Health Communication
ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20
Testing a Social Cognitive Theory-Based Model of Indoor Tanning: Implications for Skin Cancer Prevention Messages Seth M. Noar, Jessica Gall Myrick, Alexandra Zeitany, Dannielle Kelley, Brenda Morales-Pico & Nancy E. Thomas To cite this article: Seth M. Noar, Jessica Gall Myrick, Alexandra Zeitany, Dannielle Kelley, Brenda Morales-Pico & Nancy E. Thomas (2015) Testing a Social Cognitive Theory-Based Model of Indoor Tanning: Implications for Skin Cancer Prevention Messages, Health Communication, 30:2, 164-174, DOI: 10.1080/10410236.2014.974125 To link to this article: http://dx.doi.org/10.1080/10410236.2014.974125
Published online: 03 Dec 2014.
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Date: 05 November 2015, At: 17:43
Health Communication, 30: 164–174, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2014.974125
Testing a Social Cognitive Theory-Based Model of Indoor Tanning: Implications for Skin Cancer Prevention Messages Seth M. Noar
Downloaded by [University of Cambridge] at 17:43 05 November 2015
School of Journalism and Mass Communication and Lineberger Comprehensive Cancer Center University of North Carolina at Chapel Hill
Jessica Gall Myrick The Media School Indiana University
Alexandra Zeitany School of Medicine University of North Carolina at Chapel Hill
Dannielle Kelley School of Journalism and Mass Communication University of North Carolina at Chapel Hill
Brenda Morales-Pico School of Medicine University of North Carolina at Chapel Hill
Nancy E. Thomas Lineberger Comprehensive Cancer Center and School of Medicine University of North Carolina at Chapel Hill
The lack of a theory-based understanding of indoor tanning is a major impediment to the development of effective messages to prevent or reduce this behavior. This study applied the Comprehensive Indoor Tanning Expectations (CITE) scale in an analysis of indoor tanning behavior among sorority women (total N = 775). Confirmatory factor analyses indicated that CITE positive and negative expectations were robust, multidimensional factors and that a hierarchical structure fit the data well. Social cognitive theory-based structural equation models demonstrated that appearance-oriented variables were significantly associated with outcome expectations. Outcome expectations were, in turn, significantly associated with temptations to tan, intention to tan indoors, and indoor tanning behavior. The implications of these findings for the development of messages to prevent and reduce indoor tanning behavior are discussed
Correspondence should be addressed to Seth M. Noar, PhD, Professor, School of Journalism and Mass Communication, 382 Carroll Hall (Campus Box 3365), University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3365. E-mail: [email protected]
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in two domains: (a) messages that attempt to change broader societal perceptions about tan skin, and (b) messages that focus more narrowly on indoor tanning—challenging positive expectations, enhancing negative expectations, and encouraging substitution of sunless tanning products.
Recent data make a convincing case that indoor tanning is associated with the development of several types of skin cancer. Systematic reviews and meta-analyses have demonstrated a relationship between indoor tanning and the incidence of cutaneous melanoma (Boniol, Autier, Boyle, & Gandini, 2012), basal-cell carcinoma (Wehner et al., 2012), and squamous-cell carcinoma (Wehner et al., 2012). The evidence suggests that ultraviolet (UV) exposure via indoor tanning at younger ages (i.e., before age 35 years) may particularly increase the risk of melanoma (Boniol et al., 2012) and nonmelanoma skin cancers (Wehner et al., 2012). Studies reveal that young, White women are particularly likely to tan indoors (Centers for Disease Control and Prevention, 2012; Watson et al., 2013). Epidemiologic studies have revealed concurrent increases in melanoma among young White women (Hausauer, Swetter, Cockburn, & Clarke, 2011; Purdue, Freeman, Anderson, & Tucker, 2008), with indoor tanning emerging as the likely culprit (Coelho & Hearing, 2010). Health communication campaigns are imperative for the prevention and reduction of indoor tanning (Holman et al., 2013; Lazovich & Forster, 2005). Despite this, there is a paucity of message design research to inform such campaigns. In this article, we (a) briefly summarize existing research on health communication and indoor tanning, (b) discuss a new line of theory-based research in this area, and (c) report results of a new study and discuss implications for indoor tanning prevention messages.
