Using Appearance-Based Messages to Increase Sun Protection in Adolescent Young Adult Cancer Survivors: A Pilot Study of Ultraviolet Light Photography

Abstract

Despite risk for secondary skin cancers, many adolescent and young adult (AYA) cancer survivors do not practice recommended sun protection (SP). Ultraviolet light photography (UVP), which demonstrates the negative impact of sun exposure on physical appearance, has been shown to increase SP in community AYA samples. This study of 58 AYA cancer survivors demonstrates that UVP is acceptable and not distressing to this population. Follow-up data on 23 AYAs demonstrated that those given UVP significantly improve their SP behaviors, while those receiving standard educational materials do not. Results demonstrate UVP is a promising tool for increasing SP in AYA survivors.

Introduction

Despite increased risk for secondary skin cancers^1,2 and recommendations to limit ultraviolet light (UVL) exposure,^3–5 studies show many adolescent and young adult (AYA) survivors do not practice adequate sun protection (SP).^6,7 A National Health Interview Survey study for example, showed survivors were no more likely to practice recommended SP than the general population, with AYA survivors found the least likely to be adherent.⁶ Similarly, a study of 152 cancer survivors diagnosed before age 30 conducted by our research team found that only 27% were adherent to recommend SP and also found that younger survivors were less adherent.⁸

Novel interventions highlighting the negative impact of UVL exposure on physical appearance (e.g., wrinkles and age spots) have been shown effective in promoting SP in young adults in the general population.^9–12 Ultraviolet light photography (UVP), which reveals skin damage from previous UVL exposure not visible under normal conditions, has been shown to be a particularly effective method for delivering appearance-based messages. Research indicates, providing young adults with a UVP photograph increases the salience and certainty of the negative appearance consequences of sun exposure¹⁰ and increases their subsequent SP.^10–12 To determine if UVP could be a useful tool for educating AYA survivors, we conducted a two-phase pilot study to investigate how AYA survivors responded to being provided with a UVP photograph of themselves. The primary aim of this pilot study was to determine if AYA survivors had any negative reactions to the UVP photo when it was given to them at the time of a scheduled survivorship care visit. A secondary aim was to assess how a UV photo might enhance the effects of standard written information on their SP attitudes and behaviors.

Methods

Participants

Participants were 58 AYA cancer survivors, 29 males and 29 females followed at a single cancer center. Median age was 25; 38 participants were between age 18 and 29; 13 were age 30–39; and 7 were age 40–44. Cancer diagnoses included leukemia (n = 13), lymphoma (n = 20), brain tumor (n = 5), and other solid tumors (n = 20). Eligibility criteria included being: (1) age 18 to 45 at enrollment; (2) ≥2 years postcancer diagnosis and ≥1 year posttreatment; (3) no skin cancer history. In addition, as we were interested in evaluating the effect of UVP on AYAs not already practicing SP, survivors who reported using sunscreen or protective clothing >80% of the time during intentional or unintentional sun exposure were not eligible. Participants were enrolled at a survivorship clinic visit and received a $20 gift certificate for participation. Procedures were approved by the cancer center's Institutional Review Board.

Study design and procedures

Phase 1 (n = 14)

Phase1 participants received a UVP of their face, a UVP education sheet, and a standard SP education sheet (described in Materials section below). They completed a Behavior Assessment before receiving intervention materials and the Reactions Assessment after reviewing the study materials. All procedures were completed in a single study visit.

Phase 2 (n = 44)

Phase 2 participants were assigned to either a UVP (n = 25) or Control (n = 19) condition, in a stratified manner to try to achieve age and gender balance. For both groups the Behavior Assessment was collected before the receipt of study materials. Similar to Phase 1 participants, participants in the Phase 2 UVP condition received a UVP of their face along with the UVP and standard SP education sheets. Control participants received only the SP education sheet. After reviewing their materials, participants completed the Reactions Assessment and the measures of Sun Protection Intentions and Perceived Vulnerability. These procedures were completed in a single session. Phase 2 participants were mailed a second Behavior Assessment at the end of the summer after they enrolled, and 23 returned a follow-up assessment; 13 completed <6 months from baseline and 10 completed ≥6 months after baseline. Responders were more likely to be female (70%; p = 0.03) and older (M = 30.81 years) at the time of intervention compared with nonresponders (M = 25.5 years; p = 0.02), but did not differ on time from baseline.

