Health Psychology Review
ISSN: 1743-7199 (Print) 1743-7202 (Online) Journal homepage: http://www.tandfonline.com/loi/rhpr20
Assessing the efficacy of appearance-focused
interventions to prevent skin cancer: a systematic
review of the literature
Lorna J. Dodd & Mark J. Forshaw
To cite this article: Lorna J. Dodd & Mark J. Forshaw (2010) Assessing the efficacy of
appearance-focused interventions to prevent skin cancer: a systematic review of the literature,
Health Psychology Review, 4:2, 93-111, DOI: 10.1080/17437199.2010.485393
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Date: 05 May 2017, At: 06:52
Health Psychology Review
Vol. 4, No. 2, September 2010, 93111
Assessing the efficacy of appearance-focused interventions to prevent
skin cancer: a systematic review of the literature
Lorna J. Dodda* and Mark J. Forshawb
a
Department of Psychology & Counselling, Newman University College, Bartley Green,
Birmingham B32 3NT, UK; bCentre for Health Psychology, Staffordshire University, College
Road, Stoke-on-Trent ST4 2DE, UK
(Received 11 July 2009; final version received 12 April 2010)
Purpose. Ultraviolet (UV) radiation is associated with adverse health effects.
Although the immediate appearance values of tanning seem to outweigh the longterm health consequences, interventions emphasising the negative effects of UV
exposure on appearance may be effective in modifying such behaviour. Method.
A systematic review assessing the efficacy of appearance-focused interventions in
modifying UV exposure and/or protection. Relevant publications were identified
from a comprehensive search strategy of 16 electronic bibliographic databases
from inception to March 2009, hand searches of six subject relevant journals and
references lists of identified articles. Results. Data were extracted from 12 studies
that were found to be eligible. Significant effects were found for UV protection
behaviour in favour of the interventions. Though the interventions only had
moderate success in modifying UV exposure behaviour, plausible explanations
were provided. There was no clear pattern to suggest that quality of the studies or
type of intervention was associated with effectiveness of the interventions.
Conclusion. Appearance-focused interventions represent a promising method for
modifying tanning behaviour. There is scope to evaluate the generalisability of
these interventions on different populations and regions.
Keywords: appearance; intervention; review; skin cancer; UV
Introduction
Ultraviolet (UV) radiation is emitted from the sun and other sources (e.g., artificial
tanning devices), and such exposure is associated with adverse health effects (e.g.,
skin cancer, premature aging, cataracts and immune suppression; World Health
Organisation [WHO], 2009a, 2009c, 2009d). The two main types of skin cancer
linked to UV exposure are non-melanoma and malignant melanoma (Cancer
Research UK, 2009d). The incidence and prevalence of both these skin cancers are
increasing globally each year, with 23 million and 132,000 cases reported yearly,
respectively (WHO, 2009b). Worldwide, exposure to UV light is a significant
contributor to ill health and mortality. Furthermore, because of its effects taking
time to develop, that is the temporal separation of cause and effect, it represents a
challenge to health promotion. In warmer climates such as Australia and the United
States of America (USA) reports have shown skin cancer accounts for more than
80% and 50%, respectively, of all new cancers diagnosed each year (American Cancer
*Corresponding author. Email: l.dodd@newman.ac.uk
ISSN 1743-7199 print/ISSN 1743-7202 online
# 2010 Taylor & Francis
DOI: 10.1080/17437199.2010.485393
http://www.informaworld.com
94
L.J. Dodd and M.J. Forshaw
Society, 2006; Cancer Council Australia, 2009). Notably, within the United Kingdom
(UK) where UV levels and hours of sunshine are significantly less, latest figures show
skin cancer still accounts for more than 30% of new cancer diagnoses each year
(Cancer Research UK, 2009d). In fact, skin cancer deaths in the UK are greater than
Australia (Cancer Research UK, 2009b). Furthermore, within the UK malignant
melanoma is the second most common cancer in adults aged 1534 years (Cancer
Research UK, 2009d); this is comparable to both Australia and USA statistics
(American Cancer Society, 2006; Cancer Council Australia, 2009). Additionally, skin
cancer is not gender or age specific as 5213 females and 4370 males were diagnosed
with malignant melanoma in 2005 in the UK, and cases have been found in children
as young as 10 years old (Cancer Research UK, 2009c; ISD, 2009; Northern Ireland
Cancer Registry, 2009; Office for National Statistics [ONS], 2009). Consequently, UV
protection represents a major, global health concern for all ages and sexes.
Phenotypic features play a role in the development of skin cancer, most notably
blue eyes, blonde or red hair colour, pale skin, tendency to sunburn rather than tan,
freckles and moles/naevi (WHO, 2009c). Nevertheless, UV exposure should be easily
modifiable through a number of primary prevention strategies such as avoiding sun
exposure during peak UV levels, wearing protective clothing, applying sunscreen
protection, seeking shade and avoiding artificial tanning devices (Cancer Research
UK, 2009a).
Previous studies reveal that western populations are aware of the risk factors
associated with tanning behaviour and the preventable measures, though UV
exposure is still frequent (e.g., Ddadlani & Orlow, 2008; Peacey, Steptoe, Sanderman,
& Wardle, 2006).
