Advertisement

Effect of appearance-based education compared with health-based education on sunscreen use and knowledge: A randomized controlled trial

Published:February 07, 2014DOI:https://doi.org/10.1016/j.jaad.2013.12.007

      Background

      Appearance-based education shows promise in promoting sunscreen use although resource-intensive methods used in prior studies preclude wide dissemination. Appearance-based video education can be made easily accessible.

      Objective

      We sought to compare the effectiveness of appearance-based video education with that of health-based video education in improving sunscreen use and knowledge.

      Design

      In a randomized controlled trial, participants viewed either an appearance-based video on ultraviolet-induced premature aging or a health-based video emphasizing ultraviolet exposure and skin cancer risk.

      Results

      Fifty high-school students participated in the study, conducted from February through March 2012. The health-based group had a nonstatistically significant increase in sunscreen use (0.9 ± 1.9 d/wk, P = .096), whereas the appearance-based group demonstrated a statistically significant increase in sunscreen use (2.8 ± 2.2, P < .001). Between-group comparisons revealed that the appearance-based group applied sunscreen at significantly greater frequencies compared with the health-based group (2.2 ± 1.4 vs 0.2 ± 0.6, P < .001). Knowledge scores significantly improved in both study groups. The difference in knowledge scores between the study groups was not significant.

      Limitations

      The study population may not reflect the general population.

      Conclusion

      Appearance-based video education appears to be effective in promoting sunscreen use and knowledge in adolescents.

      Key words

      • Skin cancer prevention interventions include appearance-based or health-based messages to educate schoolchildren.
      • Appearance-based video education was found to be superior to health-based video education in promoting sunscreen use.
      • Appearance-based educational techniques delivered by video can effectively disseminate knowledge and promote sun-protective behaviors in adolescents.
      Many skin cancer prevention efforts to date are “health-based” in that they emphasize the relationship between enhanced ultraviolet (UV) exposure and skin cancer risk. Health-based interventions performed within schools have improved skin cancer knowledge and behavioral intent.
      • Geller A.C.
      • Cantor M.
      • Miller D.R.
      • Kenausis K.
      • Rosseel K.
      • Rutsch L.
      • et al.
      The Environmental Protection Agency's national SunWise school program: sun protection education in US schools (1999-2000).
      • Geller A.C.
      • Shamban J.
      • O'Riordan D.L.
      • Slygh C.
      • Kinney J.P.
      • Rosenberg S.
      Raising sun protection and early detection awareness among Florida high schoolers.
      • Lowe J.B.
      • Balanda K.P.
      • Stanton W.R.
      • Gillespie A.
      Evaluation of a three-year school-based intervention to increase adolescent sun protection.
      • Hewitt M.
      • Denman S.
      • Hayes L.
      • Pearson J.
      • Wallbanks C.
      Evaluation of “Sun-safe”: a health education resource for primary schools.
      However, reported outcomes often fail to demonstrate significant improvement in actual sun-protection behavior.
      • Buller D.B.
      • Buller M.K.
      • Beach B.
      • Ertl G.
      Sunny days, healthy ways: evaluation of a skin cancer prevention curriculum for elementary school-aged children.
      • Buller M.K.
      • Loescher L.J.
      • Buller D.B.
      “Sunshine and skin health”: a curriculum for skin cancer prevention education.
      • Mermelstein R.J.
      • Riesenberg L.A.
      Changing knowledge and attitudes about skin cancer risk factors in adolescents.
      Past research shows that adolescents have difficulty practicing preventive health behavior because they believe themselves less likely to experience disease.
      • Roberts M.E.
      • Gibbons F.X.
      • Gerrard M.
      • Alert M.D.
      Optimism and adolescent perception of skin cancer risk.
      • Moore S.M.
      • Rosenthal D.A.
      Australian adolescents' perceptions of health-related risks.
      Therefore, health-based messages that emphasize long-term skin cancer risk may be less effective in changing behavior among young individuals who perceive less risk of skin cancer development.
      Skin cancer prevention interventions may benefit from using an “appearance-based” model. Appearance-based interventions emphasize how UV exposure contributes to the premature aging of skin (eg, wrinkle development, uneven pigmentation, sagging skin).
      • Mahler H.I.
      • Fitzpatrick B.
      • Parker P.
      • Lapin A.
      The relative effects of a health-based versus an appearance-based intervention designed to increase sunscreen use.
      • Mahler H.I.
      • Kulik J.A.
      • Gerrard M.
      • Gibbons F.X.
      Long-term effects of appearance-based interventions on sun protection behaviors.
      • Mahler H.I.
      • Kulik J.A.
      • Gibbons F.X.
      • Gerrard M.
      • Harrell J.
      Effects of appearance-based interventions on sun protection intentions and self-reported behaviors.
      • Mahler H.I.
      • Kulik J.A.
      • Harrell J.
      • Correa A.
      • Gibbons F.X.
      • Gerrard M.
      Effects of UV photographs, photoaging information, and use of sunless tanning lotion on sun protection behaviors.
      • Stock M.L.
      • Gerrard M.
      • Gibbons F.X.
      • Dykstra J.L.
      • Weng C.Y.
      • Mahler H.I.
      • et al.
      Sun protection intervention for highway workers: long-term efficacy of UV photography and skin cancer information on men's protective cognitions and behavior.
      • Olson A.L.
      • Gaffney C.A.
      • Starr P.
      • Dietrich A.J.
      The impact of an appearance-based educational intervention on adolescent intention to use sunscreen.
      One study found that college students who viewed UV-filtered photographs of their faces reported significantly higher levels of intent and actual use of sunscreen.
      • Mahler H.I.
      • Kulik J.A.
      • Harrell J.
      • Correa A.
      • Gibbons F.X.
      • Gerrard M.
      Effects of UV photographs, photoaging information, and use of sunless tanning lotion on sun protection behaviors.
      Another found that middle-school students who viewed their skin under UV-filtered light expressed significantly greater intent to apply sunscreen.
      • Olson A.L.
      • Gaffney C.A.
      • Starr P.
      • Dietrich A.J.
      The impact of an appearance-based educational intervention on adolescent intention to use sunscreen.
      Thus, messages that emphasize the short-term negative effects of UV light on physical appearance may be more effective in changing behavior.
      The purpose of our study was to compare the effectiveness of appearance-based video education with that of health-based video education on improving sunscreen use and knowledge. We hypothesized that a group of adolescents who viewed the appearance-based video would display greater sun-protection behavior and sunscreen knowledge.

