HEALTH EDUCATION RESEARCH
Vol.30 no.3 2015
Pages 380–387
Advance Access published 2 April 2015
Sun protection during snow sports: an analysis of
behavior and psychosocial determinants
Eva Janssen1, Dave van Kann1, Hein de Vries1, Lilian Lechner2 and
Liesbeth van Osch1
1
Department of Health Promotion, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary
Care (Caphri), Maastricht University, Maastricht, The Netherlands and 2Faculty of Psychology and Educational Sciences,
School for Public Health and Primary Care (Caphri), Open University of the Netherlands, Heerlen, The Netherlands
*Correspondence to: E. Janssen, E-mail: [email protected]
Received on April 30, 2014; accepted on March 8, 2015
Abstract
This study investigated sun protective behavior
during snow sports and its psychosocial determinants. A longitudinal study was conducted
among 418 Dutch adults who planned to go on
a ski holiday. Participants were asked to fill in a
questionnaire before and after their ski trip. In
the baseline questionnaire several psychosocial
factors were measured (i.e. knowledge, risk perception, worry, attitude, social influence, selfefficacy and intention). At follow-up, sunscreen
use and frequency of sunburns were measured.
The results showed that, despite their generally
high intention, a substantial part of the respondents (40%) did not use sunscreen adequately
during their ski holiday. Furthermore, onefourth of the respondents reported at least one
sunburn during their ski holiday. Men and
younger respondents used sunscreen less frequently and were sunburnt more often. Sunscreen
use was predicted by a positive attitude, high selfefficacy levels, high intention, high knowledge and
high perceived risk. The background and psychosocial variables explained 32% of the total variance of sunscreen use. Suggestions for future
research and interventions are discussed.
Introduction
Skin cancer incidence is growing rapidly worldwide
[1, 2]. In The Netherlands, the incidence has
increased from 15 000 to 40 000 cases every year
during the past decade [3]. The three most common
forms of skin cancer are basal cell carcinoma, squamous cell carcinoma and melanoma. Although the
survival rates of basal cell carcinoma and squamous
cell carcinoma are high, the personal (e.g. skin
disfigurements) and economic (e.g. health care delivery costs) consequences are often high [4, 5]. The
third form of skin cancer, melanoma, is associated
with a high mortality rate. In total, 20–25% of the
patients diagnosed with melanoma will die from this
disease [2, 6].
Skin cancer can be prevented by a reduced exposure of the skin to ultraviolet radiation (UV-radiation)
by, for instance, adequate sunscreen use and wearing protective clothing [7, 8]. Adequate protection
of the skin against the sun is not only necessary
during the summer, but also during snow sports
activities, such as skiing and snowboarding. The
increased UV-radiation in the mountains due to
a higher altitude, the clean air and the strong reflection of up to 90% of the UV-radiation from the
snow promotes faster burning of the unprotected
skin [9, 10]. Moreover, the lighter skin tone during
winter and the later recognition of sunburn due to the
cold environment increases the need for adequate
sun protection during snow sports activities.
Because of the popularity of ski holidays [11, 12],
the winter sun can be seen as a significant source
of UV-radiation and could be considered as an
important risk factor for the development of skin
cancer.
ß The Author 2015. Published by Oxford University Press. All rights reserved.
For permissions, please email: [email protected]
doi:10.1093/her/cyv013
Sun protection during snow sports
To date, scientific research and skin cancer
prevention programs have primarily targeted sun
protection during summer time (e.g. during traditional beach activities) [e.g. 4, 13–16]. Little is
known about sun protection behavior during snow
sports and its determinants [17–20]. The few studies
to date that have provided insight into sun protective
behaviors of snow sports participants showed that a
substantial proportion of this group does not adequately protect themselves from the sun [20–23].
However, the majority of these studies have been
executed in the United States and the psychosocial
factors that are associated with sunscreen use during
snow sports are largely unknown since mainly
demographic and environmental determinants have
been investigated so far [20–23]. A thorough understanding of the psychosocial factors that influence
this behavior is needed to guide the development of
effective interventions to stimulate people’s uptake
of adequate sun protection.
