PREVENTIVE
MEDICINE
21, 754-765
(1992)
Compensation Strategies in Sun Protection Behaviors Population with Nonmelanoma Skin Cancer’*2 JUNE
K.
ROBINSON,
Departments of Dermatology and Surgery, Northwestern Chicago Avenue, Chicago, Illinois 60611; and Veterans
by a
M.D. University Administration
Medical School, 303 East Lakeside Medical Center
Background. Initiation of sun protection strategies can be promoted, to some extent, by educational efforts, but little is known about the merit of continuing education interventions in sustaining the desired behaviors or adding new behaviors. This prospective study clarifies the choices individuals make among the four strategies that allow them to maintain lifestyle changes. Methods. From 1983 to 1987, the population received education about sun protection coupled with the removal of a nonmelanoma skin cancer. One year later, their choice of sun protection methods was determined. Then annually from 1985 to 1989, they received written recommendations about sun protection for a period of 26 years after the initial education. The maintenance, cessation, and addition to the initial sun protection behaviors were ascertained by a questionnaire, as was the intention to change. Frequency of physician visits and development of subsequent nonmelanoma skin cancer were evaluated by medical chart review for the 2-6 year phase of continued education. Results. One percent of the population consisting mostly of women described ceasing tanning after 2-6 years of education. The population related a greater use of protective clothing and/or sunscreen with an SPF of 15 or greater as their reported restrictions on outdoor activities ceased. An emerging new strategy of some of the population (n = 185) was the use of sunscreens with an SPF less than 15 in association with attempts to deliberately tan and longer daily outdoor exposure. Neither frequency of physician visits nor numbers of subsequent nonmelanoma skin cancers influenced continuation or addition of sun protection behaviors. Conclusions. While the greatest reported change in behavior was temporarily associated with educational intervention linked to removal of the skin cancer, continued educational efforts may have recruited some individuals to cease tanning and encouraged others to adopt the use of protective clothing or more frequent sunscreen use as they were unable to maintain the limitations on outdoor activities. It is not possible to structure a control group restricted from mass media education; therefore, the effectiveness of specific behaviordirected education cannot be precisely determined. Nonetheless, the population described using knowledge to develop compensation sun protection strategies that preserved lifestyle.
0 1992 Academic
Press, Inc.
INTRODUCTION
Skin cancer is amenable to prevention by four simple sun protection strategies. These include cessation of deliberate tanning; daily use of a sunscreen with a sun protection factor (SPF) of 15 or greater; use of protective clothing, such as a hat and/or long-sleeved shirt; and limitation of outdoor activities either by ceasing them entirely or by avoiding sun exposure during the hours between 10:00 AM and i Paper read at the Annual * This work was supported
Meeting of the American Dermatological Association, in part by the Edson Family Philanthropic Fund. 754
0091-7435/92
$5.00
Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form reserved.
February
22, 1992.
SUN
PROTECTION
BEHAVIORS
755
2:00 PM. While adoption of such strategies provides immediate benefits by reducing sunburns, the long-term benefit of skin cancer prevention is not readily observed and cannot be achieved without sustained maintenance of some sun protection strategy. Initiation of such strategies can be promoted, to some extent, by educational efforts, but little is known about the merit of continued educational interventions in sustaining the behavior. An obvious target population for educational efforts is patients who have already developed one or more skin cancers. Such patients have an elevated risk of developing additional skin cancers (1). Detection and treatment of skin cancer make them aware of their susceptibility, which may enhance their receptivity to recommendations for adoption of prevention strategies. Such recommendations may also be communicated to family members, who may then reinforce them on an ongoing basis. Physician visits and written recommendations provide additional opportunities to communicate and/or reinforce such recommendations, but it is not known whether this promotes maintenance of prevention behaviors or adoption of new ones. Barriers to initiation and maintenance of such strategies include cost, complexity of the behavioral change, messiness of using sunscreens, a perception that skin cancer is not a severe problem, and the need for changes in lifestyle that the individual finds unacceptable. Lifestyle plays an important role in the use of prevention measures. Because in skin cancer prevention the immediate rewards are limited, social reinforcement by friends and family members will likely be an important factor in the initiation and maintenance of that behavior. Prior studies (2-5) have assessed the subjects’ knowledge about skin cancer sun protection and motivation factors, but have not examined the impact of educational interventions upon adoption and long-term maintenance of lifestyle changes. The hypothesis tested in this prospective study was that the population would use knowledge gained during the yearly educational interventions from 2 to 6 years after surgery to add additional sun protection strategies to the ones initially adopted 1 year after surgery (6). In addition, the potential influence of the frequency of physician visits and development of subsequent nonmelanoma skin cancers was examined. MATERIALS
AND METHODS
From May 1983 to May 1987, a group of 1,592 patients that had had at least one nonmelanoma skin cancer removed surgically received written and verbal recommendations about sun protection from the physician or one of three nurses at the time of the preoperative consultation and 2 weeks and 6 months after surgery. Prior to surgery, the patient was interviewed and responses were recorded on a survey questionnaire. One year after surgery, a mail-in survey questionnaire (Appendix) with a return-addressed stamped envelope was sent to the patient, who was assured that his identity would remain unknown to the physician and nurses. The results of the survey 1 year after education coupled with surgery about the individual’s cessation of deliberate tanning, use of sunscreens and protective clothing, and limitation of outdoor activities were reported (Table 1) (6). Then the study entered into the long-term phase, with education provided on a
756
JUNE
K.