Primary prevention interventions for skin cancer such as community-based
interventions (e.g., media campaigns to a target audience), public health campaigns
(e.g., mass media campaigns) and educational interventions (e.g., lectures, presentations, workbooks in education-based settings) have been the main source for
transferring such knowledge, primarily focusing on the health consequences (e.g.,
skin cancer) of such behaviour. Though to date such interventions have demonstrated that whilst they have been successful at enhancing knowledge and attitudes
related to UV exposure and protection, few have been successful in modifying UV
exposure/protection behaviours (e.g., Baum & Cohen, 1998; Buller & Borland, 1999;
Cummings, Tripp, & Herrmann, 1997; Hart & DeMarco, 2008; Morris & Elwood,
1996; Saraiya et al., 2004).
Despite, the adverse health effects associated with tanning, UV exposure seems to
be gaining considerable popularity and for many having ‘a tan’ is associated with
attractiveness and feeling healthy (Cokkinides et al., 2001; Lazovich & Forster, 2005;
Miles, Waller, Hiom, & Swanston, 2005; Miller, Ashton, McHoskey, & Gimbel,
1990). Subsequently, appearance-issues related to UV exposure have recently been at
the forefront of research (e.g., Hillhouse, Turrisi, Stapleton, & Robinson, 2008;
Mahler, Kulik, Butler, Gerrard, & Gibbons, 2008; Olson, Gaffney, Starr, & Dietrich,
2008). In a UK study assessing sun-safe knowledge and behaviour, 5077% of the
sample reported they were aware of preventive measures of skin cancer (e.g.,
sunscreen, seeking shade, protective clothing), though only one-third reported that
they adhered to such preventive practices. Furthermore, over 50% reported that a tan
made them look healthier and more attractive (Miles et al., 2005). The appearance
value of seeking a tan may further explain the popularity and growth of the artificial
Health Psychology Review
95
tanning industry (e.g., Hillhouse, Turrisi, Holwiski, & McVeigh, 1999). Consequently, it seems that immediate appearance-related benefits of tanning outweigh the
long-term health effects. As a result, the limited effectiveness of the previous
interventions could be attributed to the lack of focus on appearance factors.
There is now a growing body of literature on interventions emphasising the
negative consequences of UV exposure on appearance by targeting the proximal
effects of tanning, such as premature skin aging wrinkles and pigmented age spots
(e.g., Barron et al., 2007; Gibbons, Gerrard, Lane, Mahler, & Kulik, 2005; Hillhouse
et al., 2008; Mahler, Fitzpatrick, Parker, & Lapin, 1997; Mahler et al., 2008).
Furthermore, such interventions seem to generate greater interest (e.g., Jones &
Leary, 1994; Mahler et al., 1997; Weinstock & Rossi, 1998).
The literature suggests that appearance-focused interventions should theoretically reduce UV exposure. To date such interventions have not been systematically
reviewed. Thus, considering the serious health consequence of UV exposure, the
enhanced popularity of this behaviour, and the limited effectiveness of previous skin
cancer reduction programmes in modifying UV exposure/protection practices,
assessing the efficacy of such interventions is paramount; thus this review is
particularly timely.
The objective of this review was to provide a systematic evaluation of the efficacy
of appearance-focused interventions in modifying UV exposure and/or protection
from baseline to the end of the intervention period or at follow-up.
Method
Search strategy
Relevant publications were identified from a comprehensive search strategy of
electronic bibliographic databases, hand searches of subject relevant journals and
reference lists of identified articles. All the databases were searched for relevant
publications from inception to March 2009. Search strategies were customised when
required to meet the requirements of the databases. Where available, filters were
imposed to capture-related terms, reviews and human-only studies. The following
11 Ovid electronic bibliographic databases were searched: AMED, British Nursing
Index, Business Source Premier, CINAHL, Econlit, GreenFile, International Bibliography of the Social Sciences, MEDLINE, Pre-CINAHL, PsycARTICLES and
SPORTDiscus. A further five bibliographic databases were scrutinised for relevant
publications (the later three databases were searched for the purpose of identifying
grey literature): Web of Knowledge, Cochrane Library, ProQuest Dissertation &
Theses Databases, Index to Theses in Great Britain and ISI Proceedings. To identify
relevant studies that may have not been added to these databases, the following six
journals were hand-searched from 2008 to March 2009: Social Science & Medicine,
Health Education Research, Health Psychology, Basic & Applied Social Psychology,
Archives of Dermatology and Journal of Behavioral Medicine. The search strategy
included keywords that focused on the desired intervention type ‘appearancefocused’ (e.g., age spots, appearance, appearance-diminishing, photoageing, photodamage, wrinkles), which were then combined with the health behaviour (e.g., skin
cancer prevention, solar radiation, sun/UV protection, sunscreen, tanning, UV
96
L.J. Dodd and M.J. Forshaw
exposure) and the associated illness terms (e.g., melanoma, skin cancer, skin
tumour). Boolean operators were utilised to identify the most relevant literature.
Selection strategy
The inclusion criteria were kept fairly broad in order to capture all relevant articles.