      Methods

      This randomized controlled study was approved by the Institutional Review Board of University of California, Davis (protocol number 251825-2). The study population consisted of 50 11th-grade students from an inner-city high school located in Northern California. We conducted the study between February and March 2012. Participation in the study was integrated into the students’ health education class although study participation was not mandatory. Participants were eligible for the study if they were English-speaking, at least 13 years of age, and able to hear and view the educational videos. Participants were required to obtain parent/guardian informed consent and provide assent to participate.
      Fifty participants were randomized in a 1:1 simple, nonstratified randomization scheme (Fig 1) with allocation concealment preserved through the use of sequentially numbered, opaque, sealed envelopes. Twenty-five participants were randomized to the appearance-based video group and 25 were randomized to watch the health-based video. Participants viewed the video to which they were assigned as a group.
      Figure thumbnail gr1
      Fig 1Study schema and flow diagram for a randomized controlled trial comparing appearance-based video education with health-based video education.

       Health-based and appearance-based video description

      The videos were approximately 5 minutes in duration and guided by the Health Belief Model.
      • Rosenstock I.M.
      Why people use health services.
      This model predicts that individuals are more likely to adopt a new behavior if they perceive: (1) a negative health outcome of not performing a behavior to be severe, (2) themselves to be susceptible to the negative outcome, (3) the benefits to a behavior to be high, and (4) the barriers to adopting a behavior to be low.
      • Rosenstock I.M.
      Why people use health services.
      The health-based video discussed the growing incidence of melanoma among young people and the link between skin cancer and UV radiation. It also explained how sun protection could lower skin cancer risk. The appearance-based video discussed the contribution of UV light to premature cutaneous aging and how sunscreen use could help delay signs of skin aging.
      A mixed-race actress, who was featured in both videos, was chosen to mirror our young and ethnically diverse target population. Computer-generated images, animations, popular culture references, and humor made the educational videos more relatable. The health-based video (http://youtu.be/wJ5nJLa6gtY) and appearance-based video (http://youtu.be/jQDPKMItMCM) can be viewed online.