HEALTH COMMUNICATION AND INDOOR TANNING Research on indoor tanning prevention message design, and indoor tanning interventions more broadly, is in its infancy. A small number of indoor tanning interventions have been developed and tested to date (Turrisi, Hillhouse, Mallett, Stapleton, & Robinson, 2012). Interventions have had some success, using methods such as UV photo imaging (Gibbons, Gerrard, Lane, Mahler, & Kulik, 2005), peer-delivered motivational interviewing (Turrisi, Mastroleo, Stapleton, & Mallet, 2008), appearance workbooks (Hillhouse, Turrisi, Stapleton, & Robinson, 2008), and caregiver involvement (Lazovich et al., 2013). While many of these interventions use messages in some capacity, they do not advance an understanding of the effects of particular message types. We identified only two studies that focused on indoor tanning message design, using statistical, narrative, and normative messaging research as a guide. The first study tested a statistical message format (risks of using tanning beds
and information about skin cancer) against a narrative format (story about a young women who develops facial skin cancer after using a tanning bed) among college women (Greene & Brinn, 2003). Results indicated the statistical format was perceived as more informative, while the narrative message was perceived as more realistic. While both messages reduced intentions to tan indoors, only the statistical message reduced indoor tanning behavior (1 month later). The second study expanded on the first study by adding a normative message (percentage of students who avoided using tanning beds) condition (Greene, Campo, & Banerjee, 2010). The normative message worked best to reduce normative tanning perceptions, while the narrative message best attracted attention. However, there were few effects on beliefs across message conditions, with no effects of any message condition on intentions to tan indoors.
A THEORY-BASED APPROACH TO INDOOR TANNING RESEARCH To provide the most solid foundation for indoor tanning messaging research, a theory-based understanding of the beliefs that underlie indoor tanning behavior is needed. However, research on motivations for indoor tanning has been quite limited (Hillhouse & Turrisi, 2012). While previous studies demonstrate that various attitudes and beliefs are associated with indoor tanning (Hillhouse & Turrisi, 2012; Hillhouse, Turrisi, Holwiski, & McVeigh, 1999; Lazovich et al., 2004), research in this area has been limited by (a) a lack of validated, comprehensive measures and (b) a lack of theory-based research. We have recently applied social cognitive theory (SCT; Bandura, 1986) to the area of indoor tanning. SCT is a comprehensive theory of behavior change that posits that health behaviors must be understood in the context of reciprocal determinism, or the idea that characteristics of a person, that person’s environment, and behavior interact to determine whether an action is performed. While SCT posits numerous intrapersonal, interpersonal, and environmental factors to influence behavior, two of its core determinants are outcome expectations and self-efficacy (Bandura, 2004). Outcome expectations are beliefs about the expected (positive and negative) consequences of engaging in a behavior, and they represent a key motivational factor (i.e., should I perform this behavior?). While positive expectations represent incentives for engaging in a behavior, negative expectations represent disincentives. For instance, a young woman may believe that tanning indoors would be relaxing and make her look
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great (positive expectations), while she may be somewhat less concerned that the behavior will lead to wrinkles and saggy skin later in life (negative expectations). The balance of positive versus negative expectations is thought to determine motivation level for performing the behavior, and extant health behavior research has provided support for this claim (Prochaska et al., 1994). The second factor is self-efficacy, which refers to one’s confidence in performing a behavior across a range of situations. This represents a capability factor (i.e., can I perform this behavior?), and scores of studies empirically demonstrate the importance of self-efficacy to behavior (Bandura, 1997). The more one believes in one’s ability to perform the behavior, the more likely one is to engage in that behavior. When the behavior is risky, however, self-efficacy may be more usefully conceptualized as its mirror opposite—temptations (Velicer, DiClemente, Rossi, & Prochaska, 1990). In this conceptualization, temptations to engage in the behavior promote the unhealthy behavior. Temptations have been shown to longitudinally predict smoking behavior (Prochaska, Velicer, Guadagnoli, Rossi, & DiClemente, 1991), and they may be more intuitive for respondents to report on for risky behaviors (i.e., reporting on temptations to engage in the risky behavior rather than confidence to not engage in the risky behavior) (Velicer et al., 1990). In the context of indoor tanning, a young woman may be particularly tempted to tan indoors when a special event is coming up, it’s the winter season, or she perceives her skin to be too pale, for instance. Given that both outcome expectations and self-efficacy are amenable to change, they represent important theoretical factors that can be emphasized in messages. We began our program of research by focusing first and foremost on outcome expectations, given the limited literature on tanning motivations. We developed the Comprehensive Indoor Tanning Expectations (CITE) scale (Noar, Myrick, MoralesPico, & Thomas, 2014), an outcome expectations measure that consists of 11 dimensions (six positive and five negative) that may influence indoor tanning behavior. In the Noar et al. (2014) study, which involved a sample of 706 young women, CITE was found to be reliable and to significantly correlate with a set of established measures from the indoor tanning literature, including appearance motivations to tan and intentions to tan indoors. We also assessed temptations to tan indoors and found it to be significantly correlated with all 11 CITE scales. Moreover, across three tanner types (nontanners, former tanners, current tanners), significant differences were found on all 11 CITE subscales, building evidence for the validity of this new scale. The indoor tanning literature suggests additional appearance-oriented influences that may be important to this behavior (Hillhouse & Turrisi, 2012; Lazovich & Forster, 2005). For example, the proliferation of the tanning industry and tan celebrities in recent decades provides many opportunities for observational learning of this behavior.