Initially, titles or abstracts were included and full manuscripts were retrieved for
further inspection if the study was an intervention that focused on appearance and
tanning (including artificial tanning). If these initial inclusion requirements were
unable to be extracted from the title/abstract, the full manuscript was retrieved to
enable a judgement about inclusion.
The inclusion and exclusion criteria were defined in terms of the intervention,
outcome measure and study design (Centre for Reviews and Dissemination [CRD],
2001). The full manuscripts were then scrutinised and included in the systematic
review if the following criteria were met: (1) intervention was appearance-focused; (2)
intervention evaluated change in intention and/or behaviour towards UV exposure
and/or protection; (3) at a minimum the study design was quasi-experimental; and
(4) the articles were published in English language. There was no restriction on
population type or age group. Papers were excluded if they were: (1) discussions and/
or reviews (though their reference lists were examined); (2) if the intervention was
a multi-component programme where there was little emphasis on aspects of
appearance, for example, if a considerable number of the components focused on the
health effects of the behaviour; (3) if there was no pre- and post-assessment of the
desired outcomes; or (4) if they were not original articles.
Review strategy
A data extraction form was developed and applied systematically to all eligible
articles that met the inclusion criteria. The form was used to extract the following
information from the articles: article, study and intervention characteristics, outcome
measures and analysis.
A quality assessment checklist of 13 quality indicators was devised in accordance
with published recommendations (e.g., Bellamy, 2005 QUEST criteria; Jacobsen,
Donovan, Vadaparamphil, & Small, 2007; Ryan et al., 2007). All eligible studies were
subjected to the quality assessment checklist. This process is essential for studies that
are evaluated in review papers in order to limit bias, to allow for potential
comparisons between individual studies to be made and to allow for meaningful
conclusions to be drawn (Higgins & Green, 2008). Unless specified, each quality
assessment indicator was awarded 4 points for full detail, 3 for substantial detail,
2 for partial detail and 1 for no detail or providing insufficient detail for reasonable
assessment. The following aspects of each paper were assessed and scored using the
above criteria: study design (i.e., randomised controlled trial (RCT), randomisation
without control group, control trial without randomisation, quasi-experimental,
points awarded 4, 3, 2, 1, respectively), sample size, a priori estimate of sample size,
sampling procedure, conditions comparable on measures of interest at baseline, refusal
rate reported at baseline, allocation concealment/blinding, measurement tool of
outcomes (i.e., objective measurement, self-report behaviour, report of intended
behaviour, points awarded 4, 3, 2, respectively), intervention details, attrition rate at
Health Psychology Review
97
follow-up, statistical techniques reported, statistical outputs reported and a discussion
of generalisability. Scores were summated to create a score between 14 and 52.
Studies were considered well-conducted and reported if they scored 42, average
between 33 and 42 and poor if they scored less than 33 (refer to Table 2). The ranges
were based on Bellamy’s (2005) QUEST criteria.
Procedure and data synthesis
Once full manuscripts of eligible studies (studies meeting the initial inclusion criteria
at the title/abstract stage of searching) were retrieved, each study was scrutinised
using the data extraction sheet. Fifty percent were scrutinised by the co-author as
a reliability precaution. Only one discrepancy was reported between reviewers
regarding the inclusion of a paper and a consensus was reached through further
scrutiny of the paper and discussion.
A meta-analysis was not undertaken because the desired outcome measure
content was too heterogeneous to integrate statistically. For example, the studies’
assessments of UV exposure/protection timeframe varied from the previous weekend
to the previous 12 months, and various studies’ interpretations of UV exposure/
protection were operationalised inconsistently. Furthermore, there were differences
in methodological quality. Thus, findings are synthesised in a systematic descriptive
form.
Results
Trial flow
The initial comprehensive search strategy generated 815 potentially relevant
citations. Of these, 148 were duplicates and thus excluded, and a further 628 were
discarded for not meeting the initial inclusion criteria at the title/abstract stage of the
search strategy. Full manuscripts were retrieved for the remaining 39 papers and were
subjected to a full data extraction, of which 12 papers fulfilled the full inclusion
criteria and are included in the review. Figure 1 depicts the output of the search
strategy and reasons for exclusions.
Study characteristics of the appearance-focused intervention studies
Demographics characteristics
A brief summary of characteristics of the included studies are described in Table 1.
In eight of the studies the sample consisted of university students with an age range
of 1744 years (Gibbons et al., 2005; Hillhouse & Turrisi, 2002; Hillhouse et al.,
2008; Jackson & Aiken, 2006; Mahler et al., 2008; Mahler, Kulik, Gerrard, &
Gibbons, 2007; Mahler, Kulik, Harrell, Correa, & Gibbons, 2005; McClendon &
Prentice-Dunn, 2001). Two studies consisted of adolescents (Novick, 1997; Olson
et al., 2008), and two studies consisted of beach patrons, age range of 1867 years
(Mahler, Kulik, Gerrard, & Gibbons, 2006; Pagoto, McChargue, & Fuqua, 2003).
