STUDY
Measures of Sun Exposure and Sun Protection
Practices for Behavioral and Epidemiologic Research
Karen Glanz, PhD, MPH; Amy L. Yaroch, PhD; Monica Dancel, MPH; Mona Saraiya, MD, MPH;
Lori A. Crane, PhD; David B. Buller, PhD; Sharon Manne, PhD; David L. O’Riordan, PhD;
Carolyn J. Heckman, PhD; Jennifer Hay, PhD; June K. Robinson, MD
Objective:
To develop, in a collaborative project, core
measures of sun exposure and sun protection habits, since
the lack of standard outcome measures hampers com-
parison of population surveys and interventions used in
skin cancer prevention research.
Design:
A work group of investigators evaluated avail-
able questionnaire measures of sun exposure and pro-
tection. Their deliberations led to a proposed set of core
questionnaire items for adults, adolescents aged 11 to 17
years, and children 10 years or younger. These core items
were used in cognitive testing by the investigators. Cross-
site summaries of methods, response samples, and de-
scriptive data were prepared.
Setting:
Nine locations across the United States.
Participants:
The study population comprised 81
individuals.
Results:
No unusual response patterns were detected
in any of the respondent groups or for any specific
question. Some revisions to the survey items resulted
from the need for clarification or emphasis of frames of
reference such as adding or underlining key phrases in
a question.
Conclusions:
The combination of expert review fol-
lowed by cognitive interviewing yielded standardized
core survey items with good clarity and applicability
for measuring sun exposure and sun protection be-
haviors across a broad range of
populations.
They
are appropriate for studies tracking morbidity and/
or mortality and evaluating prevention program
effects.
Arch Dermatol. 2008;144(2):217-222
S
KIN CANCER
,
THE MOST COM
-
mon cancer in the United
States,
1
is diagnosed in about
1 million Americans each
year.
2
The incidence of skin
cancer has increased dramatically world-
wide in the last decade,
1,2
establishing the
3 main types of skin cancer—malignant
melanoma,
squamous cell
cancer,
and
basal cell cancer—as significant public
health concerns.
1,3
Squamous cell cancer
risk increases with high levels of cumu-
lative sun exposure, and malignant mela-
noma and basal cell cancer risk factors in-
clude a history of severe sunburn and
intense intermittent exposure to the sun
at an early age.
4
Although the incidence of skin cancer
is increasing, it is considered one of the
most preventable types of cancer. UV ra-
diation (UVR) exposure is the major en-
vironmental risk factor for skin cancers,
5
and reducing UVR exposure and adopt-
ing sun protection habits (eg, wearing sun-
screen, hats, shirts, and sunglasses) are the
main public health recommendations for
prevention.
6
PREVIOUS SURVEYS
OF SUN PROTECTION BEHAVIORS
AND SUN EXPOSURE
Given the importance of increasing sun pro-
tection behaviors and reducing sun expo-
sure, the measurement of these behavioral
factors is a priority in national surveys and
in evaluating intervention efforts. In the
United States, several national surveys mea-
sured sun protection and sun exposure;
however, because of space and/or budget re-
strictions there is usually 1 key measure of
sun exposure (sunburn) and an array of sun-
protective behavior items. In 2000, the Na-
tional Health Interview Survey, a house-
hold survey of the noninstitutionalized,
adult civilian population, asked questions
about sunburn, and data showed that ap-
See also page 225
Author Affiliations: Rollins
School of Public Health, Emory
University, Atlanta, Georgia
(Dr Glanz and Ms Dancel);
National Cancer Institute,
Bethesda, Maryland
(Dr Yaroch); Centers for
Disease Control, and
Prevention, Atlanta
(Dr Saraiya); University of
Colorado at Denver and Health
Sciences Center, Denver
(Dr Crane); Klein Buendel Inc,
Golden, Colorado (Dr Buller);
Fox Chase Cancer Center,
Philadelphia, Pennsylvania
(Drs Manne and Heckman);
University of Queensland,
Herston, Australia
(Dr O’Riordan); Memorial
Sloan-Kettering Cancer Center,
New York, New York (Dr Hay);
and Northwestern University
School of Medicine, Chicago,
Illinois (Dr Robinson).