The aim of this study was therefore to investigate
sun protection behavior of snow sports participants
and the psychosocial factors associated with this behavior. The I-Change Model has been used as the
psychosocial framework [24]. This model has been
successfully applied in explaining summer sun
protection behaviors [4, 14]. The I-Change Model
is derived from the Attitude-Social influenceSelf-efficacy (ASE) model and integrates several
concepts of social cognitive models (e.g. Ajzen’s
Theory of Planned Behavior [25] and Bandura’s
Social Cognitive Theory [26]). Based on the
I-Change Model, pre-motivational factors, such as
predisposing factors (e.g. demographics) and awareness factors (i.e. knowledge and risk perception),
motivational factors (i.e. ASE expectations), and intention were included in this study.
Methods
Respondents and procedure
Dutch adults who planned to go on a ski holiday
were asked between January and May 2009 to fill
in an online questionnaire before and after their ski
trip. Recruitment took place by means of two
approaches: (i) advertisements were placed on various popular ski websites, and (ii) members of Dutch
ski associations were personally approached by
e-mail in collaboration with the executive committees of the associations. Respondents were directed
to the questionnaire by clicking on a link in the
advertisement or e-mail. After their ski trip participants received an invitation e-mail to fill in the
second questionnaire. This invitation was send
1 week after they were supposed to return from
their ski holiday as was reported at baseline. The
first questionnaire was filled in by 498 respondents
and 418 respondents filled in both questionnaires
(84% of those who filled in the baseline questionnaire). Prior to the first measurement, participants
were given a written introduction to this study, an
explanation that confidentiality would be ensured
and they were asked to give their informed consent.
A lottery based incentive (the opportunity to win
multiple gift vouchers ranging between e10 and
250) was offered to encourage participation in
both studies.
Questionnaire
The questionnaire was based on the I-change Model
[24]. At baseline (T1), pre-motivational factors,
such as predisposing factors (e.g. demographics)
and awareness factors (i.e. knowledge and risk
perception), motivational factors (i.e. ASE expectations), and intention were assessed. The follow-up
measurement (T2) included measures assessing sunscreen use, sunburns and weather conditions.
‘Knowledge’ (T1) concerning sunscreen use was
measured with four questions. Respondents were
asked to indicate whether the following statements
are correct: ‘If you already have a tan, it is not necessary to use sunscreen’, ‘During snow sports your
skin burns on average two times faster than usual if
you don’t protect your skin using sunscreen’, ‘You
don’t have to use sunscreen during snow sports
when it is cloudy’, ‘Some of the active ingredients
of sunscreen start to break down over time’
(1 ¼ ‘correct’; 2 ¼ ‘incorrect’; 3 ¼ ‘I don’t know’).
A knowledge index was calculated by adding all
correct answers (minimum score 0 and maximum
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E. Janssen et al.
score 4) [4]. The ‘don’t know’ category was recoded
as incorrect.
‘Risk perception’ (T1) was measured by five
items reflecting perceived cognitive and affective
likelihood [27], worry [28] and perceived general
[29] and comparative severity [30] since recent research has indicated the importance of distinguishing cognitive and affective aspects of health risk
beliefs [27, 31]. ‘Cognitive likelihood’ was assessed
by asking: ‘If I do not protect my skin adequately
from the sun using sunscreen, my chances of getting
skin cancer at some point in my life are. . .’
(1 ¼ ‘very low’, 2 ¼ ‘low’, 3 ¼ ‘neither low nor
high’, 4 ¼ ‘high’, 5 ¼ ‘very high’). ‘Affective likelihood’ was assessed by asking: ‘If I do not protect
my skin adequately from the sun using sunscreen,
I feel. . .’ (1 ¼ ‘definitely not vulnerable to getting
skin cancer’, 2 ¼ ‘not vulnerable to getting skin
cancer’, 3 ¼ ‘little vulnerable to getting skin
cancer’, 4 ¼ ‘vulnerable to getting skin cancer’,
5 ¼ ‘very vulnerable to getting skin cancer’).
