous reviews and meta-analyses have indicated that appearance-focused interventions such as photoageing and UV photo are associated with positive effects in reducing UV exposure and/or increasing sun protection. Previous reviews identified methodological issues with research on this topic, which included limited a priori power calculations and a general lack of long-term follow-ups. What does this study add? This review concludes that photoageing information in combination with UV photo is associated with a medium positive effect size on sun protection intentions. Photoageing can be manipulated according to theoretical constructs (e.g., Theory of Alternative Behaviours), which may contribute to its effectiveness. Issues such as homogeneity of settings and participants and limited a priori power calculations in the included studies have been identified. This review specifically recommends that future research is conducted in locations with less overall sun exposure, and with a more diverse participant range (e.g., more males and older participants).