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proximately 36% of US adults experienced at least 1 sun-
burn during the past year.
7
The Behavioral Risk Factor Sur-
veillance System asked about sunburns in 1999, 2003, and
2004. Data from 2003 showed that approximately 39% of
the US population reported a sunburn in the past year, with
higher rates in Midwestern and northern states.
8
The National Health Interview Survey has included ques-
tions about sun sensitivity and sun protection since 1992.
Despite slight variations in question wording over time, this
survey indicates that sun-protective behaviors have a mod-
erate to low prevalence and that sun exposure is high. Data
from 2003 showed that 61% of adults were very likely to
practice at least 1 sun protective behavior, but when it came
to individual behaviors, the prevalence was low: 33% were
very likely to use sunscreen, 33% were very likely to wear
protective clothing, and 31% were very likely to use shade.
9
The overall prevalence of any one of these sun protection
behaviors has hovered around 30% since the early 1990s.
This was confirmed by the Health Information National
Trends Survey 2005, a random-digit dial telephone sur-
vey. Of the respondents, 27% reported always or often wear-
ing sunscreen when outside for more than 1 hour on a warm
sunny day; 43%, staying in the shade; 16%, wearing a long-
sleeve shirt; and 45%, wearing long pants.
10
Since 1999, the Youth Risk Behavioral Survey, a school-
based survey of students in the 9th through 12th grades,
has contained the same question on sunscreen use. Data
from 2003 showed that even the most common sun-
protective behavior among adolescents, sunscreen use,
has remained low, with approximately 17% of white ado-
lescents reporting they use it most of the time or always.
This prevalence has not changed markedly over the 5-year
period.
11
There are few national sun protection surveys of chil-
dren younger than 11 years. In 1998, the Centers for Dis-
ease Control and Prevention conducted a survey with par-
ents of white children aged 6 months to 11 years. They
found that children spent a median of 20 hours a week
outdoors during the summer. Sunscreen and shade were
the most frequently used protection methods (62% and
26.5%,
respectively).
They also found that approxi-
mately 43% of white children experienced 1 or more sun-
burns in the past year.
12,13
Sunscreen is the most frequent method of sun protec-
tion used across all age groups in Australia and internation-
ally.
14
The other forms of recommended sun protection (hats
andclothes)weremorelikelytooccuramongtheveryyoung,
older adults, and men. Differences across countries exist
for sun exposure and sun protection for adults, adoles-
cents, and children.
15
In the United States, most of the sur-
veys report low prevalence of protection and high preva-
lence of sunburns. The prevalence of these behaviors has
not changed markedly in the last 2 decades. Surveys vary
in content and questions, making comparisons within and
between countries and age groups problematic.
MEASUREMENT NEEDS
IN SKIN CANCER PREVENTION
The majority of
studies use verbal
reports or self-
reports to measure habitual sun exposure and solar pro-
tection behaviors.
16
Despite well-known limitations of ver-
bal reports, these measures are the most practical for both
population surveillance and intervention research. A cen-
tral concern in monitoring progress and summarizing the
evidence for effective prevention strategies with broad
applicability is the comparability of assessments across
population-based surveys and outcome measures used
in intervention research. The present article describes the
process and results of a collaborative national effort to
develop a recommended set of core items for surveys and
intervention research in skin cancer prevention.
METHODS
INVESTIGATOR WORKSHOP AND
WORK GROUP ON SUN EXPOSURE
AND SUN PROTECTION MEASURES
In December 2005, the National Cancer Institute and the Emory
Prevention Research Center convened a 2-day workshop for
skin cancer prevention investigators from across the United
States, with the aim of developing a consensus-based set of core
survey questions on UVR exposure and protection behaviors.
Two workgroups were formed: work group A focused on out-
door sun exposure and sun protection, and work group B ad-
dressed indoor tanning behaviors. This article is limited to the
methods used by work group A (see “Additional Information”
at the end of this article for list of members).
Prior to the workshop, participants were asked to submit
relevant questionnaire measures that they were currently using,
along with scoring algorithms and available psychometric data.
Questionnaires from 13 investigators were received and com-
piled for review before and during the workshop. Additional
measures from the published literature were also included.