‘Worry’ was measured by asking participants how
often they worry about getting skin cancer
(1 ¼ ‘never’, 2 ¼ ‘rarely’, 3 ¼ ‘sometimes’, 4 ¼
‘often’, 5 ¼ ‘very often’). ‘Perceived general severity’ was measured by asking participants: ‘How bad
would you find it if you got skin cancer?’ (1 ¼ ‘not
so bad’, 2 ¼ ‘little bad’, 3 ¼ ‘somewhat bad’,
4 ¼ ‘bad’, 5 ¼ ‘very bad’). ‘Perceived comparative
severity’ was assessed by asking participants: ‘compared with other forms of cancer, the consequences
of skin cancer are. . .’ (1 ¼ ‘much less bad’;
2 ¼ ‘somewhat less bad’, 3 ¼ ‘neither less bad nor
worse’, 4 ¼ ‘somewhat worse’, 5 ¼ ‘much worse’).
‘Attitude’ (T1) was measured with four items
( ¼ 0.71) [4, 14]. Two items assessed the advantages and two items assessed the disadvantages towards sunscreen use during snow sports.
Respondents were asked to what extent they agree
with the following statements: ‘I think using sunscreen (SPF 15+) every 2 h during snow sports
is. . .: (i) important, (ii) pleasant, (iii) overdone,
(iv) troublesome’ (1 ¼ ‘completely disagree’,
2 ¼ ‘disagree’, 3 ¼ ‘neither disagree nor agree’,
4 ¼ ‘agree’, 5 ¼ ‘completely agree’). To develop a
382
mean score, the items measuring the disadvantages
of using sunscreen were recoded.
‘Social influence’ (T1) was measured by two
items reflecting social modeling and social support
[14]. ‘Social modeling’ was measured by asking
respondents how many people of their travel group
will use sunscreen adequately [1 ¼ ‘(practically)
none’, 2 ¼ ‘a minority’, 3 ¼ ‘about half of the
people’, 4 ¼ ‘most people’, 5 ¼ ‘(practically) everyone’). Social support was measured by asking
to what extent these people will stimulate the
respondent to use sunscreen adequately
(1 ¼ ‘never’, 2 ¼ ‘rarely’, 3 ¼ ‘sometimes’, 4 ¼
‘often’, 5 ¼ ‘always’).
‘Self-efficacy’ (T1) was measured by two items
asking respondents to what extent they think they
are able to use sunscreen adequately (1 ¼ ‘I will certainly not be able to’, 2 ¼ ‘I will probably not be able
to’, 3 ¼ ‘neither not be able to nor able to’, 4 ¼ ‘I
will probably be able to’, 5 ¼ ‘I will certainly be able
to’) and how difficult it would be for them to use
sunscreen adequately (1 ¼ ‘very difficult’, 2 ¼ ‘difficult’, 3 ¼ ‘neither difficult nor easy’, 4 ¼ ‘easy’,
5 ¼ ‘very easy’) (a ¼ 0.81) [4, 14].
‘Intention’ (T1) was assessed by one question
asking respondents whether they intended to use
sunscreen adequately during their ski holiday
(1 ¼ ‘definitely not’, 2 ¼ ‘probably not’, 3 ¼ ‘neither not nor yes’, 4 ¼ ‘probably yes’, 5 ¼ ‘definitely
yes’) [4, 14]. Immediately before answering this
question, on a separate screen, information was
given about what is meant by adequate sunscreen
use according to the Dutch guidelines (i.e. applying
sunscreen 30 min before sun exposure, using sunscreen with a minimum sun protection factor of
15, and reapplying sunscreen approximately every
2 h) [32].