ROBINSON
yearly basis for 2-6 years after surgery. Subjects entered into this long-term study included those for whom preoperative data about sun protection had been collected, who responded to the questionnaire 1 year after surgery (1984-1988), who received yearly written recommendations about sun protection (1985-1990), and who had yearly check-up examinations with the author. The number of subjects meeting these criteria was 1,022. The sun protection recommendations were cessation of deliberate tanning, use of protective clothing such as a hat or a long-sleeved shirt, limiting the time of outdoor activities by avoiding sun exposure between 10:00 AM and 230 PM, and daily use of a sunscreen with an SPF of 15 or greater with special emphasis on use prior to anticipated sun exposure. In 199&1991 another mail-in survey questionnaire with the same questions (Appendix) about the individual’s current sun protection habits as the initial survey was sent with assurance that the subject’s identity would remain unknown to the physician and nurses. In both surveys, in addition to questions about their current use of the four sun protection behaviors, subjects were asked the current number of hours of outdoor exposure a day and the time of day of that exposure. If they were not currently using a protective strategy, they were asked if they intended to do so within the next year, and if they had ceased using a protective strategy, how many years ago had they stopped. They were also asked the number of visits to a dermatologist during years 2 to 6 and the number of subsequent skin cancers as determined by biopsy during years 2 to 6. A subset of the population (n = 268) received all skin cancer care at 6-month or yearly intervals for 5 years after surgery from the same physician (J.K.R.). For these individuals, the number of visits to the physician and the number of nonmelanoma skin cancers biopsied and treated were obtained by reviewing the medical record. The rest of the population received care from other physicians in addition to a yearly visit with the author. The data from these written questionnaires were entered into a program (dBase III) on a computer (IBM Personal Computer-AT) and analyzed using a statistical program (SPSYPCT). This data base also contained age, sex, and educational information. The responses to the survey given in 1984-1988 (1 year after surgery coupled with education) and those to the survey in 1990-1991 to evaluate the continuation of previously initiated behaviors were compared. RESULTS Preoperative and preeducational data were obtained from 1,592 patients, but only 1,042 responded to the mail-in survey questionnaire 1 year after surgery (6). Of these 1,042 patients, 1,022 maintained yearly check-up examinations with the author. The other 570 individuals either failed to respond to the survey 1 year after surgery or chose yearly examinations with another physician. The survey evaluating behavior 2-6 years after surgery was sent to the 1,022 individuals who received yearly written information about sun protection habits and yearly examinations. Of the 1,022 respondents, 50% were male and 50% were female. At the time of the survey, the mean age of males was 60.5 years and that of females, 59.5. Ninety-four percent had a basal cell carcinoma and 6% a squa-
SUN
PROTECTION
757
BEHAVIORS
mous cell carcinoma as the initial skin cancer. The population was white, with 40% having some education beyond high school. There was no age or sex bias to 20 nonrespondents. Changes in Sun Protection Outdoor Activities
Behaviors
of the Total Population’s
Habits regarding outdoor activities reported at the three data collection points are summarized in Table 1. Behavioral changes in these areas show that the restriction of outdoor activities reported 1 year after surgery was not maintained over the next 2-6 years. After the first year, 16% of the population ceased their self-imposed ban on outdoor activities. Similarly, after the first year, 36% of the group performed outdoor activities between 10 AM and 2 PM. This liberalization of restrictions on outdoor activities was most apparent in the reported length of time outdoors per day. At the completion of 2-6 years of education, a small group of 200 individuals had lengthened their total number of hours