16
Work group members used an “expert evaluation” process to
review the available questionnaire measures. The group consid-
ered the following factors in evaluating the measures: (1) What
are the most important skin cancer prevention–related behav-
iors to measure that should be recommended for assessment in
all skin cancer prevention research efforts? (2) For each behav-
ior, what questionnaire wording will be most applicable across
geographic regions, climate conditions, and populations? (3) What
item wording would be most adaptable across survey modalities
and formats (ie, self-administered, telephone, or personal inter-
view)? (4) What response options will be most understandable
across populations, be useful in discriminating between levels of
behavior, and capture an appropriate range of behaviors? (5) What
would be the most appropriate time frame for answering behav-
ioral questions (eg, behavior in a typical week; behavior during
a particular time of day; behavior on weekends vs weekdays)?
Through consideration of these key questions and review
of existing measures, the group reached consensus on 7 core
questionnaire items for adults, 8 core items for adolescents aged
11 to 17 years, and 7 core items for parents reporting for chil-
dren 10 years or younger. Consensus was also reached for sec-
ondary items (5 for adults, 2 for adolescents, and 3 for parents
reporting for children 10 years or younger).
COGNITIVE INTERVIEWING TO REDUCE
SYSTEMATIC ERROR OF SELECTED ITEMS
Rationale for Cognitive Interviewing
To further develop core measures that would be widely appli-
cable to skin cancer prevention surveillance and behavioral re-
search, the proposed core items were cognitively tested among
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the intended participants (ie, adults, adolescents, and parents
reporting for children). Cognitive interviewing is a commonly
used technique to aid in the improvement of questionnaire de-
velopment.
17
Typically, one-on-one interviews are conducted
with participants after they complete survey items to help un-
cover cognitive processes that are used when answering the items
(eg, how well a person understands and interprets survey ques-
tions, issues of memory retrieval, and how a particular subject
responds to a question).
17
In short, cognitive interviewing can
be particularly useful in helping to identify and decrease sources
of systematic error in self-report measures before the main field-
ing of the survey, thereby potentially increasing the validity and
reliability of the measure.
17
It is commonly used to pretest sur-
vey items going into national surveys, such as the National Health
Interview Survey and Health Information National Trends Sur-
vey.
18,19
This method was used recently to help develop core
self-report measures of colorectal cancer screening.
20
Cognitive Interviewing Protocol
Four of the coauthors (L.A.C., J.K.R., K.G., and A.L.Y.) devel-
oped a cognitive interviewing moderator’s protocol. The pro-
tocol was slightly modified to be specific for each of the 3 popu-
lations in which it would be tested (ie, adults, adolescents, and
parents reporting for children). The protocol was used as a stan-
dardized guide to help elicit feedback from the subjects on their
cognitive processes for answering the questions, including com-
prehension of the questions. Before cognitive testing, a con-
ference call was conducted to review procedures and discuss
site investigators’
questions about procedures.
DATA COLLECTION PROCEDURES
To obtain a wide variety of respondents from different geo-
graphical settings, 9 study sites were available to conduct cog-
nitive interviewing. The institutional review boards of Emory
University (Atlanta, Georgia), Fox Chase Cancer Center (Phila-
delphia,
Pennsylvania),
Klein Buendel Inc (Golden,
Colo-
rado), Memorial Sloan-Kettering Cancer Center (New York, New
York), Northwestern University (Chicago, Illinois), Univer-
sity of Colorado Health Sciences Center (Denver), University
of Hawaii (Honolulu), University of South Florida (Tampa),
and Virginia Commonwealth University (Richmond) ap-
proved the research protocol. Specific recruitment methods var-
ied according to the site’s location and targeted study popula-
tion. Five university sites used on-campus recruitment strategies
such as e-mail announcements, fliers, visiting classes, and ap-
proaching individuals. One site recruited adolescents aged 11
to 17 years through acquaintances. Three sites that targeted pa-
tients with a history of skin cancer or their first-degree rela-
tives recruited people who had participated in previous stud-
ies or in person during visits for dermatologic examination.
Participants were screened for eligibility according to each site’s
inclusion criteria. People who worked in the tanning industry or
lived with people employed in the tanning industry and those in
marketing research, advertising, or public relations were ineli-
gible. All written surveys were completed on-site, and cognitive
interviews were conducted in person and audiotaped.