Materials

Ultraviolet light photograph

UVPs were taken using a single-lens reflex Polaroid UV Detect Camera, using Polaroid 677 black-and-white instant film. The filtered UVL is absorbed where there is melanin in the skin, and the resulting black-and-white photograph accentuates nonuniform pigmentation of the epidermis not visible in normal light conditions. This pigment variation indicates where UVL has caused skin damage. The UVP is developed and printed alongside a visible light image on a single sheet of film so participants can compare the images (Fig. 1).

FIG. 1.

Sample UVP photograph showing normal (left) and UV light image (right). UVP, ultraviolet light photography. Reprinted with permission from Mahler, 2015.

Written educational materials

The SP education sheet, adapted from existing educational materials,^10,13 described sun exposure risks and effective sunscreen use. The UVP teaching sheet (developed for this study with content adapted from published materials¹⁴) described the UVP, showed examples of pigment variability visible on UVP, and explained how such variability may indicate sun damage to the skin.

Measures

Reactions to SP materials

The Reactions Assessment, created for this study, consisted of 13 items rated on a 5-point scale that were summed to construct a Total Score (α = 0.84), as well as five subscales: Learning, General Impression, Upset, Behavior Change, and Amount of Detail. Higher scores indicated more positive appraisal.

SP behaviors and attitudes

To assess SP behaviors and attitudes toward SP, we used three previously developed measures. These measures were based on previous studies of SP in the general population^11,15 and were adapted for and described in detail in our 2012 descriptive study of SP in young adult cancer survivors.⁸

SP intentions

Ten items, adapted from a validated measure^10,11,15 assessed participants' intentions to use sunscreen in the future. Items were rated on a 5-point scale and summed to form the Overall Intentions Index (α = 0.91), with higher scores indicating greater intentions to use sunscreen.

Perceived vulnerability

Vulnerability to the effects of UV exposure was measured with a 9-item Perceived Vulnerability Scale.⁸ Items were standardized and averaged to form Total Perceived Vulnerability as well as Vulnerability to Appearance Change and Vulnerability to Skin Cancer scores. Higher scores indicated greater perceived vulnerability.

Sun exposure and protection behaviors

The Behaviors Assessment⁸ assessed seven sun exposure and behaviors in a “typical week.” Exposure and protective behaviors (e.g., wearing sun screen or a hat) were rated separately for intentional exposure, defined as “time in the sun with the goal of ‘getting some color’,” and incidental exposure, defined as “time in the sun doing something other than sunbathing.” For participants who indicated that they “never, ever sunbathe,” exposure data were only available for hours of incidental sun exposure.

Results

Reactions to SP materials (primary aim)

Using data from Phase1 and Phase 2, the Reactions Assessments of participants who received the UVP versus Control materials were compared using the Mann–Whitney U-test (Table 1). Reactions did not differ across groups on the Reactions Total Score (p = 0.09), or the Learning, General, Change, or Upset subscales (all p ≥ 0.10). Significantly, lower scores on the Detail subscale in the UVP group (M = 12.00 vs. M = 12.95) indicated that UVP participants rated the materials more negatively than Controls on this dimension (p = 0.05). To follow-up, the two groups responding to the individual Detail items were assessed (z-test for independent proportions), demonstrating more UVP participants reporting that their materials had too much details (31% vs. 5%; z-test for difference between independent proportions = 2.19, p = 0.03) and were boring to read (44% vs. 16%; z = 2.09, p = 0.04). Only one participant in each condition reported anxiety or distress (UVP 5%; Control, 3%; z = 0.53, p = 0.60).

Table 1.