       Measures and scales

      Sunscreen application behavior was assessed at baseline and at 6 weeks postintervention using standard questions from the National Health and Nutrition Examination Survey on sun-protective behaviors. Sunscreen application behavior was defined as the average number of days per week that participants applied sunscreen during the preceding 30 days. Knowledge regarding proper sunscreen use and the effects of UV light was assessed at baseline, immediately after watching the video, and 6 weeks postintervention with a questionnaire consisting of the same questions.

       Statistical analysis

      Statistical analyses were based on an intention-to-treat approach using software (SPSS 20.0, IBM Corp, Armonk, NY). Two-tailed tests were performed for all statistical analyses. Unpaired Student t test was used to analyze continuous variables for between-group comparisons, and paired Student t test was used for within-group comparisons. We performed χ2 tests for categorical variables. For all statistical analyses, P less than .05 was considered statistically significant.

      Results

      Fifty participants enrolled and completed the study. Demographic information and responses to questionnaire items on sun-protective behaviors are presented in Table I, Table II, respectively.
      Table IBaseline demographic factors between participants randomized to the appearance-based video and health-based video
      Appearance-based (n = 25)Health-based (n = 25)P value
      Sex
       Female76% (19)84% (21).725
      Fisher exact
       Male24% (6)16% (4)
      Age, y
       Mean ± SD17.1 ± 0.8817.2 ± 0.44.545
      Student t
      Ethnicity
       White12% (3)4% (1).609
      Fisher exact
       Non-white88% (22)96% (24)
      Lunch program eligibility
       No36% (9)36% (9)1
      Fisher exact
       Yes64% (16)64% (16)
      Skin type
       Burns easily, difficult to tan24% (6)20% (5).675
      χ2 tests were used to determine significance.
       Tans after initial burn16% (4)24% (6)
       Tans easily, difficult to burn60% (15)56% (14)
      No. of sunburns in last year
       Mean ± SD1.08 ± 1.111.00 ± 1.12.801
      Student t
      Percentages are followed by number of cases (in parentheses).
      Fisher exact
      Student t
      χ2 tests were used to determine significance.
      Table IISun-protective behaviors at baseline and at 6-week follow-up between participants randomized to appearance-based and health-based video education
      Appearance-based (n = 25)Health-based (n = 25)P
      P value when comparing results between video groups. Baseline significance is followed by 6-wk follow-up significance (after semicolon).
      (between-group)
      Baseline6-wk Follow-upP
      P value when comparing baseline values with 6-wk follow-up results (within-group results).
      (within-group)
      Baseline6-wk Follow-upP
      P value when comparing baseline values with 6-wk follow-up results (within-group results).
      (within-group)
      How often do you stay in the shade when out in the sun for >1 h?
       Never/rarely20% (5)20% (5)1.0008% (2)12% (3)1.000.417; .702
       At least sometimes80% (20)80% (20)92% (23)88% (22)
      How often do you wear a hat that shades your face, ears, and neck when out in sun for >1 h?
       Never/rarely92% (23)80% (20).45384% (21)76% (19).727.667; 1.000
       At least sometimes8% (2)20% (5)16% (4)24% (6)
      How often do you wear a long-sleeved shirt when out in the sun for >1 h?
       Never/rarely76% (19)64% (16).37588% (22)88% (22)1.000.463; .095
       At least sometimes24% (6)36% (9)12% (3)12% (3)
      Sunscreen adherence (mean d/wk ± SD)0.6 ± 1.12.8 ± 2.2<.0010.7 ± 1.90.9 ± 1.9.096.792; .003
      Percentages are followed by number of cases (in parentheses).
      P value when comparing baseline values with 6-wk follow-up results (within-group results).
      P value when comparing results between video groups. Baseline significance is followed by 6-wk follow-up significance (after semicolon).