outdoors a day to 6.5-8 hr. Prior to education coupled with surgery, none intended to change their habits of outdoor activities. Both at 1 year after the initial education and after 2-6 years of education, approximately 20% of the group intended to change the time of activities. Tanning One year after education coupled with surgery, 77% (792/1,022) of the population did not deliberately sunbathe to promote a tan. All of these individuals maintained this behavior. After 2-6 years of education, a few additional women ceased deliberate tanning (Table 1). A group of patients (n = 185) using sunscreens with a lower SPF to deliberately tan emerged. These individuals reported between 4
REPORTED
TABLE 1 PATTERN OF OUTDOOR
Prior to education coupled with surgery 1983-1987
No work or recreational outdoor activities Outdoor activities done before 10 AM or after 2 PM Outdoor activities done between 10 AM and 2 PM Usual time outdoors/day 0.5-2 hr 2.5-A hr 4.5-6 hr 6.5-8 hr No deliberate tanning Try to tan
ACTIVITIES
One year after education 198h1988
After 2-6 years of education 1985-1990
(n = 1,022)
(n = 1,022)
(n = 1,022)
30
291
118
175
281
81
817
450
823
511 435 74 2 334 688
596 345 80
490 306 26 200 797 225
1 792 230
758
JUNE K. ROBINSON
and 8 hr of outdoor activities a day. This represented an increased 2 hr of outdoor activities for these individuals in comparison with their reported activities prior to surgery. Protective Clothing
Eleven percent (114/1,022) of the population used protective clothing 1 year after education. All of these people continued the activity and an additional 41% added the behavior of use of protective clothing to their sun protection strategy (Table 2). The use of protective clothing was compared with the pattern of outdoor activities for the total population (Table 3). An increase in outdoor activity was associated with increased protective clothing use (x2 = 616, P < 0.0001) (7). This major shift in sun protection strategies by the population indicated a compensating method of sun protection, protective clothing, in place of restriction of outdoor activities, which was difficult to maintain. There was a slight preference for wearing a hat among men and for a long-sleeved shirt among women. At both 1 year and 24 years after education, 21% indicated an intention to start wearing one of the two items of protective clothing. Sunscreen Use
In the first year of educational intervention, participants who used a sunscreen prior to education shifted to using a sunscreen with an SPF of 15 or greater. The survey after 2-6 years of education confirmed that most participants used sunscreens with an SPF of 15 or greater and defined the pattern of use as daily in 24% (244/1,022) and only when sun exposure was expected in 53% (539/1,022). In the survey prior to education, 10 individuals failed to completely answer the question about sunscreen use. The last survey after 2-6 years of education had 9 fail to answer this question. Two hundred thirty did not use sunscreen at the time of the last survey. Of these, 118 reported no work or recreational activities. Most of these individuals TABLE USE OF PROTECTIVE
CLOTHING
ANDIOR
SUNSCREEN
One year after education 1984-1988 (n = 1,022)
Continued education 2-6 years after surgery 1985-1990 (n = 1,022)
15
114
531
681 327 14
266 95 661
230 185 607
331 0
636 120
539 244
Prior to education coupled with surgery 1983-1987 (n = 1,022) Wear protective clothing Sunscreen Not use Use SPF < 15 Use SPF 2 15 Use only when expect to be outdoors Use daily
2
SUN PROTECTION TABLE CHANGE
759
BEHAVIORS 3
IN USE OF PROTECTIVE CLOTHING FROM 1 YEAR AFTER EDUCATION EDUCATION 2-6 YEARS AFTER SURGERY
TO CONTINUED
Outdoor activityb
Use of protective clothing”
Increased
Same
Increased Same Total
340 (91.2%) 33 373
77 (11.9%) 572 649
Note. x2 (1) = 616, P < 0.0001. a Increased use of protective clothing-more use of hats and long-sleeve shirts reported in the second survey than the first. Same use of protective clothing-no change in reported use of protective clothing between the two surveys. b Increased outdoor activity-more outdoor activity reported in the second survey between 10 AM and 2 PM than in the first survey. Same outdoor activity-no change in reported time of the day of outdoor activity between the first and second surveys.
