The development of successful interventions to alter health behaviors such as UV protection and exposure is largely dependent upon understanding the attitudes and beliefs that predict specific behaviors and behavioral intentions. The current study provides evidence for attitudes and beliefs that are closely related to UV protection and exposure intentions among young adults. In the discussion that follows, we summarize the study results, compare our results with the existing literature, and discuss the implications of these findings for descriptive and intervention research.
As hypothesized, the key IM constructs – background/individual variables, attitudes, beliefs, norms, and self-efficacy - played a role in predicting skin protection, sun exposure, and indoor tanning intentions. With regard to skin protection, distress about skin damage (a background/individual construct), sunscreen self-efficacy (a self-efficacy construct), and perceived behavioral control over skin protection (a self-efficacy construct) contributed independently to intentions, with the overall model accounting for 34% of the variance. With regard to sun exposure, behavioral outcome beliefs about one’s ability to tan without burning (a beliefs construct) and low self-efficacy for sun avoidance (a self-efficacy construct) contributed independently to intentions, with the overall model accounting for 25% of the variance. Finally, with regard to indoor tanning, perceived skin damage (a background/individual construct), tanning outcome evaluation (a beliefs construct), tanning norms (a norms construct), and favorability of one’s image of a prototypical indoor tanner (a norms construct) contributed independently to intentions, with the overall model accounting for 32% of the variance. Thus, IM variables accounted for a significant amount of variance in each of the models of skin protection and UV exposure intentions.
We originally predicted that similar attitudes and beliefs would be associated with both indoor and outdoor exposure intentions and that skin protection and exposure intentions would be associated with similar variables but that these relationships would be in opposite directions of one another. However, skin protection, indoor exposure, and outdoor exposure intentions were associated with both common and unique attitudes and beliefs, but not always in the ways we hypothesized.
The only correlate that was common to 2 behavioral intentions was self-efficacy, providing some support of our hypothesis that self-efficacy would be associated with all the behavioral intentions. Consistent with previous work, self-efficacy was found to be an important common correlate in both skin protection and sun exposure intentions models. However, self-efficacy was not associated with indoor tanning in the current study. While one might consider skin protection behaviors to be relatively simple health behaviors compared to others (e.g., quitting smoking, weight loss), the degree of self-efficacy for skin protection varies across individuals. Some individuals may intend to protect their skin in general, but may have low self-efficacy for sustaining skin protection behaviors as is required to reduce risk for skin cancer. Interventions designed to reduce sun exposure and increase skin protection could be strengthened by focusing on enhancing self-efficacy to maintain long-term protective habits despite potential social and situational barriers.
In addition to self-efficacy, we hypothesized that the remaining IM constructs would also be associated with more than one of the behavioral intentions. However, contrary to these predictions, the other 7 independent correlates identified were unique to only one of the 3 behavioral intentions. Correlates associated with only one outcome included background, attitude, and norms variables. For example, norms only contributed to indoor tanning intentions. It is particularly surprising that normative beliefs were not significant in the sun exposure model since sunbathing is often a social activity. However, it makes sense that normative beliefs would be more important for indoor tanning since the reinforcing properties of sunbathing are broader or more generalized (e.g., vacation, the outdoors/nature, socializing) than those of indoor tanning, which is more narrowly limited to UV exposure for attractiveness reasons. Interventions to reduce indoor tanning should include attempts to alter normative perceptions of indoor tanning among others. Together these differences suggest that outdoor and indoor tanning have unique behavioral correlates. Thus, interventions within the overarching domain of skin cancer risk reduction may need to be targeted specifically for each type of exposure behavior. This finding is consistent with a prior study that also reported on the distinctiveness of sun exposure and protection behavior.47
However, in that study, self-efficacy predicted sun protection but not intention to limit sun exposure.47
These data provide evidence for which IM beliefs are most closely related to which behavioral intentions among young adults. According to Hornik and Woolf,48
successful behavioral interventions should target beliefs that are related to the behavior and are changeable and individuals who do not already hold the belief. Future trials could target individuals who do not hold the beliefs and tailor intervention components to focus on the specific beliefs of each individual. For example, one of the strongest IM correlates identified was outcome evaluation beliefs for intentions to indoor tan. Thus, a successful intervention to reduce indoor tanning should focus on minimizing beliefs about indoor tanning’s positive effects such as attractiveness of a tanned appearance and maximizing beliefs about negative effects such as burning, dry skin, fake appearance, cost, and time. Indeed, several trials that have taken such an approach have produced significant reductions in indoor tanning.
IM interventions focusing on the self-efficacy construct could be useful for both increasing skin protection as well as reducing sun exposure. There are a number of potential thoughts, feelings, and behaviors that may contribute to these behaviors. For example, there are several ways to protect one’s skin including wearing various types of clothing and accessories and applying broad-spectrum high-SPF sunscreen thickly and regularly several times a day. Interventions designed to increase sustained self-efficacy would need to help participants to be aware of the specifics of how to protect the skin, obtain the appropriate items, plan ahead, remember the items, motivate him or herself to use the items, potentially handle criticism from others (e.g., “You look so pale.”). In a prior study, self-efficacy for skin self-examination was also found to be a significant mediator of a skin self-examination intervention among individuals at high risk for melanoma.29
However, it is unknown which aspect of self-efficacy is most important for initiating and maintaining behavior. Of course, this would also likely vary from behavior to behavior and/or population to population.
The Integrative Model has not previously been investigated in the domain of skin cancer risk reduction, and most prior skin cancer prevention studies have focused on one prevention outcome and have not compared across 3 related outcomes within a single study and participant sample. Thus it has been difficult to discern whether differences in study findings can be accounted for by variations across behaviors, samples, or procedures. The current study demonstrated that the IM components relevant to each particular health behavior varied in importance across behaviors, even behaviors within the same domain (e.g., skin cancer risk reduction behaviors), as was proposed by Fishbein and Cappella.8
Strengths of the current study include the interpretation of associations among 3 unique but related behavioral intentions within the IM theoretical framework which allows for additional hypothesis generation to guide future research and prevention intervention development in this area. These findings offer the potential for improving the impact of behavioral interventions on reducing skin cancer incidence.
Limitations include the cross-sectional nature of the data and the assessment of intentions rather than behaviors. Additionally, a convenience sample of primarily Caucasian female college students was used; thus, participants may have been more interested in skin cancer prevention than non-participants. Skin cancer-related belief measures are not standardized, and there was quite a bit of variability in responses to some of the scales. Finally, 5 variables were assessed with one item.
Future prospective research should investigate whether the variables identified here predict actual behaviors in addition to being associated with intentions, which we will be able to do as our intervention trial concludes. It is well-known that intentions are not perfectly correlated with behaviors. For example, one study of parents found intentions to be the most important predictor of sunscreen use,49
whereas another study of fifth graders found that intentions were not significantly associated with sunscreen use.50
Most studies focus on one population, but future research should investigate differences in behavioral correlates by population such as children, young adults, and older adults.
In summary, the current study identified several background, attitudinal, normative, and self-efficacy variables that were independently associated with skin protection, sun exposure, and indoor tanning intentions among young adults. The behavior significantly associated with both sun protection and exposure intentions was self-efficacy. We identified a number of unique correlates of these 3 behavioral intentions. The current findings suggest targeting these unique correlates of each behavioral intention in order to obtain optimal intervention outcomes. Research into future intervention efforts should evaluate whether these variables predict actual behavior over time.