       Improvement in sunscreen application behavior

      The appearance-based group (0.6 ± 1.1 d/wk) and health-based group (0.7 ± 1.9) had similar baseline frequencies of sunscreen application per week (P = .792). Within-group analysis showed that the appearance-based group reported significantly higher mean sunscreen use at the 6-week follow-up period (2.8 ± 2.2 d/wk) compared with baseline (P < .001). In contrast, the health-based video intervention group reported a mean sunscreen application frequency of 0.9 ± 1.9 days per week that was not significantly different from baseline (P = .096).
      Between-group comparisons revealed that the mean increase in sunscreen application was significantly higher in the appearance-based group (2.2 ± 1.4 d/wk) than the health-based group (0.2 ± 0.6; P < .001).

       Improvement in sunscreen knowledge

      The appearance-based group (6.6 ± 1.3) and health-based group (5.8 ± 1.7) had similar knowledge scores at baseline (P = .061). Within-group analysis showed that the knowledge score of the appearance-based group was significantly higher immediately after watching the video (7.9 ± 0.9) compared with baseline (6.6 ± 1.3; P = .001). After 6 weeks, knowledge score remained significantly higher than baseline at 7.5 ± 1.0 (P = .013). Similarly, the health-based group exhibited a significant improvement in sunscreen knowledge immediately after watching the video (7.4 ± 1.0) compared with baseline (5.8 ± 1.7; P < .001). The knowledge score at 6 weeks postintervention was 7.0 ± 2.0, which was significantly higher than baseline (P = .008).
      Between-group comparison showed that the mean improvement in knowledge immediately after watching the video was not significantly different between the appearance-based group (1.6 ± 1.6) and health-based group (1.3 ± 1.6; P = .533). Likewise, the difference in improvement after 6 weeks was not significant between the appearance-based group (1.2 ± 2.0) and health-based group (0.9 ± 1.7; P = .651).

      Discussion

      Sun-protection behaviors have been shown to reduce the risk of nonmelanoma skin cancers with some evidence suggesting a reduction in melanoma risk as well.
      • Drolet B.A.
      • Connor M.J.
      Sunscreens and the prevention of ultraviolet radiation-induced skin cancer.
      • Gimotty P.A.
      • Glanz K.
      Sunscreen and melanoma: what is the evidence?.
      • Green A.C.
      • Williams G.M.
      • Logan V.
      • Strutton G.M.
      Reduced melanoma after regular sunscreen use: randomized trial follow-up.
      • Lazovich D.
      • Vogel R.I.
      • Berwick M.
      • Weinstock M.A.
      • Warshaw E.M.
      • Anderson K.E.
      Melanoma risk in relation to use of sunscreen or other sun protection methods.
      Significant risk for skin cancer from solar radiation begins during childhood and early sun-safe practices may reduce the incidence of UV-induced skin cancers that occur later in life. Thus, it is beneficial to tailor education to younger individuals for more effective skin cancer prevention and control.
      Appearance-based studies have shown greater promise in promoting sun-protective behavior compared with traditional health-based education. However, many appearance-based studies have used UV photography or similar technology that may be too resource intensive to be disseminated population-wide.
      Video can be an effective medium for delivering educational content, promoting behavior change, and improving clinical outcomes.
      • Gagliano M.E.
      A literature review on the efficacy of video in patient education.

      Tuong W, Larsen ER, Armstrong AW. Videos to influence: a systematic review of effectiveness of video-based education in modifying health behaviors. J Behav Med doi:10.1007/s10865-012-9480-7. Published online November 28, 2012.