The protocol began by having interviewers thank partici-
pants for participating and informing them of the purpose of
the study and that the interviews would be audiotaped. Before
completing survey items, participants were told by interview-
ers that they would be asked to “think aloud” about how they
answered particular questions. Thinking aloud was defined as
stating everything that participants were thinking from the time
they read each question until they wrote down the answers. The
participants were instructed to act as if they were alone in a
room and speaking to themselves, which would include talk-
ing out their thoughts about a particular question. After the par-
ticipants completed all of the survey items, they were queried
about each individual survey item (eg, how they came up with
the answer and whether the items were difficult to answer). Spe-
cific probes were used to help prompt them to discuss their
thought processes in deriving their answers. For instance, one
item asked, “On average, how many hours are you outside be-
tween 10
AM
and 4
PM
in the summer on weekdays?” One main
probe for this item was, “how did you come up with this num-
ber?” If more follow-up was needed, participants were asked
“Did you do any calculations in your head or did you ball park
this?” This was completed for all of the individual survey items,
and participants’
responses were written down by researchers
and audiotaped.
DATA ANALYSIS
Preliminary data analysis was completed at each data collec-
tion site by a researcher who reviewed written notes and ques-
tionnaire notations and listened to the audiotapes. Data ana-
lysts prepared a site report summarizing their recruitment
procedures, response rates, and the results of cognitive inter-
views and sent documentation to the coordinating center at
Emory University. Cross-site summaries were then prepared.
Qualitative analysis of the cognitive testing results was com-
pleted following the methods outlined by Willis.
17
A code book
was developed to synthesize cross-site issues related to the pro-
posed questions, including categories such as clarity, knowledge/
memory, response categories, instructions, and sensitive word-
ing. Two research team members coded the response summaries
for each question and each site. Coding discrepancies were dis-
cussed in meetings, and a final decision about how to code dis-
crepant comments was made in consultation with the lead au-
thor (K.G.). Coded comments were then compiled into a summary
table by question and by site, and problem areas were identified.
The coordinating center reviewed the results of the cogni-
tive testing and used them to recommend revisions to the ini-
tial set of core measures. All participating investigators were
asked to provide comments by e-mail, and a conference call
was convened to discuss the results and make final recommen-
dations for the core questionnaire items.
RESULTS
SAMPLE CHARACTERISTICS
A total of 81 respondents completed the cognitive inter-
viewing across 9 study sites. Response rates ranged from
6% to 66% for patients with skin cancer and 70% to 100%
for nonpatient samples. There were 72 respondents for
the adult survey, 19 of whom were parents of children
aged 1 to 10 years who also completed the child-specific
questions.
Nine adolescents (aged 11-17 years) com-
pleted cognitive interviewing. Overall, 72% of the sample
were female and 72% were white, with an age range from
11 to 74 years and a median age of 31 years. Fifty-five
percent of participants had a college degree or higher.
SURVEY ITEM REVISIONS
Examination of descriptive statistics for the responses re-
vealed distributions similar to those found in the inves-
tigators’
previous research and in national surveys. Be-
cause there were no unusual response patterns detected
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Final Core Items - ADOLESCENTS
For each question listed, please select the one answer that is the best response to the
question.
1. In the summer, on average, how many hours are you outside per day between 10
AM
and 4
PM
…on WEEKDAYS (Monday-Friday)?
30 minutes or less........................................
31 minutes to 1 hour....................................
2 hours .........................................................
3 hours .........................................................
4 hours .........................................................
5 hours .........................................................
6 hours .........................................................
2. In the summer, on average, how many hours are you outside per day between 10
AM
and 4
PM
…on WEEKEND DAYS (Saturday & Sunday)?
30 minutes or less........................................
31 minutes to 1 hour....................................
2 hours .........................................................
3 hours .........................................................
4 hours .........................................................
5 hours .........................................................
6 hours .........................................................
3. In the past 12 months, how many times did you have a red OR painful sunburn that
lasted a day or more?
A
B
C
Final Core Items - ADULTS
For each question listed, please select the one answer that is the best response to the
question.