‘Sunscreen use’ (T2) was measured by asking
respondents whether they had used sunscreen adequately during their ski holiday (1 ¼ ‘never’,
2 ¼ ‘rarely’, 3 ¼ ‘sometimes’, 4 ¼ ‘often’, 5 ¼ ‘always’). Prior to this question, respondents were informed about the Dutch guidelines for adequate
sunscreen use. Moreover, we also assessed the
number of ‘sunburns’ they had during their ski trip
Sun protection during snow sports
(1 ¼ ‘none’, 2 ¼ ‘one’, 3 ¼ ‘two or three’, 4 ¼ ‘four
or five’, 5 ¼ ‘more than 5’).
‘Predisposing factors’ that were assessed
included gender (T1), age (T1), educational level
(T1), skin type (T1) (1 ¼ ‘skin burns very rapidly
and does not (or rarely) tan’, 2 ¼ ‘skin burns rapidly
and rarely tans’, 3 ¼ ‘skin burns sometimes and tans
well’, 4 ¼ ‘skin burns rarely and tans very well’)
[32], number of previous ski holidays (T1) (1 ¼ ‘first
time’, 2 ¼ ‘second time’, 3 ¼ ‘third time’; 4 ¼ >3
times’) and weather condition (T2) (1 ¼ ‘very
cloudy’, 2 ¼ ‘mostly cloudy with some sun’,
3 ¼ ‘partly cloudy with sun‘; 4 ¼ ‘very sunny’).
Statistical analysis
Descriptive statistics were used to describe demographic characteristics within the study sample. Chisquare testing (X2) and independent samples t-tests
were performed to investigate differences between
frequent (often or always) and infrequent (sometimes, rarely or never) sunscreen users in predisposing and psychosocial attributes. Blockwise
hierarchical linear regression analysis was performed to identify predisposing and psychosocial
attributes predicting sunscreen use based on the
model structure of the I-change model [24]. Block
1 included the predisposing variables (i.e. gender,
age, educational level, skin type and weather
condition). The second block included the variables
of block 1 as well as the awareness factors
knowledge and risk perception. The third block
included the variables of block 2 and the motivational factors ASE. The fourth block included the
variables of block 3 and the intention to use
sunscreen. The level of significance was set at
P < 0.05. Analyses were conducted using SPSS
version 20.0.
Results
37% had a medium level of education (secondary
vocational school or high school), and 53% had a
high level of education (higher vocational school or
university). In total, 7% of the respondents had skin
type I, 39% had skin type II, 44% had skin type III
and 10% had skin type IV. Seventy-eight percent of
the respondents indicated that they went on a ski
holiday for more than three times, whereas only
6% indicated that this was their first ski holiday.
The majority of the respondents (60%) indicated
that they frequently used sunscreen during their
ski holiday (Table I). Men used sunscreen significantly less often than women and younger respondents used sunscreen less often compared with older
respondents. No significant differences were found
for educational level, skin type and weather
condition. A quarter of the respondents got sunburnt
at least once during their ski holiday (i.e. 20%
got sunburnt once, 4% got sunburnt two or three
times and 1% got sunburnt four or five times),
with men (X2 ¼ 5.70; P < 0.05), younger respondents (t ¼ 4.64; P < 0.01), respondents who experienced sunny weather conditions (X2 ¼ 25.61;
P < 0.01), and those that reported infrequent sunscreen use (X2 ¼ 11.14; P < 0.01), suffering more
sunburns.
Psychosocial differences between frequent
and infrequent sunscreen users
Table I shows that frequent users had significantly
higher levels of knowledge about sunscreen
use, reported higher cognitive and affective likelihood estimates and worried more often about getting
skin cancer. They also reported higher comparative severity estimates, a more positive attitude towards using sunscreen, more positive social
influences towards sunscreen use and higher
self-efficacy expectations. Finally, frequent users
had stronger intentions to use sunscreen than infrequent users.
Characteristics of the sample
The mean age of the respondents was 37 years
(SD ¼ 14.2). Fifty-five percent of the respondents
were female. Ten percent of the respondents had a
low level of education (primary or basic vocational),
Regression analysis
The results of the regression analysis are depicted in
Table II. The results from the first block showed that
being older and being female were associated with
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E. Janssen et al.