This ties directly to SCT in that modeling, or viewing similar others engaging a behavior, may encourage one to engage in the same behavior (Bandura, 1986). Those who wish their appearance to be more like tan celebrities may, in turn, hold more positive beliefs about indoor tanning (Cafri et al., 2008). Those who are motivated by appearance factors in general (i.e., appearance motivation), as well as those who view tanned skin as more attractive or healthy (i.e., general appearance motivation to tan), may similarly hold more positive beliefs about tanning (Cafri et al., 2008; Hillhouse et al., 1999). Testing an SCT-based model including all of these factors can advance our understanding of the belief systems that underlie indoor tanning behavior, laying the groundwork for evidence-based message design.
CURRENT STUDY The first goal of this study was to test the CITE scale’s psychometric structure with confirmatory factor analysis. The second goal was to test an SCT-based model of indoor tanning intentions and behavior to inform evidence-based message design. The hypothesized model predicted that perceived skin type, appearance motivation, general appearance motivations to tan, and media appearance motivations to tan would be associated with both positive and negative expectations about indoor tanning. The model also hypothesized that positive and negative expectations would be associated with temptations to tan indoors and indoor tanning intentions and behavior. Finally, temptations to tan indoors were expected to directly predict indoor tanning intentions and behavior (see Figure 1).
METHOD Participants and Procedure We conducted an online survey of members of eight sororities at a private university in the southeastern United States. The project was promoted in collaboration with the sororities’ governing body, which sent the invitation to participate, as well as three reminder e-mails over the course of the 3-week survey period. Sorority representatives also placed posters with the survey URL in high-traffic areas in the sorority houses. Due to an institutional review board (IRB) stipulation, sorority members had to be at least 18 years of age to participate in the survey. Interested sorority members accessed the survey online, where it was described as a study of appearance, health, and tanning. After providing their age and consenting to participate in the study, participants completed the 20-minute survey. Sororities that met certain thresholds of participation earned Visa Check Cards. Chapters with at least a 50% participation rate received a $100 gift card, with graduated
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FIGURE 1 Hypothesized model.
incentives at 70% ($150) and 90% ($200) participation. At the end of the survey period, a total of 775 participants had completed the survey; three were excluded due to the minimum age requirement. This represented a 65% (775/1,188) response rate. The IRB approved all procedures used in this research. Measures Comprehensive Indoor Tanning Expectations (CITE) scale. Outcome expectations for indoor tanning were assessed by the six positive subscales (28 items) and five negative subscales (21 items) (Noar et al., 2014). Positive subscales were appearance benefits (α = .92), convenience (α = .88), mood enhancement, (α = .93), health improvement (α = .89), social approval (α = .89), and parental approval (two items; r = .87), while negative subscales were health threat (α = .95), psychological/physical discomfort (α = .87), appearance harms (α = .91), social disapproval (α = .89), and parental disapproval (two items; r = .89). Participants were asked “If I went indoor tanning . . .” and responses were recorded on a 5-point scale ranging from definitely wouldn’t to definitely would. Examples items are “It would make me more attractive” (positive—appearance benefits) and “It would lead to skin cancer” (negative—health threat). Temptations to tan indoors. Indoor tanning temptations were assessed by a 14-item scale (Noar et al., 2014). Participants were asked “How tempted would you be to tan indoors when . . .” and were presented with situations such as “your current tan is wearing off,” “your friends are going tanning,” or “you are feeling anxious or stressed.” Participants answered on a 5-point scale that ranged from
not at all tempted to extremely tempted. Coefficient alpha was .97. Perceived skin type. Participants responded to three items assessing untanned skin color, tannability, and burn tendency. These items asked what color one’s untanned skin is (from six options), as well as what would happen to one’s skin if it were exposed, without protection, to bright sunlight for 1 hour (burn tendency) or repeatedly (tannability), with five response options (Kricker et al., 2007). Coefficent alpha of the three items was .77. Appearance motivation. Appearance motivation was assessed with a four-item scale (Hillhouse et al., 1999). Participants rated their agreement or disagreement on a 5point scale to items such as “How I look is important to me” and “It is important that others view my physical attractiveness positively.” Coefficient alpha was .78. Appearance motivations to tan—General and media. Appearance motivations to tan were assessed with Cafri et al. (2008) 5-point scales. For general motivations to tan, participants rated their agreement or disagreement with six items, such as “having a tan gives a person more sex appeal.” For media motivations to tan, participants rated their agreement or disagreement with four items, including “I wish I was as tan as celebrities in the media.” Coefficient alpha of the scales was .87 (general) and .96 (media). Indoor tanning intentions and behavior. Indoor tanning intentions were assessed by asking participants (on a 5-point scale ranging from definitely won’t to definitely will) whether they planned on tanning indoors sometime in the future (Lazovich et al., 2004). Indoor tanning behavior was assessed by asking participants to indicate how many times
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they had tanned indoors in the past 12 months (Lazovich et al., 2008).