Seven of the studies (58%) included both male and female participants, although
a greater proportion in each study were females ranging from 53 to 83% (range
based on those studies that provided information on the gender split; Gibbons
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L.J. Dodd and M.J. Forshaw
Potentially relevant citations identified and screened
for retrieval at title/abstract stage (N=815)
Duplicate citations excluded (N=148)
Non-duplicate citations retrieved (N=667)
Articles excluded, did not fulfil initial
inclusion criteria (N=628; see text
for details)
Full manuscripts retrieved for possible inclusion in
review (N=39)
Articles excluded not meeting full inclusion
criteria (see text for details; N=27)
Duplication of participants (n=1)
Not an intervention (n=3)
Desired outcome measures not addressed (n=4)
Discussion/review/descriptive article (n=4)
Post-test design only (n=4)
Multiple component intervention with minimal
appearance focus (n=2)
Pre-post measures of desired outcomes not
included (n=1)
Intervention focus not appearance based (n=6)
Not English (n=2)
Studies included in final systematic review (N=12)
Figure 1.
Search strategy.
et al., 2005; Mahler et al., 2005, 2006, 2007, 2008; McClendon & Prentice-Dunn,
2001; Pagoto et al., 2003). Four studies included females only (Hillhouse & Turrisi,
2002; Hillhouse et al., 2008; Jackson & Aiken, 2006; Novick, 1997) and in one
study sex of the sample was unable to be determined (Olson et al., 2008). Seven of
the studies reported their samples’ ethnic origin as either entirely Caucasian or
with a substantial bias towards Caucasian ethnic groupings (Jackson & Aiken,
2006; Mahler et al., 2005, 2006, 2007, 2008; Novick, 1997; Olson et al., 2008). All
the studies included were carried out in the USA and four of the studies were
carried out by the same first author. Therefore, it was deduced that the
generalisability of the findings may be limited as the study samples are
predominately drawn from university students, the sample is predominantly
females, and data are collected from one, albeit well-populated, country.
Health Psychology Review
99
Design characteristics
The total sample size for each study ranged from 30 to 430 at baseline
(median 133). For three of the studies, sample size for at least one of the
conditions was relatively small (B30 per condition; Mahler et al., 2008; McClendon
& Prentice-Dunn, 2001; Novick, 1997), whilst the remaining studies’ condition size
was moderate (30 toB200). A priori estimate for sample size was reported in two
studies only (Jackson & Aiken, 2006; Mahler et al., 2008), thus for the remaining
articles (83%) it is not clear whether the studies were adequately planned to detect for
differences. Nine studies were described as RCTs (Gibbons et al., 2005; Hillhouse &
Turrisi, 2002; Hillhouse et al., 2008; Jackson & Aiken, 2006; Mahler et al., 2005,
2006, 2007, 2008; Novick, 1997). One study utilised a randomisation design with
a wait-list control group (McClendon & Prentice-Dunn, 2001), one involved a
controlled trial without randomisation (Pagoto et al., 2003) and the remaining study
was a prepost comparison without a control (Olson et al., 2008). Eleven studies
included a follow-up component ranging from 2 weeks to 12 months (Gibbons et al.,
2005; Hillhouse & Turrisi, 2002; Hillhouse et al., 2008; Jackson & Aiken, 2006;
Mahler et al., 2005, 2006, 2007, 2008; McClendon & Prentice-Dunn, 2001; Novick,
1997; Pagoto et al., 2003). The maximum number of conditions (including control
condition) found in a single study was five (Mahler et al., 2008).
Recruitment characteristics
Seven of the 10 randomised trials reported that the conditions were comparable at
baseline assessment (Hillhouse & Turrisi, 2002; Hillhouse et al., 2008; Jackson &
Aiken, 2006; Mahler et al., 2005, 2006, 2007, 2008). A non-random recruitment
method was used by six of the 12 included studies (Hillhouse & Turrisi, 2002;
Jackson & Aiken, 2006; Mahler et al., 2005, 2006, 2007, 2008), three studies used a
randomised sampling technique (Gibbons et al., 2005; Hillhouse et al., 2008; Novick,
1997), only one described how the technique was implemented (Hillhouse et al.,
2008) and the remaining three studies did not report their sampling procedure
(McClendon & Prentice-Dunn, 2001; Olson et al., 2008; Pagoto et al., 2003). Of
those studies using a non-random sampling procedure only 27% reported participants’ refusal rate (Hillhouse & Turrisi, 2002; Hillhouse et al., 2008; Mahler et al.,
2006). Thus, it is not clear of the magnitude of bias that may have occurred in the
sample (Clark-Carter, 2004).
Intervention characteristics
To some extent, type (e.g., booklet, workbook, essay, UV photograph), delivery (e.g.,
video, presentation, lecture) and content of the appearance-focused interventions
varied between studies and varied depending on intervention condition (e.g., for
those studies comparing more than one appearance-focused intervention type). In
brief, intervention variation consisted of photoageing/appearance information and/
or UV photo/light (depicting underlying UV damage to skin; Gibbons et al., 2005;
Hillhouse & Turrisi, 2002; Hillhouse et al., 2008; Jackson & Aiken, 2006; Mahler
et al., 2005, 2006, 2007, 2008; McClendon & Prentice-Dunn, 2001; Olson et al., 2008;
Pagoto et al., 2003) and photoageing/appearance information and UV photo plus
100
L.J. Dodd and M.J. Forshaw
supplementary information (e.g., sunless tanning lotion, social norms; Mahler et al.,
2005, 2008). In one study, photographs of the face were taken and converted by
computer imagery to demonstrate ageing and lesions (Novick, 1997). In those studies
where some aspect of the intervention duration was reported, these aspects were of
short duration, for example, duration ranged from 2 to 75 minutes long (medium
21 minutes; Gibbons et al., 2005; Jackson & Aiken, 2006; Mahler et al., 2005, 2007;
McClendon & Prentice-Dunn, 2001; Olson et al., 2008).
