A Mediator Model of Sunscreen Use: A Longitudinal Analysis of Social-Cognitive Predictors and Mediators

  • Catrinel Craciun
  • Natalie Schüz
  • Sonia Lippke
  • Ralf Schwarzer



Sun safety behaviors to prevent skin cancer, such as sunscreen use, are difficult to adopt and maintain.


Most social-cognitive theories assume that the intention to change a behavior is the best predictor of actual change. But unforeseen barriers emerge, or people give in to temptations, such as getting a tan despite their initial good intentions. The Health Action Process Approach proposed by Schwarzer (Appl Psychol 57:1–29, 1) is used to explore the self-regulatory mechanisms of sunscreen use.


An international longitudinal survey was conducted with 524 individuals. Intentions, positive outcome expectancies, distal self-efficacy, and risk perception were assessed at time 1, whereas intention, planning, and proximal self-efficacy were measured 2 weeks later at time 2. Sunscreen use was reported at 3-month follow-up (time 3).


A structural equation model fit the data well. Positive outcome expectancies, risk perception, and self-efficacy predicted the behavioral intention. Self-efficacy and planning predicted sunscreen use, and planning mediated the relation between intended and performed sunscreen use.


The findings contribute to the understanding of psychological mechanisms in health behavior change. They also point to the particular role of mediator variables in the context of sun protection behaviors, which may have implications for designing skin cancer preventive interventions.