Section 1 -Sun Habits
1. In the summer, on average, how many hours are you outside per day between 10
AM
and 4
PM
…on WEEKDAYS (Monday-Friday) ?
30 minutes or less.........................................
31 minutes to 1 hour.....................................
2 hours ..........................................................
3 hours ..........................................................
4 hours ..........................................................
5 hours ..........................................................
6 hours ..........................................................
2. In the summer, on average, how many hours are you outside per day between 10
AM
and 4
PM
…on WEEKEND DAYS (Saturday & Sunday) ?
30 minutes or less.........................................
31 minutes to 1 hour.....................................
2 hours ..........................................................
3 hours ..........................................................
4 hours ..........................................................
5 hours ..........................................................
6 hours ..........................................................
3. In the past 12 months, how many times did you have a red OR painful sunburn that
lasted a day or more?
0
1
2
3
4
5
OR
MORE
0
1
2
3
4
5
OR
MORE
0
1
2
3
4
5
OR
MORE
For the following questions, think about what you do when you are outside during the
summer on a warm sunny day.
NEVER
RARELY
SOMETIMES
OFTEN
ALWAYS
NEVER
RARELY
SOMETIMES
OFTEN
ALWAYS
NEVER
RARELY
SOMETIMES
OFTEN
ALWAYS
NEVER
RARELY
SOMETIMES
OFTEN
ALWAYS
NEVER
RARELY
SOMETIMES
OFTEN
ALWAYS
NEVER
RARELY
SOMETIMES
OFTEN
ALWAYS
4. How often do you wear SUNSCREEN? ..........
5. How often do you wear a SHIRT WITH
SLEEVES that cover your shoulders? ..........
6. How often do you wear a HAT?......................
7. How often do you stay in the SHADE or
UNDER AN UMBRELLA? ...............................
8. How often do you wear SUNGLASSES?** ....
9. How often do you spend time in the sun in order to get a tan?**
10. What is the color of your untanned skin?**
Very Fair........................................................
Fair ................................................................
Olive ..............................................................
Light Brown...................................................
Dark Brown....................................................
Very Dark.......................................................
SECTION 2 - Skin Examination
11. Have you EVER had your skin checked for skin cancer from head to toe by a health
professional?**
No ..................................................................
Yes.................................................................
Skip to question 13
12. If yes, what is the month and year when you
last had your skin checked from head to toe?
Write Month/Year
Write number
13. In the last 12 months, have you or a partner examined your entire body, including your
back, for skin cancer?
No ..................................................................
Yes.................................................................
14. If yes, how many times?
**Secondary Items (all others
are Primary Core Items)
Final Core Items - ADULT for CHILD age 1 to 10 years
For each question listed, please think about your CHILD who is 1 to 10 years old and
select the one answer that is the best response to the question.
If you have more than one child who is 1 to 10 years old, please answer this survey thinking
about your OLDEST child who is 1 to 10 years old.
4 hours .........................................................
5 hours .........................................................
6 hours .........................................................
4. In the summer, on average, how many hours is this child outside per day between
10
AM
and 4
PM
on WEEKEND DAYS (Saturday & Sunday) ?
30 minutes or less........................................
31 minutes to 1 hour....................................
2 hours .........................................................
3 hours .........................................................
4 hours .........................................................
5 hours .........................................................
6 hours .........................................................
5. In the past 12 months, how many times did this child have a red OR painful sunburn
that lasted a day or more?
For the following questions, think about what this child does when outside during the
summer on a warm sunny day.
6. How often does this child wear
SUNSCREEN?...............................................
7. How often does this child wear a SHIRT
WITH SLEEVES that cover the shoulder? ....
8. How often does this child wear a HAT?........
9. How often does this child stay in the SHADE
or UNDER AN UMBRELLA?..........................
10. How often does this child wear
SUNGLASSES?**.........................................
11. How often does this child spend time in the sun in order to get a tan?**
12. What is the color of this child's untanned skin?**
Very fair........................................................
Fair ...............................................................
Olive .............................................................
Light brown ..................................................
Dark brown...................................................
Very dark ......................................................
Section 1 - Background Information
1. Thinking of your oldest child between the ages of 1 and 10, what is the age of this child?
Less than 1 year old .....................................