Results are displayed in Table 1. As can be seen, the null and one-factor models provided a poor fit to the data. In contrast, both the correlated factors and hierarchical models provided a good fit. We accepted the hierarchical model as the model of best fit, both theoretically and empirically. The positive expectations model had a comparative fit index (CFI) of .90 and a root mean square error of approximation (RMSEA) of .08. The negative expectations model had a CFI of .94 and a RMSEA of .08 (see Figures 2 and 3).
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RESULTS The study sample was primarily White (94%) and the mean age was 19.86 years (SD = 1.15). Most participants lived in on-campus dorms (65%), off campus (27%), or in a sorority house (6%), and participants were freshmen (23%), sophomores (32%), juniors (26%), or seniors (19%). Participants’ skin type tended to be fair (50%), olive (26%), or very fair (13%), and most reported engaging in sun safety behaviors more than half the time (67%). Forty-three percent had tanned indoors in their lifetime and 27% in the past 12 months.
Structural Equation and Path Modeling Next, Amos was used to run latent variable structure equation modeling to test our hypothesized model (described earlier). Our approach was to compute our hypothesized model, examine fit and modification indices, and make iterative changes to the model based on both theoretical and empirical considerations (Kline, 2011). The outcome expectations scales were entered as higher order factors—that is, each positive or negative dimension served as the latent factor, with each subscale serving as indicators of the factor. Exogenous variables were allowed to correlate. An initial test of this model revealed sub-optimal fit, as can be seen in Table 2. Five paths in the initial model were not significant and were removed from the model. Because no significant paths from media appearance motivations to tan remained in the model after those paths were deleted, that variable was removed entirely. Additionally, three pairs of conceptually similar items on the temptations variable and one pair of items on the motivations to tan variable had error terms with extremely high modification indices and were therefore allowed to correlate in order to improve model fit. The final model consisting of all significant paths demonstrated improved fit (see Table 2 and Figure 4 for the final model). Bootstrapping procedures (2,000 bootstrap samples, 95% bias-corrected confidence intervals) were used to test
Confirmatory Factor Analysis The first goal of the study was to test the psychometric structure of CITE using confirmatory factor analysis (Noar, 2003). We also sought to examine the dimensionality of the scale by comparing null, single-factor, correlated factors, and higher-order factor models. These models were created in Amos 19 and tested against the independence (null) model, which assumes all constructs are unrelated and serves as a baseline model. The single-factor model tested whether the positive and negative expectations factors, respectively, are measuring one general construct. The correlated factors model tested CITE as having several subscales, with each subscale correlated with the others. The hierarchical model tested a second-order factor relationship for indoor tanning outcome expectations. This model suggests that there is a higher order construct that underlies each positive and negative set of subdimensions, respectively.
TABLE 1 Confirmatory Factor Analysis of the Comprehensive Indoor Tanning Expectations (CITE) Scale (N = 775) Fit Indexes Positive Expectations: Models Null One factor Correlated factors Higher order factors
χ2
df
CFI
RMSEA
SRMR
17,235.61∗∗∗ 5,928.97∗∗∗ 1,708.09∗∗∗ 2,016.78∗∗∗
378 350 335 344
.00 .67 .92 .90
.24 (.237–.243) .14 (.140–.147) .07 (.069–.076) .08 (.076–.083)
— .11 .05 .07
Fit Indexes Negative Expectations Models Null One factor Correlated factors Higher order factors
χ2
df
CFI
RMSEA
SRMR
14,003.76∗∗∗
210 189 179 184
.00 .66 .95 .94
.29 (.288–.296) .18 (.176–.184) .07 (.065–.074) .08 (.072–.081)
— .12 .05 .07
4,910.60∗∗∗ 845.88∗∗∗ 1,011.65∗∗∗
Note. CFI = comparative fit index; RMSEA = root mean square error of approximation; SRMR = standardized root mean square residual. ∗∗∗ p < .001.