Outcomes measured
Included studies assessed intention and/or behaviour of the desired outcome
measures; UV exposure and/or protection, assessing change from baseline to the
end of the intervention period or at follow-up. Those studies that measured
behaviour by both self-report and by an objective measure (e.g., skin reflectance
spectrophotometer to assess change in skin colour), measured both UV exposure and
protection behaviour and measured both intention and behaviour had both sets of
data extracted.
Outcome measure questions content varied in: quantity (e.g., number of
questions per outcome measure), timeframe (e.g., outcome measures questions
ranged from asking about the previous weekend to the previous 12 months, hours of
partaking in the behaviour and/or frequency reported of the behaviour), type of
behaviour (e.g., UV exposure and/or protection, indoor tanning/sun exposure, type
of protection, i.e., sunscreen/wearing a hat/seeking shade) and measurement method
(e.g., self-reported behaviour vs. objective skin-colour measure skin reflectance
spectrophotometer).
Quantitative analysis
The statistical technique ANCOVA was predominantly utilised to analyse the data
within the studies (with baseline data controlled for as the covariate). This is deemed
an appropriate statistical test to assess for differences between conditions when
examining changes from baseline to the end of the intervention or follow-up, when
the assumptions of this test are adhered to (e.g., measurement level of the outcome
variable is ratio/interval level).
Quality assessment of the appearance-focused intervention studies
Table 2 provides an overview of the scores awarded for the 13 quality indicators for
each of the 12 studies. Quality assessment was rated good for one study (Jackson &
Aiken, 2006), average for seven (58%) of the studies (Gibbons et al., 2005; Hillhouse
& Turrisi, 2002; Hillhouse et al., 2008; Mahler et al., 2005, 2006, 2007, 2008) and
poor for four (33%) of the studies (McClendon & Prentice-Dunn, 2001; Novick,
1997; Olson et al., 2008; Pagoto et al., 2003). The following areas of the quality
indicator: a priori estimate of sample size, allocation concealment/blinding and
refusal rate reported at baseline, were given a low-quality score (e.g., 1) in the
majority of the studies (83%, 83%, 67%, respectively).
Table 1.
Characteristics of included studies.
Study (first
author,
year)
Population
Sample size
at baseline
Country
Design
Outcome
measures
Control
condition(s)
Intervention
condition(s)
Quality
score
Gibbons
(2005)
University
students
(male and
female)
Exp.
1 70
C 35
I 35
Exp.
2 134
C 67
I 67
USA
RCT,
one-month
follow-up
Indoor tanning
behavioura
Exp. 1 debrief
with intervention
information
Exp. 2 received
the same as the
intervention group
except the UV
photo
Exp. 1 and Exp.
2-Photoageing/
appearance information
(communicated by oral
presentation and
brochures) and UV photo
Hillhouse
(2008)
University
students
(female)
430
C 230
I 200
USA
RCT, six-month
follow-up
Indoor tanning
intentiona and
behaviour
No intervention
40
Photoageing/appearance
information with an
emphasis on norms
(communicated by a written
booklet)
Hillhouse
(2002)
University
students
(female)
147
C ?
I ?