were elderly. Thus it appears that their various infirmities restricted their activities and made sunscreen use meaningless (Tables 1 and 2). In the final survey, there were 185 who used a sunscreen with an SPF less than 15 (Table 2). These same individuals reported trying to tan, and are among those who increased their amount of daily outdoor exposure by 2 hr. This newly emerging strategy in the population was best summarized by the comment made by some that they were tanning safely because they used sunscreens. There was an increasing daily use of sunscreen over the duration of the study (Table 2). The use of sunscreen was compared with the pattern of outdoor activities reported by the population (Table 4). An increase in outdoor activity was associated with increasing use of sunscreen (x2 = 218, P < 0.0001) (7). There was no identifiable age or sex bias among those ceasing limitation of outdoor activities or changing their pattern of sunscreen use. At 1 year and 2-6 year after education surveys, 24% indicated an intention to use sunscreen daily. The change in use of protective clothing had a stronger correlation with liberalization of restrictions on outdoor activity (x2 = 616) than did the change in sunscreen use (x2 = 218) (7). Furthermore, change in protective clothing is related TABLE CHANGE
IN SUNSCREEN
USE FROM
4
1 YEAR AFTER EDUCATION YEARS AFTER SURGERY
TO CONTINUED
EDUCATION
2-6
Outdoor activity
Sunscreen use’
Increased
Same
Increased Same Total
120 253 373
4 645 649
Note. x2 (1) = 218, P < 0.0001. (1 Sunscreen use increased-reported change between surveys of increasing from occasional use to daily use or initiation of sunscreen use. Sunscreen use same-no change in reported use of sunscreen.
760
JUNE K. ROBINSON
to change in sunscreen use (x2 = 111, P < 0.0001) (7) (Table 5). A multivariate analysis was used to assess the relative statistical importance of increased use of protective clothing and increased use of sunscreen with increased outdoor activity (7). An increase in outdoor activity was accompanied by a significant change in protective clothing (P < 0.0001) and an additional independent significant change in sunscreen use (P < 0.0001). Thus the change in sunscreen use was important in and of itself, not just because it was related to change in protective clothing. Sun Protection Behavior Association with Frequency of Physician Subsequent Skin Cancer Formation
Visits or
In the subset of the population followed exclusively by one physician (J.K.R.) (n = 268), there was no correlation between frequency of visits and numbers of subsequent skin cancers on the continuation or intention to start any behavior. There was no difference in behaviors between those followed exclusively by one physician and those seen by other physicians. This may be a function of the study design. Patients who did not receive all care from one physician received yearly written recommendations about sun protection and were seen on a yearly basis. Paired t tests were used to evaluate this data. Variability
in Sun Protection
by Yearly Cohorts
The years of continued education of the population ranged from 6 to 2 years; thus, five cohorts exist with continued education dates starting in 1985, 1986, 1987, 1988, and 1989. An analysis for differences or similarities in use of sun protection strategies in these live cohorts was performed. The percentage of patients increasing their outdoor activities ranged from 27% for the 1985 cohort to 46% for the 1989 cohort. Of those increasing their outdoor activity, the percentage of those increasing use of protective clothing went up from 60 to 100%. Later cohorts (1988, 1989) had a greater increase in outdoor activity and a greater increase in the use of protective clothing (x2 (4) = 78.9, P < 0.0001) (Fig. 1). Later cohorts (1988, 1989) had more people who maintained the same habits of sunscreen use (x2 (3) = 115, P < 0.0001). The earlier cohorts, who had more educational interventions, had the most change in the use of sunscreen. Two changes were seen in years 1985, 1986, and 1987. Some individuals increased the frequency of use of a sunscreen with an SPF of 15 or greater from use only when
CHANGE
IN BEHAVIOR
FROM
TABLE 5 1 YEAR AFTER EDUCATION
TO CONTINUED
EDUCATION
2-6 YEARS
AFTER SURGERV
Sunscreen use
Protective clothing
Increased
Same
Increased Same Total
104 18 122
313 587 !m
Note. x2 (1) = 111, P < 0.0001.
SUN
PROTECTION
761
BEHAVIORS
Percent increasing outdoor activity
n
= % increasing use of Protective Clothing
% Shaded area is of whole bar
60%
85% Xz14) = 78.9
96%
100%
100%
p
MEDICINE
21, 754-765
(1992)
Compensation Strategies in Sun Protection Behaviors Population with Nonmelanoma Skin Cancer’*2 JUNE
K.