1-3 years old.................................................
4-6 years old.................................................
7-10 years old...............................................
2. Is this child a…?
Boy ...............................................................
Girl................................................................
Section 2 - Sun Habits
3. In the summer, on average, how many hours is this child outside per day between
10
AM
and 4
PM
…on WEEKDAYS (Monday-Friday) ?
30 minutes or less........................................
31 minutes to 1 hour....................................
2 hours .........................................................
3 hours .........................................................
For the following questions, think about what you do when you are outside during the
summer on a warm sunny day.
4. How often do you wear SUNSCREEN? ........
5. How often do you wear a SHIRT WITH
SLEEVES that cover your shoulders? ........
6. How often do you wear a HAT?....................
7. How often do you stay in the SHADE or
UNDER AN UMBRELLA? .............................
8. How often do you wear SUNGLASSES?** ..
10. What is the color of your untanned skin?**
Very fair.......................................................
Fair ..............................................................
Olive ............................................................
Light brown .................................................
Dark brown..................................................
Very dark .....................................................
9. How often do you spend time in the sun in order to get a tan?
Figure. Core skin cancer prevention items for adults (A), adults reporting for children 10 years or younger (B), and adolescents aged 11 to 17 years (C).
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in any of the respondent groups or for any specific ques-
tion items, the cognitive interviewing results were used
to guide further revisions to the core items.
The main revisions to survey items resulted from the
need for clarification or emphasis of frames of reference
such as adding or underlining key phrases in the ques-
tion. For example, for the survey item “How often do you
wear a shirt with sleeves?” the phrase “that covers your
shoulders” was added to the end of the question because
several respondents mentioned that they were unsure of
what length of sleeve to consider in their answer. On the
set of items for which adults were asked to report on their
child, several respondents who had more than 1 child in-
dicated the need for greater clarity about which child to
report on; thus, the instructions were revised to clarify that
parents were to answer the survey while considering their
oldest child aged between 1 and 10 years.
Response options for questionnaire items were also
revised to reflect answers most commonly used and un-
derstood by respondents. For the item “What is the color
of your untanned skin?” the response options of “light
brown” and “dark brown” were added, while “dark” and
“black”—options that had been found confusing—
were dropped. Response options were kept uniform across
all 3 survey types.
Respondents noted inherent limitations to self-reports
that could not be solved by altering the questions. For ex-
ample, some parents expressed concerns that they did not
always know what their child did for sun protection be-
cause they were often separated from the child.
RECOMMENDED MEASURES
The recommended core items are listed in the
Figure
.
These measures are recommended for use in population-
based surveillance and both descriptive and experimen-
tal behavioral research. The work group suggests that re-
searchers make minor adaptations to the questions based
on their study aims, relevant geographic or seasonal con-
siderations, and unique population characteristics such
as race/ethnicity and skin cancer history. In addition, re-
searchers are encouraged to evaluate the reliability and
validity of these measures in various research contexts.
COMMENT
It is well recognized that the measures used to assess UVR
exposure and sun protection practices vary, making com-
parisons between populations problematic.
14,15
The devel-
opment and adoption of standardized core survey items will
advance the science in a number of ways. First, studies that
track morbidity and/or mortality and evaluate the success
of intervention programs would be more feasible and pre-
cise. Second, the field could achieve greater comparability
between populations. A strength of the present effort is that
it was conducted in a much larger sample of participants
than is typical of cognitive interviewing studies.
17
This study reflects a growing trend in behavioral sci-
ences to highlight and address the quality of self-report
measures through multiple strategies, including but not
limited to cognitive interviewing.
While use of self-
reports has been recommended as the most feasible mea-
sure for large population surveys and intervention stud-
ies,
16
the paucity of data on psychometric properties of
behavioral measures of skin cancer prevention is an im-
portant limitation for research in this area. Self-report mea-
sures are limited by individuals’ recall errors, difficulty in
estimating the frequency of common habits, and social de-
sirability. Still, self-reports will likely remain the most com-
monly used assessment method, as they are in many other
health behavior arenas (eg, diet, physical activity, and to-
bacco use). Thus, ongoing examination of feasibility, re-
liability, and validity of self-report measures is an impor-
tant priority. Cognitive interviewing helped to improve our
items and responses in terms of clarity, accuracy, speci-
ficity, and breadth, improving feasibility and establishing
face validity.