USA
RCT, 2 weeks
and two-month
follow-up
Indoor tanning
intentiona and
behavioura
No intervention
Appearance-focused
information (workbook
format)
38
Jackson
(2006)
University
students
(female)
211
C 105
I 106
USA
RCT, two-week
follow-up
Intention to
UV protecta
and sunbath,a
UV exposurea/
protectiona
behaviour
Stress management
intervention
Photoageing/appearance,
image norm information
(communicated by a variety
of formats, e.g., video,
worksheets)
(Multi-component
appearance-focused
intervention)
100
37
Health Psychology Review
101
102
Table 1 (Continued )
Study (first
author,
year)
Population
Sample size
at baseline
Country
University
students
(male and
female)
125
C 25
I1 25
I2 25
I3 25
I4 25
USA
Mahler
(2007)
University
students
(male and
female)
133
C 34
I1 34
I2 35
I3 30
USA
Outcome
measures
RCT, one-month UV protection
follow-up
behavioura
RCT, 45 and
12 months
follow-up
Control
condition(s)
Intervention
condition(s)
42
No intervention
UV exposurea/
No intervention
protectiona
behaviour, actual
skin coloura
Quality
score
I1photoageing/appearance
information (communicated
by written material with
visual material) and UV
photo (the basic
intervention)
I2 basic intervention plus
injunctive norm
information
I3 basic intervention plus
descriptive norm
information
I4 basic intervention plus
both the injunctive and
descriptive norm
information
L.J. Dodd and M.J. Forshaw
Mahler
(2008)
Design
40
I1 photoageing/
appearance information
(communicated by video
format)
I2 UV photo
I3 photoageing/
appearance information and
UV photo
Table 1 (Continued )
Study (first
author,
year)
Population
Sample size
at baseline
Country
Beach
patrons
(male and
female)
244
C 60
I1 61
I2 62
I3 62
USA
Mahler
(2005)
University
students
(male and
female)
146
C 50
I1 50
I2 46
USA
McClendon University
(2001)
students
(male and
female)
58
C 30
I 28
USA
Outcome
measures
Control
condition(s)
RCT, two-month UV protection
follow-up
behaviour,a
actual skin
colour
No intervention
RCT, one-month UV exposure/
follow-up
protectiona
behaviour
No intervention
Intention to
UV protecta
and sunbath,a
UV exposure
behavioura
Wait-list control
Randomised
design with a
wait-list control
group
Intervention
condition(s)
Quality
score
42
I1 photoageing/
appearance information
(communicated by
laminated card) and UV
photo
I2 UV photo
I3 photoageing/
appearance information
38
I1 photoageing/
appearance information
(communicated by video
format) and UV photo
I2 photoageing/
appearance information and
UV photo plus sunless
tanning lotion
Photoageing/appearance
information (essay) and
video focusing on someone
who has skin cancer
Health Psychology Review
Mahler
(2006)
Design
31
103
104
Table 1 (Continued )
Study (first
author,
year)
Population
Sample size
at baseline
Country
Adolescence 30
(female)
C 14
I1 8
I2 8
USA
Olson
(2008)
Adolescence 113
(?)
Pagoto
(2003)
Beach
patrons
(male and
female)
a
257
C ?
I ?
Outcome
measures
Control
condition(s)
Intervention
condition(s)
Quality
score
28
RCT, 6 weeks
follow-up
(weekly logs)
UV exposure/
protection
behavioura
Provided with
sunscreen and a
photograph was
taken, but the
photo was not
modified.
USA
Prepost
comparison
without a
control
Intention to
use sunscreena
No control group
23
Photoageing/appearance
information, risk of UV
exposure and strategies to
protect (communicated by a
session with visual material)
and UV light (appearancefocused educational
intervention)
USA
Controlled trial
without
randomisation,
two-month
follow-up
UV exposure/
protectiona
behaviour
No intervention
24
Appearance-focused
multi-component plus a UV
photo
Significant effects.
? denotes papers where sample size for the control group and the experimental group was not provided.
I1 photograph
demonstrating ageing
I2 photograph
demonstrating ageing and
cancerous lesions
(The photographs were
computer-enhanced)
All participants were
provided with sunscreen
L.J. Dodd and M.J. Forshaw
Novick
(1997)
Design
Table 2.
Quality assessment of included studies.
Study (first
author, year)
4
4
4
4
4
4
4
4
2
4
1
2
4
1
4
1
3
1
4
3
4
4
4
1
4
1
4
1
4
1
4
1
4
1
2
Statistical
technique
and
Attrition statistical
rate
outputs
Conditions
comparable
at baseline
Refusal rate
reported at
baseline
Allocation
concealment/
blinding
Measurement
tool
Intervention
details
3
1
3
1
3
4
4
4
4
4
1
3
4
3
2
4
3
1
3
4
3
3
4
1
3
3
4
4
3
4
1
2
3
4
3
3
4
1
1
4
4
4
3
4
3
1
4
4
4
4
4
1
1
3
4
4
1
1
1
1
4
4
4
2
1
1
1
3
3
1
1
1
1
1
1
4
3
1
1
1
1
2
4
1
4
3
4
3
4
3
4
4
4
3
4
3
3
3
3
3
4
3
3
3
2
3
3
Discussion of
generalisability
Overall
quality
score
2
37
1
40
3
38
4
45
3
42
3
40
4
42
2
38
1
31
2
28
1
23
2
24
Health Psychology Review
105
Gibbons
(2005)
Hillhouse
(2008)
Hillhouse
(2002)
Jackson
(2006)
Mahler
(2008)
Mahler
(2007)
Mahler
(2006)
Mahler
(2005)
McClendon
(2001)
Novick
(1997)
Olson
(2008)
Pagoto
(2003)
Sample size
and a priori
Study estimate of Sampling
design sample size procedure
106
L.J. Dodd and M.J. Forshaw
Findings of the appearance-focused intervention studies
Effects of appearance-focused interventions on UV exposure and/or protection
intentions
All five studies assessing UV exposure and/or protection intention yielded a
significant finding in favour of the appearance-focused intervention, either reporting
significantly fewer tanning intentions and/or greater UV protection intentions
(Hillhouse & Turrisi, 2002; Hillhouse et al., 2008; Jackson & Aiken, 2006;
McClendon & Prentice-Dunn, 2001; Olson et al., 2008). One study consisted of
multiple components with a heavy focus on appearance factors (Jackson & Aiken,
2006). One study consisted of photoageing/appearance information and a UV light
(Olson et al., 2008) and three studies favoured a photoageing/appearance information intervention (Hillhouse & Turrisi, 2002; Hillhouse et al., 2008; McClendon &
Prentice-Dunn, 2001). Two studies measured both UV exposure and protection
intentions (Jackson & Aiken, 2006; McClendon & Prentice-Dunn, 2001), two studies
measured UV exposure intentions from indoor tanning (Hillhouse & Turrisi, 2002;
Hillhouse et al., 2008) and one study measured UV protection intentions (e.g.,
sunscreen use; Olson et al., 2008). Three out of the five (60%) studies were rated as
average to good on the quality assessment checklist (Hillhouse & Turrisi, 2002;
Hillhouse et al., 2008; Jackson & Aiken, 2006).