Table I. Means (SD) and frequencies for study variables within frequent and infrequent users
N (%)
Gender (%)
Female
Male
Mean age (SD)
Education (%)
Low
Medium
High
Skin type (%)
Type 1–2
Type 3–4
Weather condition (%)
Very cloudy
Mostly cloudy with some sun
Partly cloudy with sun
Very sunny
Sunburn (%)
None
1
Mean knowledge (SD)a
Mean risk perception (SD)b
Cognitive likelihood
Affective likelihood
General severity
Comparative severity
Mean worry (SD)b
Mean attitude (SD)b
Mean social influence (SD)b
Modeling
Social support
Mean self-efficacy (SD)b
Mean intention (SD)b
Total
Infrequent
Frequent
X2/T
418 (100)
167 (40)
251 (60)
—
43.8
56.2
37.4 (14.46)
44.3
55.7
34.6 (14.98)
64.1
35.9
39.2 (13.83)
16.02***
10.5
36.1
53.3
7.8
42.5
49.7
12.4
31.9
55.8
46.2
53.8
42.5
57.5
48.6
51.4
7.7
19.9
34.0
38.5
6.0
24.0
37.7
32.3
8.8
17.1
31.5
42.6
75.1
24.9
3.6 (0.71)
66.5
33.5
3.5 (0.84)
80.9
19.1
3.7 (0.58)
3.15**
5.82
1.50
7.27
11.14***
3.21**
3.3
3.0
4.4
2.8
2.2
3.4
(0.92)
(0.93)
(0.77)
(0.71)
(0.80)
(0.71)
3.1
2.7
4.3
2.7
2.0
3.1
(0.86)
(0.88)
(0.76)
(0.71)
(0.76)
(0.67)
3.5
3.2
4.4
2.8
2.3
3.7
(0.94)
(0.91)
(0.77)
(0.71)
(0.82)
(0.62)
3.73***
5.73***
1.11
2.38*
3.44**
9.82***
3.2
3.0
3.6
4.1
(1.23)
(1.11)
(0.92)
(0.94)
2.7
2.8
3.1
3.6
(1.16)
(0.95)
(0.89)
(0.99)
3.5
3.2
3.9
4.4
(1.18)
(1.17)
(0.78)
(0.75)
6.78***
4.40***
10.07***
9.03***
Note: aScores on these variables range from 0 to 4; bScores on these variables range from 1 to 5; ***P < 0.001; **P < 0.01;
*P < 0.05.
sunscreen use. In block 2, the factors significantly
associated with sunscreen use were age, gender,
weather condition, knowledge, affective likelihood
and comparative severity. In block 3, self-efficacy
was most strongly associated with sunscreen use,
followed by attitude and weather condition. In
block 4, attitude was most strongly associated with
sunscreen use, followed by self-efficacy, intention
and weather condition. The final model explained
33% of the variance in sunscreen use.
384
Discussion
The purpose of this study was to increase insight into
the sun protective behavior of snow sports participants and the related psychosocial factors. The results showed that although a majority of the snow
sports participants had a positive intention to use
sunscreen, a substantial group (40%) did not use
sunscreen adequately. This percentage is comparable to sunscreen use during summer time [33].
Sun protection during snow sports
Table II. Regression of sunscreen use during snow sports on predisposing factors (e.g. age, gender, education; block 1), awareness
factors (knowledge, risk perception; block 2), motivational factors (attitude and self-efficacy; block 3) and intention (block 4)
Predisposing factors
Age
Gender
Education
Skin type
Weather condition
Awareness factors
Knowledge
Risk perception
Cognitive likelihood
Affective likelihood
Worry
General severity
Comparative severity
Motivational factors
Attitude
Sociale influence
Modeling
Social support
Self-efficacy
Intention
Explained variance (R2)