ROBINSON,
Departments of Dermatology and Surgery, Northwestern Chicago Avenue, Chicago, Illinois 60611; and Veterans
by a
M.D. University Administration
Medical School, 303 East Lakeside Medical Center
Background. Initiation of sun protection strategies can be promoted, to some extent, by educational efforts, but little is known about the merit of continuing education interventions in sustaining the desired behaviors or adding new behaviors. This prospective study clarifies the choices individuals make among the four strategies that allow them to maintain lifestyle changes. Methods. From 1983 to 1987, the population received education about sun protection coupled with the removal of a nonmelanoma skin cancer. One year later, their choice of sun protection methods was determined. Then annually from 1985 to 1989, they received written recommendations about sun protection for a period of 26 years after the initial education. The maintenance, cessation, and addition to the initial sun protection behaviors were ascertained by a questionnaire, as was the intention to change. Frequency of physician visits and development of subsequent nonmelanoma skin cancer were evaluated by medical chart review for the 2-6 year phase of continued education. Results. One percent of the population consisting mostly of women described ceasing tanning after 2-6 years of education. The population related a greater use of protective clothing and/or sunscreen with an SPF of 15 or greater as their reported restrictions on outdoor activities ceased. An emerging new strategy of some of the population (n = 185) was the use of sunscreens with an SPF less than 15 in association with attempts to deliberately tan and longer daily outdoor exposure. Neither frequency of physician visits nor numbers of subsequent nonmelanoma skin cancers influenced continuation or addition of sun protection behaviors. Conclusions. While the greatest reported change in behavior was temporarily associated with educational intervention linked to removal of the skin cancer, continued educational efforts may have recruited some individuals to cease tanning and encouraged others to adopt the use of protective clothing or more frequent sunscreen use as they were unable to maintain the limitations on outdoor activities. It is not possible to structure a control group restricted from mass media education; therefore, the effectiveness of specific behaviordirected education cannot be precisely determined. Nonetheless, the population described using knowledge to develop compensation sun protection strategies that preserved lifestyle.
0 1992 Academic
Press, Inc.
INTRODUCTION
Skin cancer is amenable to prevention by four simple sun protection strategies. These include cessation of deliberate tanning; daily use of a sunscreen with a sun protection factor (SPF) of 15 or greater; use of protective clothing, such as a hat and/or long-sleeved shirt; and limitation of outdoor activities either by ceasing them entirely or by avoiding sun exposure during the hours between 10:00 AM and i Paper read at the Annual * This work was supported
Meeting of the American Dermatological Association, in part by the Edson Family Philanthropic Fund. 754
0091-7435/92
$5.00
Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form reserved.
February
22, 1992.
SUN
PROTECTION
BEHAVIORS
755
2:00 PM. While adoption of such strategies provides immediate benefits by reducing sunburns, the long-term benefit of skin cancer prevention is not readily observed and cannot be achieved without sustained maintenance of some sun protection strategy. Initiation of such strategies can be promoted, to some extent, by educational efforts, but little is known about the merit of continued educational interventions in sustaining the behavior. An obvious target population for educational efforts is patients who have already developed one or more skin cancers. Such patients have an elevated risk of developing additional skin cancers (1). Detection and treatment of skin cancer make them aware of their susceptibility, which may enhance their receptivity to recommendations for adoption of prevention strategies. Such recommendations may also be communicated to family members, who may then reinforce them on an ongoing basis. Physician visits and written recommendations provide additional opportunities to communicate and/or reinforce such recommendations, but it is not known whether this promotes maintenance of prevention behaviors or adoption of new ones. Barriers to initiation and maintenance of such strategies include cost, complexity of the behavioral change, messiness of using sunscreens, a perception that skin cancer is not a severe problem, and the need for changes in lifestyle that the individual finds unacceptable. Lifestyle plays an important role in the use of prevention measures. Because in skin cancer prevention the immediate rewards are limited, social reinforcement by friends and family members will likely be an important factor in the initiation and maintenance of that behavior. Prior studies (2-5) have assessed the subjects’ knowledge about skin cancer sun protection and motivation factors, but have not examined the impact of educational interventions upon adoption and long-term maintenance of lifestyle changes. The hypothesis tested in this prospective study was that the population would use knowledge gained during the yearly educational interventions from 2 to 6 years after surgery to add additional sun protection strategies to the ones initially adopted 1 year after surgery (6). In addition, the potential influence of the frequency of physician visits and development of subsequent nonmelanoma skin cancers was examined. MATERIALS
AND METHODS
From May 1983 to May 1987, a group of 1,592 patients that had had at least one nonmelanoma skin cancer removed surgically received written and verbal recommendations about sun protection from the physician or one of three nurses at the time of the preoperative consultation and 2 weeks and 6 months after surgery. Prior to surgery, the patient was interviewed and responses were recorded on a survey questionnaire. One year after surgery, a mail-in survey questionnaire (Appendix) with a return-addressed stamped envelope was sent to the patient, who was assured that his identity would remain unknown to the physician and nurses. The results of the survey 1 year after education coupled with surgery about the individual’s cessation of deliberate tanning, use of sunscreens and protective clothing, and limitation of outdoor activities were reported (Table 1) (6). Then the study entered into the long-term phase, with education provided on a
756
JUNE
K.