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FIGURE 2 Hierarchical confirmatory factor analysis model for positive outcome expectations (all parameter estimates are standardized; N = 775).
for indirect effects (Preacher & Hayes, 2008). Appearance motivations and appearance motivations to tan had significant indirect effects on temptations to tan (β = .10, p < .001; β = .41, p < .001, respectively). The exogenous variables had significant indirect effects on indoor tanning intentions (appearance motivations: β = .07, p < .001; skin type: β = .03, p < .01; appearance motivations to tan: β = .34, p
ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20
Testing a Social Cognitive Theory-Based Model of Indoor Tanning: Implications for Skin Cancer Prevention Messages Seth M. Noar, Jessica Gall Myrick, Alexandra Zeitany, Dannielle Kelley, Brenda Morales-Pico & Nancy E. Thomas To cite this article: Seth M. Noar, Jessica Gall Myrick, Alexandra Zeitany, Dannielle Kelley, Brenda Morales-Pico & Nancy E. Thomas (2015) Testing a Social Cognitive Theory-Based Model of Indoor Tanning: Implications for Skin Cancer Prevention Messages, Health Communication, 30:2, 164-174, DOI: 10.1080/10410236.2014.974125 To link to this article: http://dx.doi.org/10.1080/10410236.2014.974125
Published online: 03 Dec 2014.
Submit your article to this journal
Article views: 397
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hhth20 Download by: [University of Cambridge]
Date: 05 November 2015, At: 17:43
Health Communication, 30: 164–174, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2014.974125
Testing a Social Cognitive Theory-Based Model of Indoor Tanning: Implications for Skin Cancer Prevention Messages Seth M. Noar
Downloaded by [University of Cambridge] at 17:43 05 November 2015
School of Journalism and Mass Communication and Lineberger Comprehensive Cancer Center University of North Carolina at Chapel Hill
Jessica Gall Myrick The Media School Indiana University
Alexandra Zeitany School of Medicine University of North Carolina at Chapel Hill
Dannielle Kelley School of Journalism and Mass Communication University of North Carolina at Chapel Hill
Brenda Morales-Pico School of Medicine University of North Carolina at Chapel Hill
Nancy E. Thomas Lineberger Comprehensive Cancer Center and School of Medicine University of North Carolina at Chapel Hill
The lack of a theory-based understanding of indoor tanning is a major impediment to the development of effective messages to prevent or reduce this behavior. This study applied the Comprehensive Indoor Tanning Expectations (CITE) scale in an analysis of indoor tanning behavior among sorority women (total N = 775). Confirmatory factor analyses indicated that CITE positive and negative expectations were robust, multidimensional factors and that a hierarchical structure fit the data well. Social cognitive theory-based structural equation models demonstrated that appearance-oriented variables were significantly associated with outcome expectations. Outcome expectations were, in turn, significantly associated with temptations to tan, intention to tan indoors, and indoor tanning behavior. The implications of these findings for the development of messages to prevent and reduce indoor tanning behavior are discussed
Correspondence should be addressed to Seth M. Noar, PhD, Professor, School of Journalism and Mass Communication, 382 Carroll Hall (Campus Box 3365), University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3365. E-mail: [email protected]
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in two domains: (a) messages that attempt to change broader societal perceptions about tan skin, and (b) messages that focus more narrowly on indoor tanning—challenging positive expectations, enhancing negative expectations, and encouraging substitution of sunless tanning products.
Recent data make a convincing case that indoor tanning is associated with the development of several types of skin cancer. Systematic reviews and meta-analyses have demonstrated a relationship between indoor tanning and the incidence of cutaneous melanoma (Boniol, Autier, Boyle, & Gandini, 2012), basal-cell carcinoma (Wehner et al., 2012), and squamous-cell carcinoma (Wehner et al., 2012). The evidence suggests that ultraviolet (UV) exposure via indoor tanning at younger ages (i.e., before age 35 years) may particularly increase the risk of melanoma (Boniol et al., 2012) and nonmelanoma skin cancers (Wehner et al., 2012). Studies reveal that young, White women are particularly likely to tan indoors (Centers for Disease Control and Prevention, 2012; Watson et al., 2013). Epidemiologic studies have revealed concurrent increases in melanoma among young White women (Hausauer, Swetter, Cockburn, & Clarke, 2011; Purdue, Freeman, Anderson, & Tucker, 2008), with indoor tanning emerging as the likely culprit (Coelho & Hearing, 2010). Health communication campaigns are imperative for the prevention and reduction of indoor tanning (Holman et al., 2013; Lazovich & Forster, 2005). Despite this, there is a paucity of message design research to inform such campaigns. In this article, we (a) briefly summarize existing research on health communication and indoor tanning, (b) discuss a new line of theory-based research in this area, and (c) report results of a new study and discuss implications for indoor tanning prevention messages.
