Abstract
Ultraviolet (UV) photos reveal the world in a different light spectrum, including damage that is caused by UV light. In the context of skin cancer control, UV photos have the potential to communicate fear because they reveal underlying skin damage. U.S. adults (N = 2219) were assigned to a 5 (visual: UV skin damage, sun exposure, sunburn, photoaging, and mole removal) × 3 (replication: three examples of each visual condition) × 4 (efficacy: no efficacy, text only, visual, visual + text) randomized controlled trial. Compared to all other visual conditions combined, UV skin damage visuals generated greater fear which triggered increased sun safe behavior expectations. Compared with other visual conditions separately, only mole removal visuals produced equivalent fear as UV skin damage visuals. Visual efficacy conditions appeared to nullify rather than magnify the indirect path through fear. The results suggest one way UV images impact sun safe behavioral expectations is via fear and that researchers should continue to examine the position of fear in fear appeal theories.
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Funding
This research was funded by a New Innovator grant (#DP2EB022360) from the National Institutes of Health (NIH) (PI: JDJ; Co-I: KKJ) and in part by the National Cancer Institute of the National Institutes of Health (K07CA196985 to YPW). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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Manusheela Pokharel, Katheryn R. Christy, Jakob D. Jensen, Elizabeth A. Giorgi, Kevin K. John, Yelena P. Wu have no conflicts of interest to declare.
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Appendices
Appendix 1: UV skin damage visuals
Appendix 2: Sun exposure visuals
Appendix 3: Sunburn visuals
Appendix 4: Photo ageing visuals
Appendix 5: Mole removal visuals
Appendix 6: Text efficacy condition stimuli
There are a number of things that you can do to reduce your risk of skin cancer, including:
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Wearing sunscreen.
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Staying out of the sun between 10 AM and 4 PM.
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Wearing protective clothing (e.g., long sleeves, long pants, a broad brimmed hat, sunglasses).
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Staying in the shade.
Next we’re going to ask you a bit about the image you just saw.
Appendix 7: Visual efficacy condition stimuli
Appendix 8: Estimated marginal means and 95% confidence intervals: visual conditions × efficacy conditions
Visual condition | Efficacy condition | Dependent variables | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Susceptibility | Severity | Self efficacy | Response efficacy | Fear | Behavior expectation | ||||||||
Mean (SE) | 95% CI | Mean (SE) | 95% CI | Mean (SE) | 95% CI | Mean (SE) | 95% CI | Mean (SE) | 95% CI | Mean (SE) | 95% CI | ||