This study is an important first step in the develop-
ment, cognitive testing, and recommendation of a set of
core items.
The results of this study could be aug-
mented by doing further quantitative evaluation to evalu-
ate internal consistency, test-retest reliability, and con-
current and criterion validity (eg,
by comparing the
current items to objective measures such as observa-
tion, skin reflectance, personal dosimetry, skin swab-
bing, and inspection of moles).
16
Also, the items need to
be tested across differing administration modalities such
as paper and pencil, face to face, telephone, and com-
puter, possibly with modifications to reduce potential bi-
ases introduced by mixed-model interviewing.
21
One strength of this study involved the inclusion of a
wide age range of participants. The questions can be used
in a variety of cohorts and easily compared, and they may
be easily adapted to other cohorts or specific time frames.
A limitation of the present study is that the sample con-
sisted mainly of female and white individuals. We also
recognize that these core items cannot serve all study pur-
poses (eg, assessing children’s behavior at events when
parents are absent). They may need to be adapted to study
goals, population, and geographic locale.
In conclusion, this project brought together many of
the leading skin cancer prevention researchers to create
a core set of self-report items and test them on a diverse
range of participants. There remains an important need
for further measure development work to increase re-
producibility and decrease redundancy across many stud-
ies and cohorts. Efforts such as this will improve our abil-
ity to track health risk behaviors with increased accuracy
and reliability and provide the opportunity for more in-
formed and tailored recommendations regarding UVR and
sun protection practices.
Accepted for Publication: December 19, 2007.
Correspondence: Karen Glanz, PhD, MPH, Rollins School
of Public Health, Emory University, 1518 Clifton Rd NE,
Room 530,
Atlanta,
GA 30322 ([email protected]
.edu).
Author Contributions: Dr Glanz had full access to all of
the data in the study and takes responsibility for the in-
tegrity of the data and the accuracy of the data analysis.
Study concept and design:
Glanz,
Yaroch,
Dancel,
Sa-
raiya, Crane, Buller, Manne, O’Riordan, Heckman, Hay,
and Robinson. Acquisition of data: Glanz, Dancel, Crane,
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Buller, Manne, O’Riordan, Heckman, Hay, and Robin-
son. Analysis and interpretation of data: Glanz and Dan-
cel. Drafting of the manuscript: Glanz, Yaroch, Dancel, Sa-
raiya, Crane, Buller, Manne, O’Riordan, Heckman, and
Hay. Critical revision of the manuscript for important in-
tellectual content: Robinson. Statistical analysis: Glanz. Ad-
ministrative, technical, and material support: Glanz and
Yaroch. Study supervision: Glanz and Yaroch.
Financial Disclosure: None reported.
Funding/Support: Support for the workshop and cog-
nitive interviewing was provided by the National Can-
cer Institute (NCI), the Georgia Cancer Coalition, and
participating investigators.
Role of the Sponsors: The NCI assisted with study de-
sign and conduct of the study, and both the Centers for
Disease Control and Prevention and NCI reviewed and
approved the manuscript.
Disclaimer: The findings and conclusions in this report
are those of the authors and do not necessarily repre-
sent the views of the Centers for Disease Control and Pre-
vention or NCI. Dr Robinson is the editor of Archives of
Dermatology. She was not involved in the editorial evalu-
ation or decision to accept this article for publication.
Additional
Contributions:
Gordon Willis,
Iris Al-
cantara, Mary Klein Buller, Katharine Fisher, Jennifer
Ford, Seft Hunter, Ilima Kane, Kara Kilian, Rebecca Moore,
Eric Nehl, Nancy Rohowyj, Jennifer Stillman, and Le-
slie Welsh assisted in the protocol development and data
collection for this study.
Additional Information: Members of work group A in-
cluded David B. Buller, PhD, Lori A. Crane, PhD, Karen
Glanz, PhD, MPH, Jennifer Hay, PhD, Carolyn J. Heck-
man, PhD, Sharon Manne, PhD, David L. O’Riordan, PhD,
June Robinson, MD, Richard Roetzheim, MD, MPH, Mona
Saraiya, MD, MPH, Alana D. Steffen, PhD, and Amy L.