HEALTH COMMUNICATION AND INDOOR TANNING Research on indoor tanning prevention message design, and indoor tanning interventions more broadly, is in its infancy. A small number of indoor tanning interventions have been developed and tested to date (Turrisi, Hillhouse, Mallett, Stapleton, & Robinson, 2012). Interventions have had some success, using methods such as UV photo imaging (Gibbons, Gerrard, Lane, Mahler, & Kulik, 2005), peer-delivered motivational interviewing (Turrisi, Mastroleo, Stapleton, & Mallet, 2008), appearance workbooks (Hillhouse, Turrisi, Stapleton, & Robinson, 2008), and caregiver involvement (Lazovich et al., 2013). While many of these interventions use messages in some capacity, they do not advance an understanding of the effects of particular message types. We identified only two studies that focused on indoor tanning message design, using statistical, narrative, and normative messaging research as a guide. The first study tested a statistical message format (risks of using tanning beds
and information about skin cancer) against a narrative format (story about a young women who develops facial skin cancer after using a tanning bed) among college women (Greene & Brinn, 2003). Results indicated the statistical format was perceived as more informative, while the narrative message was perceived as more realistic. While both messages reduced intentions to tan indoors, only the statistical message reduced indoor tanning behavior (1 month later). The second study expanded on the first study by adding a normative message (percentage of students who avoided using tanning beds) condition (Greene, Campo, & Banerjee, 2010). The normative message worked best to reduce normative tanning perceptions, while the narrative message best attracted attention. However, there were few effects on beliefs across message conditions, with no effects of any message condition on intentions to tan indoors.
A THEORY-BASED APPROACH TO INDOOR TANNING RESEARCH To provide the most solid foundation for indoor tanning messaging research, a theory-based understanding of the beliefs that underlie indoor tanning behavior is needed. However, research on motivations for indoor tanning has been quite limited (Hillhouse & Turrisi, 2012). While previous studies demonstrate that various attitudes and beliefs are associated with indoor tanning (Hillhouse & Turrisi, 2012; Hillhouse, Turrisi, Holwiski, & McVeigh, 1999; Lazovich et al., 2004), research in this area has been limited by (a) a lack of validated, comprehensive measures and (b) a lack of theory-based research. We have recently applied social cognitive theory (SCT; Bandura, 1986) to the area of indoor tanning. SCT is a comprehensive theory of behavior change that posits that health behaviors must be understood in the context of reciprocal determinism, or the idea that characteristics of a person, that person’s environment, and behavior interact to determine whether an action is performed. While SCT posits numerous intrapersonal, interpersonal, and environmental factors to influence behavior, two of its core determinants are outcome expectations and self-efficacy (Bandura, 2004). Outcome expectations are beliefs about the expected (positive and negative) consequences of engaging in a behavior, and they represent a key motivational factor (i.e., should I perform this behavior?). While positive expectations represent incentives for engaging in a behavior, negative expectations represent disincentives. For instance, a young woman may believe that tanning indoors would be relaxing and make her look
Downloaded by [University of Cambridge] at 17:43 05 November 2015
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great (positive expectations), while she may be somewhat less concerned that the behavior will lead to wrinkles and saggy skin later in life (negative expectations). The balance of positive versus negative expectations is thought to determine motivation level for performing the behavior, and extant health behavior research has provided support for this claim (Prochaska et al., 1994). The second factor is self-efficacy, which refers to one’s confidence in performing a behavior across a range of situations. This represents a capability factor (i.e., can I perform this behavior?), and scores of studies empirically demonstrate the importance of self-efficacy to behavior (Bandura, 1997). The more one believes in one’s ability to perform the behavior, the more likely one is to engage in that behavior. When the behavior is risky, however, self-efficacy may be more usefully conceptualized as its mirror opposite—temptations (Velicer, DiClemente, Rossi, & Prochaska, 1990). In this conceptualization, temptations to engage in the behavior promote the unhealthy behavior. Temptations have been shown to longitudinally predict smoking behavior (Prochaska, Velicer, Guadagnoli, Rossi, & DiClemente, 1991), and they may be more intuitive for respondents to report on for risky behaviors (i.e., reporting on temptations to engage in the risky behavior rather than confidence to not engage in the risky behavior) (Velicer et al., 1990). In the context of indoor tanning, a young woman may be particularly tempted to tan indoors when a special event is coming up, it’s the winter season, or she perceives her skin to be too pale, for instance. Given that both outcome expectations and self-efficacy are amenable to change, they represent important theoretical factors that can be emphasized in messages. We began our program of research by focusing first and foremost on outcome expectations, given the limited literature on tanning motivations. We developed the Comprehensive Indoor Tanning Expectations (CITE) scale (Noar, Myrick, MoralesPico, & Thomas, 2014), an outcome expectations measure that consists of 11 dimensions (six positive and five negative) that may influence indoor tanning behavior. In the Noar et al. (2014) study, which involved a sample of 706 young women, CITE was found to be reliable and to significantly correlate with a set of established measures from the indoor tanning literature, including appearance motivations to tan and intentions to tan indoors. We also assessed temptations to tan indoors and found it to be significantly correlated with all 11 CITE scales. Moreover, across three tanner types (nontanners, former tanners, current tanners), significant differences were found on all 11 CITE subscales, building evidence for the validity of this new scale. The indoor tanning literature suggests additional appearance-oriented influences that may be important to this behavior (Hillhouse & Turrisi, 2012; Lazovich & Forster, 2005). For example, the proliferation of the tanning industry and tan celebrities in recent decades provides many opportunities for observational learning of this behavior.