ROBINSON
yearly basis for 2-6 years after surgery. Subjects entered into this long-term study included those for whom preoperative data about sun protection had been collected, who responded to the questionnaire 1 year after surgery (1984-1988), who received yearly written recommendations about sun protection (1985-1990), and who had yearly check-up examinations with the author. The number of subjects meeting these criteria was 1,022. The sun protection recommendations were cessation of deliberate tanning, use of protective clothing such as a hat or a long-sleeved shirt, limiting the time of outdoor activities by avoiding sun exposure between 10:00 AM and 230 PM, and daily use of a sunscreen with an SPF of 15 or greater with special emphasis on use prior to anticipated sun exposure. In 199&1991 another mail-in survey questionnaire with the same questions (Appendix) about the individual’s current sun protection habits as the initial survey was sent with assurance that the subject’s identity would remain unknown to the physician and nurses. In both surveys, in addition to questions about their current use of the four sun protection behaviors, subjects were asked the current number of hours of outdoor exposure a day and the time of day of that exposure. If they were not currently using a protective strategy, they were asked if they intended to do so within the next year, and if they had ceased using a protective strategy, how many years ago had they stopped. They were also asked the number of visits to a dermatologist during years 2 to 6 and the number of subsequent skin cancers as determined by biopsy during years 2 to 6. A subset of the population (n = 268) received all skin cancer care at 6-month or yearly intervals for 5 years after surgery from the same physician (J.K.R.). For these individuals, the number of visits to the physician and the number of nonmelanoma skin cancers biopsied and treated were obtained by reviewing the medical record. The rest of the population received care from other physicians in addition to a yearly visit with the author. The data from these written questionnaires were entered into a program (dBase III) on a computer (IBM Personal Computer-AT) and analyzed using a statistical program (SPSYPCT). This data base also contained age, sex, and educational information. The responses to the survey given in 1984-1988 (1 year after surgery coupled with education) and those to the survey in 1990-1991 to evaluate the continuation of previously initiated behaviors were compared. RESULTS Preoperative and preeducational data were obtained from 1,592 patients, but only 1,042 responded to the mail-in survey questionnaire 1 year after surgery (6). Of these 1,042 patients, 1,022 maintained yearly check-up examinations with the author. The other 570 individuals either failed to respond to the survey 1 year after surgery or chose yearly examinations with another physician. The survey evaluating behavior 2-6 years after surgery was sent to the 1,022 individuals who received yearly written information about sun protection habits and yearly examinations. Of the 1,022 respondents, 50% were male and 50% were female. At the time of the survey, the mean age of males was 60.5 years and that of females, 59.5. Ninety-four percent had a basal cell carcinoma and 6% a squa-
SUN
PROTECTION
757
BEHAVIORS
mous cell carcinoma as the initial skin cancer. The population was white, with 40% having some education beyond high school. There was no age or sex bias to 20 nonrespondents. Changes in Sun Protection Outdoor Activities
Behaviors
of the Total Population’s
Habits regarding outdoor activities reported at the three data collection points are summarized in Table 1. Behavioral changes in these areas show that the restriction of outdoor activities reported 1 year after surgery was not maintained over the next 2-6 years. After the first year, 16% of the population ceased their self-imposed ban on outdoor activities. Similarly, after the first year, 36% of the group performed outdoor activities between 10 AM and 2 PM. This liberalization of restrictions on outdoor activities was most apparent in the reported length of time outdoors per day. At the completion of 2-6 years of education, a small group of 200 individuals had lengthened their total number of hours