Immediate Reactions to Study Materials

	UVP condition M (SD)	Control condition M (SD)	Independent sample Mann–Whitney z
Reactions Assessment (Phase 1 and 2; UVP n = 39; Control n = 19)
Total Score^a	53.72 (6.15)	56.26 (6.82)	1.72^b
Learning	13.74 (1.53)	14.37 (1.30)	1.65
General	12.56 (1.97)	12.89 (2.64)	1.03
Detail	12.00 (2.21)	12.95 (2.88)	1.99^c
Upset	9.10 (1.27)	9.32 (1.49)	1.30
Change	6.31 (1.73)	6.74 (1.79)	1.29
Intentions and Perceived Vulnerability (Phase 2; UVP n = 25, Control n = 19)
Overall intentions^d	33.28 (9.25)	35.84 (5.34)	0.82
Vulnerability total^e	0.00 (0.81)	−0.02 (0.75)	0.34
Vulnerability appearance	0.00 (0.85)	−0.02 (0.80)	0.27
Vulnerability skin cancer	0.00 (0.82)	−0.02 (0.85)	0.04

Means shown in boldface differ significantly (p < 0.05).

Higher scores indicate a more positive reaction.

p < 0.10.

p < 0.05.

Higher scores indicate greater agreement with recommended sun protection practices.

Higher scores indicate great perceived vulnerability. Calculations use z-score transformations.

UVP, ultraviolet light photography.

Attitudes and intentions (secondary aim)

Using Phase 2 data, the UVP and Control conditions were similarly compared on the Sun Protection Intentions and Perceived Vulnerability assessments (Mann–Whitney U-test; Table 1). Scores for the Overall Intentions Index did not differ significantly between UVP and Control participants (p = 0.41), indicating that the groups had similar intentions to practice SP. Similarly, the groups did not differ significantly on Vulnerability to Appearance Change (p = 0.79), Vulnerability to Skin Cancer (p = 0.97), or Total Perceived Vulnerability scores (p = 0.73).

Behaviors at follow-up (secondary aim)

Changes in the seven SP behaviors assessed were analyzed for the 12 UVP and 11 Control participants in Phase 2 who completed a follow-up assessment. On follow-up assessments, UVP participants improved on all seven SP behaviors, although not all changes were statistically significant (Wilcoxon matched-pairs signed-rank test; Table 2). Mean hours of incidental sun exposure decreased significantly from 12 to 8.83 (p = 0.03), and during incidental exposure frequency of both bodily sunscreen use (from 18.33% to 30.83%; p = 0.03), and hat wearing (15.00% to 27.50%; p = 0.05) increased significantly. UVP participants also reported decreased intentional sun exposure and an increase in several sunscreen use variables, but these changes were not statistically significant. Control participants by contrast reported improvement on some variables and a worsening on others, but no differences were statistically significant. To quantify the different pattern of behavior changes over time, the seven SP behaviors in Table 2 are recoded into categorical variables to capture whether participants worsened, stayed the same, or improved. Differences between the proportion of UVP and Control participants in each of these categories were compared (z-test for independent proportions: data not shown) and significant differences were found for two of the seven variables, indicating that more UVP participants had favorable changes in amount of intentional and incidental exposure. Specifically, 83.3% of UVP participants reported improvement (decreased exposure) during incidental exposure compared with 36.4% of Controls (z = 2.31, p = 0.02). Similarly, only 8.3% of the UVP group reported worsening (increased exposure) during intentional sun exposure time compared with 54.5% of Controls (z = 2.4, p < 0.02).

Table 2.