This ties directly to SCT in that modeling, or viewing similar others engaging a behavior, may encourage one to engage in the same behavior (Bandura, 1986). Those who wish their appearance to be more like tan celebrities may, in turn, hold more positive beliefs about indoor tanning (Cafri et al., 2008). Those who are motivated by appearance factors in general (i.e., appearance motivation), as well as those who view tanned skin as more attractive or healthy (i.e., general appearance motivation to tan), may similarly hold more positive beliefs about tanning (Cafri et al., 2008; Hillhouse et al., 1999). Testing an SCT-based model including all of these factors can advance our understanding of the belief systems that underlie indoor tanning behavior, laying the groundwork for evidence-based message design.
CURRENT STUDY The first goal of this study was to test the CITE scale’s psychometric structure with confirmatory factor analysis. The second goal was to test an SCT-based model of indoor tanning intentions and behavior to inform evidence-based message design. The hypothesized model predicted that perceived skin type, appearance motivation, general appearance motivations to tan, and media appearance motivations to tan would be associated with both positive and negative expectations about indoor tanning. The model also hypothesized that positive and negative expectations would be associated with temptations to tan indoors and indoor tanning intentions and behavior. Finally, temptations to tan indoors were expected to directly predict indoor tanning intentions and behavior (see Figure 1).
METHOD Participants and Procedure We conducted an online survey of members of eight sororities at a private university in the southeastern United States. The project was promoted in collaboration with the sororities’ governing body, which sent the invitation to participate, as well as three reminder e-mails over the course of the 3-week survey period. Sorority representatives also placed posters with the survey URL in high-traffic areas in the sorority houses. Due to an institutional review board (IRB) stipulation, sorority members had to be at least 18 years of age to participate in the survey. Interested sorority members accessed the survey online, where it was described as a study of appearance, health, and tanning. After providing their age and consenting to participate in the study, participants completed the 20-minute survey. Sororities that met certain thresholds of participation earned Visa Check Cards. Chapters with at least a 50% participation rate received a $100 gift card, with graduated
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FIGURE 1 Hypothesized model.
incentives at 70% ($150) and 90% ($200) participation. At the end of the survey period, a total of 775 participants had completed the survey; three were excluded due to the minimum age requirement. This represented a 65% (775/1,188) response rate. The IRB approved all procedures used in this research. Measures Comprehensive Indoor Tanning Expectations (CITE) scale. Outcome expectations for indoor tanning were assessed by the six positive subscales (28 items) and five negative subscales (21 items) (Noar et al., 2014). Positive subscales were appearance benefits (α = .92), convenience (α = .88), mood enhancement, (α = .93), health improvement (α = .89), social approval (α = .89), and parental approval (two items; r = .87), while negative subscales were health threat (α = .95), psychological/physical discomfort (α = .87), appearance harms (α = .91), social disapproval (α = .89), and parental disapproval (two items; r = .89). Participants were asked “If I went indoor tanning . . .” and responses were recorded on a 5-point scale ranging from definitely wouldn’t to definitely would. Examples items are “It would make me more attractive” (positive—appearance benefits) and “It would lead to skin cancer” (negative—health threat). Temptations to tan indoors. Indoor tanning temptations were assessed by a 14-item scale (Noar et al., 2014). Participants were asked “How tempted would you be to tan indoors when . . .” and were presented with situations such as “your current tan is wearing off,” “your friends are going tanning,” or “you are feeling anxious or stressed.” Participants answered on a 5-point scale that ranged from
not at all tempted to extremely tempted. Coefficient alpha was .97. Perceived skin type. Participants responded to three items assessing untanned skin color, tannability, and burn tendency. These items asked what color one’s untanned skin is (from six options), as well as what would happen to one’s skin if it were exposed, without protection, to bright sunlight for 1 hour (burn tendency) or repeatedly (tannability), with five response options (Kricker et al., 2007). Coefficent alpha of the three items was .77. Appearance motivation. Appearance motivation was assessed with a four-item scale (Hillhouse et al., 1999). Participants rated their agreement or disagreement on a 5point scale to items such as “How I look is important to me” and “It is important that others view my physical attractiveness positively.” Coefficient alpha was .78. Appearance motivations to tan—General and media. Appearance motivations to tan were assessed with Cafri et al. (2008) 5-point scales. For general motivations to tan, participants rated their agreement or disagreement with six items, such as “having a tan gives a person more sex appeal.” For media motivations to tan, participants rated their agreement or disagreement with four items, including “I wish I was as tan as celebrities in the media.” Coefficient alpha of the scales was .87 (general) and .96 (media). Indoor tanning intentions and behavior. Indoor tanning intentions were assessed by asking participants (on a 5-point scale ranging from definitely won’t to definitely will) whether they planned on tanning indoors sometime in the future (Lazovich et al., 2004). Indoor tanning behavior was assessed by asking participants to indicate how many times
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they had tanned indoors in the past 12 months (Lazovich et al., 2008).