Sun exposure | No efficacy | 4.24 (.15) | (3.95, 4.54) | 5.29 (.13) | (5.03, 5.55) | 4.92 (.13) | (4.67, 5.17) | 5.26 (.13) | (5.00, 5.52) | 2.24 (.16) | (1.92, 2.56) | 5.15 (.14) | (4.88, 5.42) |
Text | 4.58 (.15) | (4.28, 4.87) | 5.54 (.13) | (5.28, 5.79) | 5.35 (.13) | (5.10, 5.59) | 5.67 (.13) | (5.41, 5.92) | 2.26 (.16) | (1.94, 2.59) | 5.32 (.14) | (5.05, 5.59) | |
Visual | 4.72 (.15) | (4.42, 5.01) | 5.79 (.13) | (5.53, 6.04) | 5.48 (.13) | (5.24, 5.73) | 5.68 (.13) | (5.43, 5.94) | 2.47 (.16) | (2.15, 2.80) | 5.53 (.14) | (5.26, 5.80) | |
Visual + text | 4.32 (.15) | (4.03, 4.62) | 5.40 (.13) | (5.15, 5.66) | 5.07 (.13) | (4.82, 5.31) | 5.31 (.13) | (5.05, 5.57) | 2.58 (.16) | (2.26, 2.90) | 5.08 (.14) | (4.81, 5.35) | |
Sunburn | No efficacy | 4.67 (.15) | (4.37, 4.97) | 5.39 (.13) | (5.13, 5.64) | 4.80 (.13) | (4.55, 5.04) | 5.25 (.13) | (5.00, 5.51) | 2.44 (.16) | (2.12, 2.76) | 5.00 (.14) | (4.73, 5.27) |
Text | 4.70 (.15) | (4.40, 4.99) | 5.65 (.13) | (5.39, 5.91) | 5.00 (.13) | (4.75, 5.25) | 5.53 (.13) | (5.27, 5.79) | 2.67 (.16) | (2.34, 2.99) | 5.07 (.14) | (4.80, 5.34) | |
Visual | 4.63 (.15) | (4.33, 4.93) | 5.35 (.13) | (5.09, 5.60) | 5.08 (.13) | (4.83, 5.32) | 5.28 (.13) | (5.02, 5.54) | 2.73 (.16) | (2.40, 3.05) | 5.20 (.14) | (4.93, 5.47) | |
Visual + text | 4.75 (.15) | (4.46, 5.05) | 5.47 (.13) | (5.22, 5.73) | 5.01 (.13) | (4.76, 5.26) | 5.43 (.13) | (5.17, 5.69) | 2.59 (.16) | (2.27, 2.91) | 5.22 (.14) | (4.95, 5.49) | |
Aging | No efficacy | 4.44 (.15) | (4.14, 4.73) | 5.57 (.13) | (5.31, 5.83) | 5.21 (.13) | (4.96, 5.46) | 5.40 (.13) | (5.14, 5.66) | 2.38 (.16) | (2.06, 2.71) | 5.17 (.14) | (4.90, 5.44) |
Text | 4.74 (.15) | (4.45, 5.04) | 5.39 (.13) | (5.14, 5.65) | 5.06 (.13) | (4.81, 5.31) | 5.35 (.13) | (5.09, 5.61) | 2.87 (.16) | (2.55, 3.19) | 5.04 (.14) | (4.77, 5.30) | |
Visual | 4.72 (.15) | (4.43, 5.02) | 5.69 (.13) | (5.43, 5.94) | 5.48 (.13) | (5.23, 5.73) | 5.62 (.13) | (5.36, 5.88) | 2.85 (.16) | (2.53, 3.17) | 5.41 (.14) | (5.14, 5.67) | |
Visual + text | 4.57 (.15) | (4.27, 4.86) | 5.40 (.13) | (5.14, 5.65) | 5.17 (.13) | (4.92, 5.41) | 5.50 (.13) | (5.24, 5.76) | 2.93 (.16) | (2.60, 3.25) | 5.31 (.14) | (5.04, 5.58) | |
Mole removal | No efficacy | 4.93 (.15) | (4.63, 5.22) | 5.61 (.13) | (5.35, 5.86) | 5.28 (.13) | (5.03, 5.53) | 5.60 (.13) | (5.34, 5.86) | 3.28 (.16) | (2.96, 3.60) | 5.22 (.14) | (4.95, 5.49) |
Text | 4.48 (.15) | (4.18, 4.78) | 5.45 (.13) | (5.20, 5.71) | 5.15 (.13) | (4.90, 5.40) | 5.54 (.13) | (5.28, 5.80) | 3.05 (.16) | (2.73, 3.37) | 5.17 (.14) | (4.90, 5.44) | |
Visual | 4.56 (.15) | (4.26, 4.85) | 5.61 (.13) | (5.35, 5.87) | 5.19 (.13) | (4.94, 5.44) | 5.61 (.13) | (5.35, 5.87) | 2.91 (.16) | (2.59, 3.23) | 5.38 (.14) | (5.11, 5.65) | |
Visual + text | 4.59 (.15) | (4.29, 4.88) | 5.57 (.13) | (5.31, 5.82) | 5.29 (.13) | (5.04, 5.54) | 5.55 (.13) | (5.29, 5.81) | 2.88 (.16) | (2.55, 3.20) | 5.45 (.14) | (5.18, 5.72) | |