      • Armstrong A.W.
      • Parsi K.
      • Schupp C.W.
      • Mease P.J.
      • Duffin K.C.
      Standardizing training for psoriasis measures: effectiveness of an online training video on Psoriasis Area and Severity Index assessment by physician and patient raters.
      • Armstrong A.W.
      • Kim R.H.
      • Idriss N.Z.
      • Larsen L.N.
      • Lio P.A.
      Online video improves clinical outcomes in adults with atopic dermatitis: a randomized controlled trial.
      • Idriss N.Z.
      • Alikhan A.
      • Baba K.
      • Armstrong A.W.
      Online, video-based patient education improves melanoma awareness: a randomized controlled trial.
      • Armstrong A.W.
      • Alikhan A.
      • Cheng L.S.
      • Schupp C.
      • Kurlinkus C.
      • Eisen D.B.
      Portable video media for presenting informed consent and wound care instructions for skin biopsies: a randomized controlled trial.
      • Armstrong A.W.
      • Idriss N.Z.
      • Kim R.H.
      Effects of video-based, online education on behavioral and knowledge outcomes in sunscreen use: a randomized controlled trial.
      Coupling the increased consumption and acceptability of digital media by youth
      • Roberts D.F.
      • Foehr U.G.
      Trends in media use.
      with the promising results of appearance-based interventions suggested a way of promoting sun protection among adolescents.
      Our study found that an appearance-based video significantly improved sunscreen application frequency at a 6-week follow-up time point compared with baseline. This was not observed in the health-based video group. Both videos were effective in increasing sunscreen knowledge and resulted in greater knowledge gain at 6 weeks compared with baseline. By emphasizing the short-term effect of ambient solar radiation on appearance, the appearance-based video may have increased the salience of UV damage and the importance of proper sun protection.
      One limitation of this study was that it focused on adolescents and may not be generalizable to patients of other age groups. Nevertheless, it provides evidence that appearance-based messaging may be superior to traditional health-based messages in promoting sun-protection behaviors. Our study also demonstrates that appearance-based education can be effectively delivered by video. In contrast to appearance-based interventions using resource-intensive methods, such as UV photography, video education can be easily and widely disseminated to influence behavior.

      References

        • Geller A.C.
        • Cantor M.
        • Miller D.R.
        • Kenausis K.
        • Rosseel K.
        • Rutsch L.
        • et al.
        The Environmental Protection Agency's national SunWise school program: sun protection education in US schools (1999-2000).
        J Am Acad Dermatol. 2002; 46: 683-689
        • Geller A.C.
        • Shamban J.
        • O'Riordan D.L.
        • Slygh C.
        • Kinney J.P.
        • Rosenberg S.
        Raising sun protection and early detection awareness among Florida high schoolers.
        Pediatr Dermatol. 2005; 22: 112-118
        • Lowe J.B.
        • Balanda K.P.
        • Stanton W.R.
        • Gillespie A.
        Evaluation of a three-year school-based intervention to increase adolescent sun protection.
        Health Educ Behav. 1999; 26: 396-408
        • Hewitt M.
        • Denman S.
        • Hayes L.
        • Pearson J.
        • Wallbanks C.
        Evaluation of “Sun-safe”: a health education resource for primary schools.
        Health Educ Res. 2001; 16: 623-633
        • Buller D.B.
        • Buller M.K.
        • Beach B.
        • Ertl G.
        Sunny days, healthy ways: evaluation of a skin cancer prevention curriculum for elementary school-aged children.
        J Am Acad Dermatol. 1996; 35: 911-922
        • Buller M.K.
        • Loescher L.J.
        • Buller D.B.
        “Sunshine and skin health”: a curriculum for skin cancer prevention education.
        J Cancer Educ. 1994; 9: 155-162
        • Mermelstein R.J.
        • Riesenberg L.A.
        Changing knowledge and attitudes about skin cancer risk factors in adolescents.
        Health Psychol. 1992; 11: 371-376
        • Roberts M.E.
        • Gibbons F.X.
        • Gerrard M.
        • Alert M.D.
        Optimism and adolescent perception of skin cancer risk.
        Health Psychol. 2011; 30: 810-813
        • Moore S.M.
        • Rosenthal D.A.
        Australian adolescents' perceptions of health-related risks.
        J Adolesc Res. 1992; 7: 177-191
        • Mahler H.I.
        • Fitzpatrick B.
        • Parker P.
        • Lapin A.
        The relative effects of a health-based versus an appearance-based intervention designed to increase sunscreen use.
        Am J Health Promot. 1997; 11: 426-429
        • Mahler H.I.
        • Kulik J.A.
        • Gerrard M.
        • Gibbons F.X.
        Long-term effects of appearance-based interventions on sun protection behaviors.
        Health Psychol. 2007; 26: 350-360
        • Mahler H.I.
        • Kulik J.A.
        • Gibbons F.X.
        • Gerrard M.
        • Harrell J.
        Effects of appearance-based interventions on sun protection intentions and self-reported behaviors.
        Health Psychol. 2003; 22: 199-209
        • Mahler H.I.
        • Kulik J.A.
        • Harrell J.
        • Correa A.
        • Gibbons F.X.
        • Gerrard M.
        Effects of UV photographs, photoaging information, and use of sunless tanning lotion on sun protection behaviors.
        Arch Dermatol. 2005; 141: 373-380
        • Stock M.L.
        • Gerrard M.
        • Gibbons F.X.
        • Dykstra J.L.
        • Weng C.Y.
        • Mahler H.I.
        • et al.
        Sun protection intervention for highway workers: long-term efficacy of UV photography and skin cancer information on men's protective cognitions and behavior.
        Ann Behav Med. 2009; 38: 225-236
        • Olson A.L.
        • Gaffney C.A.
        • Starr P.
        • Dietrich A.J.
        The impact of an appearance-based educational intervention on adolescent intention to use sunscreen.
        Health Educ Res. 2008; 23: 763-769
        • Rosenstock I.M.
        Why people use health services.
        Milbank Mem Fund Q. 1966; 44: 94-127
        • Drolet B.A.
        • Connor M.J.
        Sunscreens and the prevention of ultraviolet radiation-induced skin cancer.
        J Dermatol Surg Oncol. 1992; 18: 571-576
        • Gimotty P.A.
        • Glanz K.
        Sunscreen and melanoma: what is the evidence?.
        J Clin Oncol. 2011; 29: 249-250
        • Green A.C.
        • Williams G.M.
        • Logan V.
        • Strutton G.M.
        Reduced melanoma after regular sunscreen use: randomized trial follow-up.
        J Clin Oncol. 2011; 29: 257-263
        • Lazovich D.
        • Vogel R.I.
        • Berwick M.
        • Weinstock M.A.
        • Warshaw E.M.
        • Anderson K.E.
        Melanoma risk in relation to use of sunscreen or other sun protection methods.
        Cancer Epidemiol Biomarkers Prev. 2011; 20: 2583-2593
        • Gagliano M.E.
        A literature review on the efficacy of video in patient education.
        J Med Educ. 1988; 63: 785-792
      1. Tuong W, Larsen ER, Armstrong AW. Videos to influence: a systematic review of effectiveness of video-based education in modifying health behaviors. J Behav Med doi:10.1007/s10865-012-9480-7. Published online November 28, 2012.