Block 1 b
Block 2 b
Block 3 b
Block 4 b
0.20***
0.19***
0.03
0.01
0.09
0.19***
0.10*
0.05
0.02
0.10*
0.04
0.09
0.01
0.03
0.11**
0.04
0.07
0.01
0.03
0.11**
0.13**
0.07
0.06
0.05
0.19**
0.03
0.05
0.12*
0.02
0.05
0.03
0.01
0.05
0.02
0.04
0.02
0.02
0.05
0.08
0.17
0.22***
0.21***
0.06
0.09
0.24***
0.05
0.09
0.16*
0.13*
0.33
0.32
***P < 0.001; **P < 0.01; *P < 0.05.
Moreover, the results showed that one out of four
respondents suffered at least one episode of sunburn
during their ski holiday. Important risk groups were
men and younger individuals; they used sunscreen
less often and suffered sunburns more often which is
in line with previous research regarding sun protection during winter and summer time [e.g. 4, 20, 21,
34–37].
The study further investigated the psychosocial
factors associated with sunscreen use during snow
sports. The results revealed that attitude towards
sunscreen use were the strongest correlate of sunscreen use during snow sports. Exploration of the
attitude-items showed that about half of the respondents perceived sunscreen use to be troublesome
(i.e. 55% (completely) agreed with the statement
that using sunscreen during snow sports is troublesome) and unpleasant (i.e. 46% did not (completely)
agree with the statement that using sunscreen adequately is a pleasant way to protect themselves).
Therefore, influencing people’s beliefs concerning
the negative aspects of sunscreen use through educational practices could be an effective strategy to
improve sunscreen use during snow sports activities.
Other significant correlates of sunscreen use during
snow sports were self-efficacy, intention, weather
condition, age, affective likelihood, knowledge,
comparative severity and gender. Because the predisposing and awareness factors were no longer significant in the final block, their influence might be
mediated by the motivational factors as assumed by
the I-Change Model [24]. However, their impact
should not be disregarded and it is recommended
to target educational messages to increase knowledge and risk perception levels.
The behavioral determinants of sun protection
during snow sports largely correspond with those
reported in previous studies focused on summer
sun protection [e.g. 16, 38–40]. It might therefore
be recommended to consider the adaptation of
385
E. Janssen et al.
evidence based summer sun protection interventions
focused on these determinants to be used in the
winter sun context (e.g. educational practices and
role modeling by outdoor recreation staff such as
ski instructors to influence the negative beliefs towards sunscreen use and self-efficacy expectations)
[e.g. 41, 42]. Moreover, to be informative for the
development of future interventions, future research
should focus on the specific barriers experienced by
snow sports participants since they largely perceive
sunscreen use as troublesome and unpleasant.
Moreover, men and younger age groups can be considered as important risk groups. Future research
should therefore investigate the extent to which
tailoring of intervention strategies is required for
these population subgroups by investigating the psychosocial attributes of sunscreen use for these
specific groups.
Because this is the first study investigating psychosocial determinants of sunscreen use among
snow sports participants, replication of the results
is desirable. In this study experienced participants
of snow sports and highly educated people were
overrepresented, and findings may therefore not be
fully generalizable to less experienced snow sports
participants and to lower educated people.
Moreover, it is uncertain whether the recruitment
strategy might instigate the selection of participants
who are already more prone to sun protection which
in turn could have led to an overestimation of the
actual sun protection rate. Another limitation of this
study is the use of self-reported data. Although
this is a common characteristic of research in the
domain of health promotion and evidence was
found that self-administered questionnaires can be
considered to be as reliable and valid as more objective sun protection measurements (i.e. observations and sunscreen swabbing) [43], a multi-method
approach using both self-reported measures and objective methods should be preferred in future research. Moreover, future research might also
benefit from including other sun protection behaviors such as seeking shade during breaks and using
sun protective hats.
Despite these limitations, our findings underscore
the importance of skin cancer prevention practices
386
in the winter outdoor recreation environment since
inadequate sun protection and sunburns are prevalent in this setting. Men and younger people may in
particular be important target groups for future
prevention practices.
Funding
This work was supported by the Dutch Cancer
Society.
Conflict of interest statement
None declared.
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