Results are displayed in Table 1. As can be seen, the null and one-factor models provided a poor fit to the data. In contrast, both the correlated factors and hierarchical models provided a good fit. We accepted the hierarchical model as the model of best fit, both theoretically and empirically. The positive expectations model had a comparative fit index (CFI) of .90 and a root mean square error of approximation (RMSEA) of .08. The negative expectations model had a CFI of .94 and a RMSEA of .08 (see Figures 2 and 3).
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RESULTS The study sample was primarily White (94%) and the mean age was 19.86 years (SD = 1.15). Most participants lived in on-campus dorms (65%), off campus (27%), or in a sorority house (6%), and participants were freshmen (23%), sophomores (32%), juniors (26%), or seniors (19%). Participants’ skin type tended to be fair (50%), olive (26%), or very fair (13%), and most reported engaging in sun safety behaviors more than half the time (67%). Forty-three percent had tanned indoors in their lifetime and 27% in the past 12 months.
Structural Equation and Path Modeling Next, Amos was used to run latent variable structure equation modeling to test our hypothesized model (described earlier). Our approach was to compute our hypothesized model, examine fit and modification indices, and make iterative changes to the model based on both theoretical and empirical considerations (Kline, 2011). The outcome expectations scales were entered as higher order factors—that is, each positive or negative dimension served as the latent factor, with each subscale serving as indicators of the factor. Exogenous variables were allowed to correlate. An initial test of this model revealed sub-optimal fit, as can be seen in Table 2. Five paths in the initial model were not significant and were removed from the model. Because no significant paths from media appearance motivations to tan remained in the model after those paths were deleted, that variable was removed entirely. Additionally, three pairs of conceptually similar items on the temptations variable and one pair of items on the motivations to tan variable had error terms with extremely high modification indices and were therefore allowed to correlate in order to improve model fit. The final model consisting of all significant paths demonstrated improved fit (see Table 2 and Figure 4 for the final model). Bootstrapping procedures (2,000 bootstrap samples, 95% bias-corrected confidence intervals) were used to test
Confirmatory Factor Analysis The first goal of the study was to test the psychometric structure of CITE using confirmatory factor analysis (Noar, 2003). We also sought to examine the dimensionality of the scale by comparing null, single-factor, correlated factors, and higher-order factor models. These models were created in Amos 19 and tested against the independence (null) model, which assumes all constructs are unrelated and serves as a baseline model. The single-factor model tested whether the positive and negative expectations factors, respectively, are measuring one general construct. The correlated factors model tested CITE as having several subscales, with each subscale correlated with the others. The hierarchical model tested a second-order factor relationship for indoor tanning outcome expectations. This model suggests that there is a higher order construct that underlies each positive and negative set of subdimensions, respectively.
TABLE 1 Confirmatory Factor Analysis of the Comprehensive Indoor Tanning Expectations (CITE) Scale (N = 775) Fit Indexes Positive Expectations: Models Null One factor Correlated factors Higher order factors
χ2
df
CFI
RMSEA
SRMR
17,235.61∗∗∗ 5,928.97∗∗∗ 1,708.09∗∗∗ 2,016.78∗∗∗
378 350 335 344
.00 .67 .92 .90
.24 (.237–.243) .14 (.140–.147) .07 (.069–.076) .08 (.076–.083)
— .11 .05 .07
Fit Indexes Negative Expectations Models Null One factor Correlated factors Higher order factors
χ2
df
CFI
RMSEA
SRMR
14,003.76∗∗∗
210 189 179 184
.00 .66 .95 .94
.29 (.288–.296) .18 (.176–.184) .07 (.065–.074) .08 (.072–.081)
— .12 .05 .07
4,910.60∗∗∗ 845.88∗∗∗ 1,011.65∗∗∗
Note. CFI = comparative fit index; RMSEA = root mean square error of approximation; SRMR = standardized root mean square residual. ∗∗∗ p < .001.
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FIGURE 2 Hierarchical confirmatory factor analysis model for positive outcome expectations (all parameter estimates are standardized; N = 775).
for indirect effects (Preacher & Hayes, 2008). Appearance motivations and appearance motivations to tan had significant indirect effects on temptations to tan (β = .10, p < .001; β = .41, p < .001, respectively). The exogenous variables had significant indirect effects on indoor tanning intentions (appearance motivations: β = .07, p < .001; skin type: β = .03, p < .01; appearance motivations to tan: β = .34, p