outdoors a day to 6.5-8 hr. Prior to education coupled with surgery, none intended to change their habits of outdoor activities. Both at 1 year after the initial education and after 2-6 years of education, approximately 20% of the group intended to change the time of activities. Tanning One year after education coupled with surgery, 77% (792/1,022) of the population did not deliberately sunbathe to promote a tan. All of these individuals maintained this behavior. After 2-6 years of education, a few additional women ceased deliberate tanning (Table 1). A group of patients (n = 185) using sunscreens with a lower SPF to deliberately tan emerged. These individuals reported between 4
REPORTED
TABLE 1 PATTERN OF OUTDOOR
Prior to education coupled with surgery 1983-1987
No work or recreational outdoor activities Outdoor activities done before 10 AM or after 2 PM Outdoor activities done between 10 AM and 2 PM Usual time outdoors/day 0.5-2 hr 2.5-A hr 4.5-6 hr 6.5-8 hr No deliberate tanning Try to tan
ACTIVITIES
One year after education 198h1988
After 2-6 years of education 1985-1990
(n = 1,022)
(n = 1,022)
(n = 1,022)
30
291
118
175
281
81
817
450
823
511 435 74 2 334 688
596 345 80
490 306 26 200 797 225
1 792 230
758
JUNE K. ROBINSON
and 8 hr of outdoor activities a day. This represented an increased 2 hr of outdoor activities for these individuals in comparison with their reported activities prior to surgery. Protective Clothing
Eleven percent (114/1,022) of the population used protective clothing 1 year after education. All of these people continued the activity and an additional 41% added the behavior of use of protective clothing to their sun protection strategy (Table 2). The use of protective clothing was compared with the pattern of outdoor activities for the total population (Table 3). An increase in outdoor activity was associated with increased protective clothing use (x2 = 616, P < 0.0001) (7). This major shift in sun protection strategies by the population indicated a compensating method of sun protection, protective clothing, in place of restriction of outdoor activities, which was difficult to maintain. There was a slight preference for wearing a hat among men and for a long-sleeved shirt among women. At both 1 year and 24 years after education, 21% indicated an intention to start wearing one of the two items of protective clothing. Sunscreen Use
In the first year of educational intervention, participants who used a sunscreen prior to education shifted to using a sunscreen with an SPF of 15 or greater. The survey after 2-6 years of education confirmed that most participants used sunscreens with an SPF of 15 or greater and defined the pattern of use as daily in 24% (244/1,022) and only when sun exposure was expected in 53% (539/1,022). In the survey prior to education, 10 individuals failed to completely answer the question about sunscreen use. The last survey after 2-6 years of education had 9 fail to answer this question. Two hundred thirty did not use sunscreen at the time of the last survey. Of these, 118 reported no work or recreational activities. Most of these individuals TABLE USE OF PROTECTIVE
CLOTHING
ANDIOR
SUNSCREEN
One year after education 1984-1988 (n = 1,022)
Continued education 2-6 years after surgery 1985-1990 (n = 1,022)
15
114
531
681 327 14
266 95 661
230 185 607
331 0
636 120
539 244
Prior to education coupled with surgery 1983-1987 (n = 1,022) Wear protective clothing Sunscreen Not use Use SPF < 15 Use SPF 2 15 Use only when expect to be outdoors Use daily
2
SUN PROTECTION TABLE CHANGE
759
BEHAVIORS 3
IN USE OF PROTECTIVE CLOTHING FROM 1 YEAR AFTER EDUCATION EDUCATION 2-6 YEARS AFTER SURGERY
TO CONTINUED
Outdoor activityb
Use of protective clothing”
Increased
Same
Increased Same Total
340 (91.2%) 33 373
77 (11.9%) 572 649
Note. x2 (1) = 616, P < 0.0001. a Increased use of protective clothing-more use of hats and long-sleeve shirts reported in the second survey than the first. Same use of protective clothing-no change in reported use of protective clothing between the two surveys. b Increased outdoor activity-more outdoor activity reported in the second survey between 10 AM and 2 PM than in the first survey. Same outdoor activity-no change in reported time of the day of outdoor activity between the first and second surveys.