Sun Exposure and Protection Behaviors Assessed at Baseline and Follow-Up (N = 23)

	UVP condition (n = 12)			Control condition (n = 11)
	Baseline M (SD)	Follow-up M (SD)	Wilcoxon signed rank test^a z	Baseline M (SD)	Follow-up M (SD)	Wilcoxon signed rank test^b z
Intentional sun exposure
Weekly hours	2.00 (2.59)	1.25 (1.82)	1.47	1.45 (2.07)	3.41 (4.83)	1.05
Frequency of facial sunscreen use^c	58.13 (41.91)	77.50 (29.64)	1.70^d	54.00 (41.59)	70.00 (39.37)	0.95
Frequency of bodily sunscreen use^c	43.75 (41.04)	65.00 (38.55)	1.80^d	62.00 (35.64)	84.00 (23.02	1.84^d
Incidental sun exposure
Weekly hours	12.71 (10.61)	8.83 (7.66)	2.17^e	11.27 (9.99)	11.00 (8.73)	0.30
Frequency of facial sunscreen use	44.58 (43.87)	54.17 (40.10)	1.51	40.00 (41.23)	34.55 (47.51)	0.21
Frequency of bodily sunscreen use	18.33 (24.80)	30.83 (36.05)	2.23^e	21.82 (20.89)	19.55 (23.07)	0.21
Frequency of wearing hat	15.00 (20.67)	27.50 (34.15)	1.98^e	25.45 (29.79	25.00 (25.40)	0.34

Means shown in boldface differ significantly (p > 0.05).

Comparing UVP condition at baseline and follow-up.

Comparing Control condition at baseline and follow-up.

Data on subset of participants who reported intention exposure at both time points. UVP condition, n = 8; Control condition, n = 5.

p < 0.10.

p < 0.05.

Discussion

AYA cancer survivors are vulnerable to a variety of medical late-effects that can negatively affect their health.^16,17 Care guidelines^3–5,18 recommend counseling to avoid behaviors that could increase health risks, but studies indicate a significant proportion of AYA survivors do not adhere to preventative health recommendations.^6,16 To address this problem, novel approaches to developing and delivering interventions to AYA survivors have been proposed, although comparatively little work has been done to develop SP interventions for survivors.^19–21 This may be due to the fact that most skin cancers can be successfully treated—but they bring with them unwanted health worries, increased anxiety, medical costs, and potential disfigurement^22–25 even when they are not life threatening.

UVP has been found to be a useful tool for increasing SP behaviors in the general AYA population,^10–12 but we are not aware of its application to AYA cancer survivors. Before recommending it, we were concerned that the UVP itself might be off-putting or confusing to AYA survivors because it could be misunderstood as a cancer diagnostic tool, especially when delivered in a cancer center. Our results indicate that this is not the case; only 2 of 58 participants reported a negative reaction and one of these was in the Control condition. Furthermore, Control and UVP participants rated the general acceptability of the study materials similarly, with the exception of questions about unnecessary detail. Participants who received the UVP also received an additional teaching sheet to accompany it. This is not a standard practice in most prior UVP studies and indicates that it may have contributed to additional burden as these participants were more likely to report their material was overly detailed and boring. With data on 39 AYA survivors who received a UVP intervention, the pilot study results clearly address our primary aim, supporting the acceptability of UVP with this population and encouraging investigators to incorporate it into new interventions to promote their SP.

Although these findings should dispel doubts about the safety of UVP for AYA survivors, additional research is needed to address our secondary aim of determining its effectiveness. Phase 2 of our pilot study examined effects of UVP on survivors' SP intentions, perceived vulnerability and behaviors, but limitations in the data argue for interpreting the findings with caution. No significant effect was found for the UVP intervention on intentions and vulnerability, although these measures were collected immediately following the intervention, and participants' response to the demand characteristics of the cancer center setting may have encouraged them to report moderately high levels of SP intentions regardless of the intervention. Future studies should solicit this information sometime after the intervention, using methods less open to response bias. Similarly, the SP behavior change data were limited by the small (n = 23), and potentially nonrepresentative sample of participants from whom it was available. Nonetheless, the fact that all significant differences in the data favor the UVP intervention is encouraging and suggests that it may be a promising tool to promote SP in AYA survivors. Although UV cameras can cost thousands of dollars, the technique may well prove cost-effective, given the medical costs of skin cancers.^26,27 Our findings should encourage future studies of its cost and effectiveness for preventing secondary skin cancer in young adult cancer survivors.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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