Effects of appearance-focused interventions on UV protection behaviours
All seven studies assessing behaviours towards UV protection yielded a significant
finding in favour of the appearance-focused intervention in enhancing such
behaviours (Jackson & Aiken, 2006; Mahler et al., 2005, 2006, 2007, 2008; Novick,
1997; Pagoto et al., 2003). For those studies with more than one appearance-focused
intervention, the most successful is reported. Of the seven, one study favoured an
intervention that included photoageing/appearance information and a UV photo
(Mahler et al., 2005). One study favoured an intervention that included photoageing/
appearance information, a UV photo, plus descriptive and injunctive norm
information (Mahler et al., 2008). Two studies favoured an intervention of
photoageing/appearance information (Mahler et al., 2006, 2007). In one study, a
greater endorsement of UV protection was found in the intervention condition that
viewed computer enhanced images of skin both aged and disfigured by cancerous
lesions (Novick, 1997). Two studies consisted of multiple components with a heavy
focus on appearance factors (Jackson & Aiken, 2006; Pagoto et al., 2003). All of
these studies included a longitudinal/follow-up measure ranging from 2 weeks to
12 months (Jackson & Aiken, 2006; Mahler et al., 2005, 2006, 2007, 2008; Novick,
1997; Pagoto et al., 2003). Differences were still apparent at the follow-ups ranging
from 2 weeks to 45 months, but no differences were found at 12 months follow-up
(Mahler et al., 2007). Five out of the seven (71%) studies were rated as average to
good on the quality assessment checklist.
Effects of appearance-focused interventions on UV exposure behaviour
Five studies out of the 10 measuring change in UV exposure behaviour yielded
at least one significant finding in favour of the appearance-focused intervention
Health Psychology Review
107
(Gibbons et al., 2005; Hillhouse & Turrisi, 2002; Jackson & Aiken, 2006; Mahler
et al., 2007; McClendon & Prentice-Dunn, 2001). For those studies with more than
one appearance-focused intervention, the most successful is reported. Four out of
the five (80%) studies were rated as average to good on the quality assessment
checklist.
Of the five studies, one study favoured a UV photo intervention (Gibbons et al.,
2005) and three studies favoured photoageing/appearance information intervention
(Hillhouse & Turrisi, 2002; Mahler et al., 2006; McClendon & Prentice-Dunn, 2001).
The information, however, was communicated through a number of different formats
with varying content. In the Mahler et al. (2007) study, exposure to this information
reduced incidental UV exposure and reduced skin darkening (observed by an
objective indicator of skin-colour change). Similarly, using an objective indicator,
McClendon and Prentice-Dunn (2001) revealed lighter skin post-intervention. One
study favoured a multiple component intervention with a significant focus on
appearance factors (Jackson & Aiken, 2006). Of those studies yielding a significant
result, the longest significant follow-up assessment reported was 12 months
measured by an objective indicator (Mahler et al., 2007).
Of the five studies not yielding a significant result (Hillhouse et al., 2008; Mahler
et al., 2005, 2006; Novick, 1997; Pagoto et al., 2003), one focused on photoageing/
appearance information communicated through a booklet format (Hillhouse et al.,
2008). The study reported an increase in behaviour from baseline to follow-up, but it
was argued that this was attributed to time of year when the assessment was carried
out. Baseline assessment was carried out at a period where UV exposure behaviour
(indoor tanning) is expected to be low, whereas the six-month follow-up assessment
was carried during a period when such behaviour is expected to be high (February
April). Although the control group did indulge in greater indoor tanning behaviour
at follow-up than the intervention group, the difference was not significant
(Hillhouse et al., 2008). However, as reported previously, intention to reduce indoor
tanning was significant for the experimental group post-intervention. One study
focused on a multiple component intervention with a significant focus on
appearance factors including a UV photograph (Pagoto et al., 2003). In Mahler
et al. (2006), the objective indicator of skin-colour change (the spectrophotometer
device) revealed that there was no difference in skin-colour change post-intervention.
Furthermore, an earlier study by Mahler et al. (2005) did not yield a significant
finding in UV exposure behaviour reduction between intervention and control at
follow-up. Similarly, Novick (1997) revealed a non-significant difference between the
two intervention groups (who viewed a computer enhanced image photo of
themselves with aged skin or both aged skin and cancerous lesions) and the control
group in reduction of UV exposure behaviour between 10 am and 3 pm. The latter
finding was attributed to the fact that the participants were working on summer
camps, and they were required to spend a number of hours outdoors between 10 am
and 3 pm.