were elderly. Thus it appears that their various infirmities restricted their activities and made sunscreen use meaningless (Tables 1 and 2). In the final survey, there were 185 who used a sunscreen with an SPF less than 15 (Table 2). These same individuals reported trying to tan, and are among those who increased their amount of daily outdoor exposure by 2 hr. This newly emerging strategy in the population was best summarized by the comment made by some that they were tanning safely because they used sunscreens. There was an increasing daily use of sunscreen over the duration of the study (Table 2). The use of sunscreen was compared with the pattern of outdoor activities reported by the population (Table 4). An increase in outdoor activity was associated with increasing use of sunscreen (x2 = 218, P < 0.0001) (7). There was no identifiable age or sex bias among those ceasing limitation of outdoor activities or changing their pattern of sunscreen use. At 1 year and 2-6 year after education surveys, 24% indicated an intention to use sunscreen daily. The change in use of protective clothing had a stronger correlation with liberalization of restrictions on outdoor activity (x2 = 616) than did the change in sunscreen use (x2 = 218) (7). Furthermore, change in protective clothing is related TABLE CHANGE
IN SUNSCREEN
USE FROM
4
1 YEAR AFTER EDUCATION YEARS AFTER SURGERY
TO CONTINUED
EDUCATION
2-6
Outdoor activity
Sunscreen use’
Increased
Same
Increased Same Total
120 253 373
4 645 649
Note. x2 (1) = 218, P < 0.0001. (1 Sunscreen use increased-reported change between surveys of increasing from occasional use to daily use or initiation of sunscreen use. Sunscreen use same-no change in reported use of sunscreen.
760
JUNE K. ROBINSON
to change in sunscreen use (x2 = 111, P < 0.0001) (7) (Table 5). A multivariate analysis was used to assess the relative statistical importance of increased use of protective clothing and increased use of sunscreen with increased outdoor activity (7). An increase in outdoor activity was accompanied by a significant change in protective clothing (P < 0.0001) and an additional independent significant change in sunscreen use (P < 0.0001). Thus the change in sunscreen use was important in and of itself, not just because it was related to change in protective clothing. Sun Protection Behavior Association with Frequency of Physician Subsequent Skin Cancer Formation
Visits or
In the subset of the population followed exclusively by one physician (J.K.R.) (n = 268), there was no correlation between frequency of visits and numbers of subsequent skin cancers on the continuation or intention to start any behavior. There was no difference in behaviors between those followed exclusively by one physician and those seen by other physicians. This may be a function of the study design. Patients who did not receive all care from one physician received yearly written recommendations about sun protection and were seen on a yearly basis. Paired t tests were used to evaluate this data. Variability
in Sun Protection
by Yearly Cohorts
The years of continued education of the population ranged from 6 to 2 years; thus, five cohorts exist with continued education dates starting in 1985, 1986, 1987, 1988, and 1989. An analysis for differences or similarities in use of sun protection strategies in these live cohorts was performed. The percentage of patients increasing their outdoor activities ranged from 27% for the 1985 cohort to 46% for the 1989 cohort. Of those increasing their outdoor activity, the percentage of those increasing use of protective clothing went up from 60 to 100%. Later cohorts (1988, 1989) had a greater increase in outdoor activity and a greater increase in the use of protective clothing (x2 (4) = 78.9, P < 0.0001) (Fig. 1). Later cohorts (1988, 1989) had more people who maintained the same habits of sunscreen use (x2 (3) = 115, P < 0.0001). The earlier cohorts, who had more educational interventions, had the most change in the use of sunscreen. Two changes were seen in years 1985, 1986, and 1987. Some individuals increased the frequency of use of a sunscreen with an SPF of 15 or greater from use only when
CHANGE
IN BEHAVIOR
FROM
TABLE 5 1 YEAR AFTER EDUCATION
TO CONTINUED
EDUCATION
2-6 YEARS
AFTER SURGERV
Sunscreen use
Protective clothing
Increased
Same
Increased Same Total
104 18 122
313 587 !m
Note. x2 (1) = 111, P < 0.0001.
SUN
PROTECTION
761
BEHAVIORS
Percent increasing outdoor activity
n
= % increasing use of Protective Clothing
% Shaded area is of whole bar
60%
85% Xz14) = 78.9
96%
100%
100%
p