Yaroch, PhD.
REFERENCES
1.
American Cancer Society. Cancer Facts and Figures 2007. Atlanta, GA: Ameri-
can Cancer Society; 2007.
2.
Jemal
A, Devesa SS, Hartge P, Tucker MA. Recent trends in cutaneous mela-
noma incidence among whites in the United States. J Natl
Cancer Inst. 2001;
93(9):678-683.
3.
National Cancer Institute. SEER Cancer Statistics Review, 1975-2002. Bethesda,
MD: National Cancer Institute; 2005.
4.
Armstrong BK, Kricker A. The epidemiology of UV induced skin cancer. J Pho-
tochem Photobiol B. 2001;63(1-3):8-18.
5.
Armstrong B.
How sun exposure causes skin cancer:
an epidemiological
perspective. In: Hill D, Elwood J, English D, eds. Prevention of Skin Cancer. Dor-
drecht, the Netherlands: Kluwer Academic Publishers; 2004:89-116.
6.
US Department of Health and Human Services. Healthy People 2010. 2nd ed.
Washington, DC: US Government Printing Office; 2000.
7.
Hall HI, Saraiya M, Thompson T, Hartman A, Glanz K, Rimer B. Correlates of sun-
burn experiences among US adults: results of the 2000 National
Health Inter-
view Survey. Public Health Rep. 2003;118(6):540-549.
8.
Saraiya M, Hall
HI, Uhler RJ. Sunburn prevalence among adults in the United
States, 1999. Am J Prev Med. 2002;23(2):91-97.
9.
National
Cancer Institute. Cancer trends progress report—2005 update. http:
//progressreport.cancer.gov/doc_detail.asp?pid=1&did=2005&chid=21&coid
=211&mid=#cancer. Accessed January 6, 2007.
10.
National Cancer Institute. Health information national trends survey: primary can-
cer risk behaviors. http://hints.cancer.gov. Accessed March 15, 2007.
11.
Jones SE, Saraiya M. Sunscreen use among US high school students, 1999-2003.
J Sch Health. 2006;76(4):150-153.
12.
Hall HI, McDavid K, Jorgensen CM, Kraft JM. Factors associated with sunburn
in white children aged 6 months to 11 years. Am J Prev Med. 2001;20(1):9-
14.
13.
Hall
HI, Jorgensen CM, McDavid K, Kraft JM, Breslow R. Protection from sun
exposure in US white children ages 6 months to 11 years. Public Health Rep.
2001;116(4):353-361.
14.
Stanton WR, Janda M, Baade PD, Anderson P. Primary prevention of skin can-
cer: a review of sun protection in Australia and internationally. Health Promot
Int. 2004;19(3):369-378.
15.
Dobbinson S, Hill
D. Patterns and causes of sun exposing and sun protecting
behavior. In: Hill D, Elwood J, English D, eds. Prevention of Skin Cancer. Dor-
drecht, the Netherlands: Kluwer Academic Publishers; 2004:211-240.
16.
Glanz K, Mayer JA. Reducing ultraviolet radiation exposure to prevent skin can-
cer methodology and measurement. Am J Prev Med. 2005;29(2):131-142.
17.
Willis GB. Cognitive Interviewing: A Tool
for Improving Questionnaire Design.
Thousand Oaks, CA: Sage Publications; 2005.
18.
Willis G, Schechter S. Evaluation of cognitive interviewing techniques: do the re-
sults generalize to the field? Bull Methodol Sociol. 1997;55:40-66.
19.
Nelson DE, Kreps GL, Hesse BW, et al. The Health Information National Trends
Survey (HINTS): development, design, and dissemination. J Health Commun.
2004;9(5):443-460.
20.
Vernon SW, Meissner H, Klabunde C, et al. Measures for ascertaining use of co-
lorectal cancer screening in behavioral, health services, and epidemiologic research.
Cancer Epidemiol Biomarkers Prev. 2004;13(6):898-905.
21.
Dillman D. Mail and Internet Surveys: The Tailored Design Method. New York,
NY: John Wiley & Sons; 2000.
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