Sunscreen use Self-efficacy Planning Intention Skin cancer Sun safety 


  1. 1.
    Schwarzer R. Modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors. Appl Psychol. 2008;57:1–29.Google Scholar
  2. 2.
    Lens MB, Dawes M. Global perspectives of contemporary epidemiological trends of cutaneous malignant melanoma. Br J Dermatol. 2004;150:179–85.PubMedCrossRefGoogle Scholar
  3. 3.
    Abdulla FR, Feldman SR, Williford PM, Krowchuck D, Kaur M. Tanning and skin cancer. Ped Dermatol. 2005;22:501–12.CrossRefGoogle Scholar
  4. 4.
    Gonzalez S, Fernandez-Lorente M, Gilaberte-Calzada Y. The latest on skin protection. Clin Dermatol. 2008;26:614–26.PubMedCrossRefGoogle Scholar
  5. 5.
    Green AC, Williams GM. Point: sunscreen use is a safe and effective approach to skin cancer prevention. Cancer Epidemiol Biomark Prev. 2007;16:1921–2.CrossRefGoogle Scholar
  6. 6.
    World Health Organization. Sun protection. Simple precautions in the sun. 2010. Retrieved from
  7. 7.
    Saraiya M, Glanz K, Briss P, Nichols P, White C, Das D, et al. Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation. A systematic review. Am J Prev Med. 2004;27:422–66.PubMedGoogle Scholar
  8. 8.
    Kasparian NA, McLoone JK, Meiser B. Skin cancer-related prevention and screening behaviors: a review of the literature. J Behav Med. 2009;32:406–28.PubMedCrossRefGoogle Scholar
  9. 9.
    De Vries H, Willems K, Mesters I, Reubsaet A. Skin cancer prevention behaviors during summer holidays in 14- and 18-year-old Belgian adolescents. Eur J Cancer Prev. 2006;15:431–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Lippke S, Ziegelmann JP. Theory-based health behavior change: developing, testing and applying theories for evidence-based interventions. Appl Psychol Int Rev. 2008;57:698–716.CrossRefGoogle Scholar
  11. 11.
    Abraham C, Sheeran P. Understanding and changing health behavior: from health beliefs to self-regulation. In: Norman P, Abraham C, Conner M, editors. Understanding and changing health behavior. Amsterdam: Harwood; 2000. p. 3–24.Google Scholar
  12. 12.
    Orbell S, Sheeran P. “Inclined abstainers”: a problem for predicting health-related behaviour. Br J Soc Psychol. 1998;37:151–65.PubMedCrossRefGoogle Scholar
  13. 13.
    Luszczynska A, Schwarzer R, Lippke S, Mazurkiewicz M. Self-efficacy as a moderator of the planning–behaviour relationship in interventions designed to promote physical activity. Psychol Health. 2011;26:151–66.PubMedCrossRefGoogle Scholar
  14. 14.
    Scholz U, Schüz B, Ziegelmann JP, Lippke S, Schwarzer R. Beyond behavioural intentions: planning mediates between intentions and physical activity. Br J Health Psychol. 2008;13:479–94.PubMedCrossRefGoogle Scholar
  15. 15.
    Gollwitzer PM, Sheeran P. Implementation intentions and goal achievement: a meta-analysis of effects and processes. Adv Exp Soc Psychol. 2006;38:69–119.CrossRefGoogle Scholar
  16. 16.
    Chapman J, Armitage CJ, Norman P. Comparing implementation intention interventions in relation to young adults’ intake of fruit and vegetables. Psychol Health. 2009;24:317–32.PubMedCrossRefGoogle Scholar
  17. 17.
    Luszczynska A. Effects of an implementation intention intervention on physical activity after MI are mediated by cognitive processes, change in forming action plans. Soc Sci Med. 2006;62:900–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Wiedemann A, Lippke S, Reuter T, Ziegelmann JP, Schüz B. The more the better? The number of plans predicts health behaviour change. App Psychol Health Well Being. 2011;3:87–106. doi: 10.1111/j.1758-0854.2010.01042.x.CrossRefGoogle Scholar
  19. 19.
    Gutiérrez-Doña B, Lippke S, Renner B, Kwon S, Schwarzer R. How self-efficacy and planning predict dietary behaviors in Costa Rican and South Korean women: a moderated mediation analysis. App Psychol Health Well Being. 2009;1:91–104.CrossRefGoogle Scholar
  20. 20.
    Luszczynska A, Cao DS, Mallach N, Pietron K, Mazurkiewicz M, Schwarzer R. Intentions, planning, and self-efficacy predict physical activity in Chinese and Polish adolescents: two moderated mediation analyses. Int J Clin Health Psychol. 2010;10:265–78.Google Scholar
  21. 21.
    Renner B, Kwon S, Yang BH, Paik KC, Kim SH, Roh S, et al. Social-cognitive predictors of dietary behaviors in South Korean men and women. Int J Behav Med. 2008;15:4–13.PubMedCrossRefGoogle Scholar
  22. 22.