UV | No efficacy | 4.80 (.15) | (4.51, 5.10) | 5.69 (.13) | (5.43, 5.94) | 5.07 (.13) | (4.82, 5.32) | 5.53 (.13) | (5.27, 5.79) | 3.33 (.16) | (3.00, 3.65) | 5.15 (.14) | (4.88, 5.41) |
Text | 4.50 (.15) | (4.20, 4.79) | 5.52 (.13) | (5.27, 5.78) | 5.06 (.13) | (4.81, 5.31) | 5.39 (.13) | (5.13, 5.65) | 3.16 (.16) | (2.84, 3.48) | 5.27 (.14) | (5.00, 5.54) | |
Visual | 4.56 (.15) | (4.27, 4.86) | 5.61 (.13) | (5.36, 5.87) | 5.29 (.13) | (5.04, 5.54) | 5.57 (.13) | (5.31, 5.82) | 2.86 (.16) | (2.53, 3.18) | 5.25 (.14) | (4.98, 5.52) | |
Visual + text | 4.63 (.15) | (4.33, 4.93) | 5.61 (.13) | (5.12, 5.64) | 5.05 (.13) | (4.80, 5.30) | 5.39 (.13) | (5.13, 5.64) | 2.94 (.16) | (2.62, 3.26) | 5.20 (.14) | (4.93, 5.47) | |
Appendix 9: Estimated marginal means and 95% confidence intervals for fear: UVvsAll × efficacy conditions
Visual condition | Efficacy condition | Mean (SE) | 95% CI |
|---|---|---|---|
Non-UV conditions | Control | 2.59 (.08) | (2.42, 2.75) |
Text | 2.71 (.08) | (2.55, 2.87) | |
Visual | 2.74 (.08) | (2.58, 2.90) | |
Visual + text | 2.74 (.08) | (2.58, 2.90) | |
UV condition | Control | 3.33 (.16)a | (3.00, 3.65) |
Text | 3.16 (.16)ab | (2.84, 3.49) | |
Visual | 2.86 (.16)b | (2.53, 3.18) | |
Visual + text | 2.94 (.16)b | (2.62, 3.26) |
Appendix 10: Simple mediation—tests of indirect effects of EPPM variables (MolevsAll)
N = 2220 | Models without mediator | Models with mediator | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Â | B | B | Bootstrap results for indirect effects (95% CI) | Bootstrap results for indirect effect sizes (95% CI) | ||||||||
R 2 | c | R 2 | c′ | a | b | ab | Lower | Upper | k 2 | Lower | Upper | |
Susceptibility | .00 | .10 | .12*** | .08 | .04 | .31*** | .01 | − .0400 | .0654 | .00 | .0000 | .0116 |
Severity | .00 | .10 | .33*** | .07 | .05 | .60*** | .03 | − .0570 | .1144 | .01 | .0003 | .0381 |
Self-efficacy | .00 | .10 | .52*** | .02 | .10 | .78*** | .08 | − .0273 | .1876 | .03 | .0018 | .0711 |
Response Efficacy | .00 | .10 | .38*** | .02 | .13†| .64*** | .08 | − .0144 | .1683 | .03 | .0025 | .0567 |
Fear | .00 | .10 | .05*** | .04 | .32*** | .18*** | .06* | .0233 | .0963 | .02 | .0068 | .0273 |
Appendix 11: Simple mediation models of the EPPM
Only fear significantly mediated the relation between X (MolevsAll) and Y (Behavior Expectation): effect = .06, Boot SE = .02, 95% Boot CI: .0233, .0963, Effect size (k2) = .02
†p < .10; ***p  <  .001.
Appendix 12: PROCESS model 4 simple mediation analysis output with visual conditions as predictor, fear as mediator, and behavior expectations as outcome
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Pokharel, M., Christy, K.R., Jensen, J.D. et al. Do ultraviolet photos increase sun safe behavior expectations via fear? A randomized controlled trial in a sample of U.S. adults. J Behav Med 42, 401–422 (2019). https://doi.org/10.1007/s10865-018-9997-5
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DOI: https://doi.org/10.1007/s10865-018-9997-5