Amongst the publications reporting non-significant reductions in UV exposure
behaviour post-intervention, three were rated of average quality (Hillhouse et al.,
2008; Mahler et al., 2005, 2006) and two rated as poor quality (Novick, 1997; Pagoto
et al., 2003).
108
L.J. Dodd and M.J. Forshaw
Discussion
The synthesis of results is promising; interventions focusing on appearance factors
appear to have a relatively positive effect on modifying behaviour. All seven studies
that assessed change in UV protection behaviours revealed a significant finding in
favour of the intervention. Although, in contrast, not all the studies that aimed to
reduce UV exposure behaviour experienced similar success. Only five out of the
10 studies measuring this behaviour yielded a significant result in favour of the
intervention. Reasonable explanations for such findings were provided and should
be evaluated when considering the papers and the interventions. Four of the five
studies yielding a non-significant result also measured UV protection behaviours,
where a significant increase occurred (Mahler et al., 2005, 2006; Novick, 1997;
Pagoto et al., 2003). Pagoto et al. (2003) identified that such a finding is not unusual
and have provided a very plausible explanation. They stated that individuals may
simply perceive that UV protection is an adequate measure to reduce photoageing.
Thus, future appearance-focused interventions should explicitly demonstrate that
UV protection will not reduce the effects of photoageing if tanning duration and
frequency are unchanged. There was no clear pattern to suggest that quality of
the studies was associated with effectiveness of the interventions. However,
the successful studies did have smaller sample sizes and slightly fewer conditions.
Appearance-focused interventions were successful at modifying behavioural
intention.
Furthermore, there was no clear pattern within the results where one could make
a confident conclusion about the most effective appearance-focused intervention.
Whilst they were all appearance-focused the delivery mode varied (e.g., booklet,
workbook, essay, UV photograph, video, presentation, lecture, information based,
etc.).
One must re-state at this point that even though the review of studies is promising
and that it is tempting to make comparisons between the studies, the studies were not
fully homogeneous; there were clear methodological differences. The reliability and
validity of the assessment measures are questionable; nine of the studies (75%)
utilised a self-report measure. Future research should adopt more objective skincolour measures such as the spectrophotometer. Furthermore, outcome measure
question content varied between studies, for instance, outcome questions ranged
from asking about the previous weekend UV exposure/protection to the pervious
12 months, type of behaviour measured, i.e., UV exposure (e.g., incidental and/or
intentional, indoor tanning or sun exposure), protective behaviour (e.g., sunscreen,
protective clothing and/or seeking shade) and measurement method (e.g., self-report
and/or objective method). Thus the heterogeneity of question content is worth
considering. It is clear that standardised measures are limited in this area and future
researchers should consider developing more valid measures.
There were a number of limitations to the studies that future research should
address, many of which were noted by the authors themselves. All of the reviewed
studies were conducted in the USA, a considerable percentage of the population were
female, eight of the samples (67%) were university students and the samples were
predominantly Caucasian. Thus, future research should assess whether such
interventions are effective in different climate/regions (e.g., a worldwide sample)
and on different populations. As the interventions are showing promise, younger age
Health Psychology Review
109
groups should also be targeted to discourage the idea that a tan is attractive.
However, out of the 12 studies reviewed, four of the studies were conducted by the
same first author (Mahler), another potential source impacting upon the review
findings.
Additional caveats to note include the fact that only two studies made a priori
estimate of sample size at the design stage. Thus, without such an estimate it is not
clear whether the studies were adequately planned to detect for differences, and
therefore the efficacy of the findings is potentially undermined. The majority of the
studies included a follow-up component that ranged from 2 weeks to 12 months.
Changes in UV protection behaviour were found at the follow-ups thus suggesting
that the intervention has a long-term impact. However, one must acknowledge that
the follow-up assessments predominantly relied on self-report measures of this
behaviour. Reduction in UV exposure behaviour was not as successful at the followups. It was noted by some of the authors that if individuals were able to keep the
intervention material (e.g., UV photo) as a continual reminder this may encourage a
long-lasting behavioural change. This is a very plausible explanation and should be
considered in future research. Before concluding, it is important to consider the aim
of the review and the potential limitations. The possibility remains that even with the
use of a multiple search strategy some studies may not have been identified.
Furthermore, whilst studies with multiple components were identified and viewed
carefully by the authors to assess the quantity/emphasis on appearance factors,
omissions of possible relevant studies may have occurred. These should be
considered when drawing conclusions from the review findings.
In addition to addressing the improvement elements suggested above, the authors
would further recommend that to truly assess the potential of appearance-focused
interventions comparisons should be made with health-focused interventions.
Finally, a systematic review evaluating the efficacy of the mediating variables (that
were measured in many of the studies, e.g., attitudes towards UV exposure/
protection, perceived susceptibility to photoageing and skin cancer) on the
interventions to understand behaviour change would be useful for health practitioners designing such interventions.
In conclusion, the review findings suggest that appearance-focused interventions
hold promise for motivating individuals to modify their tanning behaviour. Future
research focusing on different populations and regions as well as designing
adequately powered RCTs will provide a better insight into the effectiveness of
such interventions.
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