    Ziegelmann JP, Lippke S. Planning and strategy use in health behavior change: a life-span view. Int J Behav Med. 2007;14:30–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Jackson KM, Aiken LS. A psychological model of sun protection and sunbathing in young women: the impact of health beliefs, attitudes, norms, and self efficacy for sun protection. Health Psychol. 2000;19:469–78.PubMedCrossRefGoogle Scholar
  24. 24.
    Turrisi R, Hillhouse J, Gebert C, Grimes J. Examination of cognitive variables relevant to sunscreen use. J Beh Med. 1999;22:493–509.CrossRefGoogle Scholar
  25. 25.
    Bränström R, Ullen H, Brandberg Y. Attitudes, subjective norms and perception of behavioral control as predictors of sun related behavior in Swedish adults. Prev Med. 2004;39:992–9.PubMedCrossRefGoogle Scholar
  26. 26.
    De Vries H, Lezwijn J, Hol M, Honing C. Skin cancer prevention: behaviour and motives of Dutch adolescents. Eur J Cancer Prev. 2005;14:39–50.PubMedCrossRefGoogle Scholar
  27. 27.
    Mahler HIM, 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 Promotion. 1997;11:426–9.CrossRefGoogle Scholar
  28. 28.
    Myers LB, Horswill MS. Social cognitive predictors of sun protection intention and behavior. Behav Med. 2006;32:57–63.PubMedCrossRefGoogle Scholar
  29. 29.
    Eid M. Sun exposure and skin cancer prevention. In: Smelser NJ, Baltes PB, editors. International encyclopedia of the social & behavioral sciences. Amsterdam: Elsevier; 2001. p. 15278–81.CrossRefGoogle Scholar
  30. 30.
    Paul C, Tzelepis F, Parffit N, Girgis A. How to improve adolescents’ sun protection behaviour? Age and gender issues. Am J Health Behav. 2008;32:387–98.PubMedGoogle Scholar
  31. 31.
    Jones F, Abraham C, Harris P, Schulz J, Chrispin C. Modeling the cognitive prerequisites of sunscreen use in Australian and UK samples. Psychol Health. 2001;16:191–206.CrossRefGoogle Scholar
  32. 32.
    Van Osch L, Reubsaet A, Lechner L, Candel M, Mercken L, De Vries H. Predicting parental sunscreen use: disentangling the role of action planning in the behavior–intention relationship. Psychol Health. 2007;23:1–19.Google Scholar
  33. 33.
    Carmel S, Shani E, Rosenberg L. The role of age and an expended health belief model in predicting skin cancer protective behaviour. Health Edu Research. 1994;9:433–47.CrossRefGoogle Scholar
  34. 34.
    Grunfeld EA. What influences university students intentions to practice safe sun exposure behaviors? J Adolesc Health. 2004;35:486–92.PubMedGoogle Scholar
  35. 35.
    Mcclendon BT, Prentice-Dunn S. Reducing skin cancer risk: an intervention based on protection motivation theory. J Health Psychol. 2001;6:321–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Kristjansoon S, Bränström R, Ullen H, Helgason AR. Transtheoretical model: the investigation of adolescents’ sunbathing behavior. Eur J Cancer Prev. 2003;12:501–8.CrossRefGoogle Scholar
  37. 37.
    Graham JW. Missing data analysis: making it work in the real world. Ann Rev Psychol. 2009;60:549–76.CrossRefGoogle Scholar
  38. 38.
    Pagoto S, McChargue D, Fuqua RW. Effects of a multicomponent intervention on motivation and sun protection behaviors among Midwestern beachgoers. Health Psychol. 2003;22:429–33.PubMedCrossRefGoogle Scholar
  39. 39.
    Prentice-Dunn S, McMath BF, Cramer RJ. Protection motivation theory and stages of change in sun protection behavior. J Health Psychol. 2009;14:297–305.PubMedCrossRefGoogle Scholar
  40. 40.
    Craciun C, Schüz N, Lippke S, Schwarzer R. Risk perception moderates how intentions are translated into sunscreen use. J Behav Med. 2010;33:392–8. doi: 10.1007/s10865-010-9269-5.PubMedCrossRefGoogle Scholar
  41. 41.
    Dwyer T, Blizzard L, Gies PH, Ashbolt R, Roy C. Assessment of habitual sun exposure in adolescents via questionnaire—a comparison with objective measurement using polysulphone badges. Melanoma Res. 1996;6:231–9.PubMedCrossRefGoogle Scholar
  42. 42.
    Shoveller JA, Lovato CY, Young RA, Moffat B. Exploring the development of sun-tanning behavior: a grounded theory study of adolescents’ decision-making experiences with becoming a sun tanner. Int J Behav Med. 2003;10:299–314.PubMedCrossRefGoogle Scholar
  43. 43.
    Cook C, Heath F, Thompson RL. A meta-analysis of response rates in web- or internet-based surveys. Edu Psychol Measurement. 2000;60:821–36.CrossRefGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2011

Authors and Affiliations

  • Catrinel Craciun
    • 1
    • 2
  • Natalie Schüz
    • 2
  • Sonia Lippke
    • 2
    • 3
  • Ralf Schwarzer
    • 2
  1. 1.Babes-Bolyai UniversityCluj NapocaRomania
  2. 2.Freie Universität BerlinBerlinGermany
  3. 3.Maastricht UniversityMaastrichtThe Netherlands

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