        • Armstrong A.W.
        • Parsi K.
        • Schupp C.W.
        • Mease P.J.
        • Duffin K.C.
        Standardizing training for psoriasis measures: effectiveness of an online training video on Psoriasis Area and Severity Index assessment by physician and patient raters.
        JAMA Dermatol. 2013; 149: 577-582
        • Armstrong A.W.
        • Kim R.H.
        • Idriss N.Z.
        • Larsen L.N.
        • Lio P.A.
        Online video improves clinical outcomes in adults with atopic dermatitis: a randomized controlled trial.
        J Am Acad Dermatol. 2011; 64: 502-507
        • Idriss N.Z.
        • Alikhan A.
        • Baba K.
        • Armstrong A.W.
        Online, video-based patient education improves melanoma awareness: a randomized controlled trial.
        Telemed J E Health. 2009; 15: 992-997
        • Armstrong A.W.
        • Alikhan A.
        • Cheng L.S.
        • Schupp C.
        • Kurlinkus C.
        • Eisen D.B.
        Portable video media for presenting informed consent and wound care instructions for skin biopsies: a randomized controlled trial.
        Br J Dermatol. 2010; 163: 1014-1019
        • Armstrong A.W.
        • Idriss N.Z.
        • Kim R.H.
        Effects of video-based, online education on behavioral and knowledge outcomes in sunscreen use: a randomized controlled trial.
        Patient Educ Couns. 2011; 83: 273-277
        • Roberts D.F.
        • Foehr U.G.
        Trends in media use.
        Future Child. 2008; 18: 11-37