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Do ultraviolet photos increase sun safe behavior expectations via fear? A randomized controlled trial in a sample of U.S. adults

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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Correspondence to Manusheela Pokharel.

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Conflict of interest

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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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Informed consent was obtained from all individual participants included in the study.

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Appendices

Appendix 1: UV skin damage visuals

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Appendix 2: Sun exposure visuals

figure d
figure e
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Appendix 3: Sunburn visuals

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figure h
figure i

Appendix 4: Photo ageing visuals

figure j
figure k
figure l

Appendix 5: Mole removal visuals

figure m
figure n
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Appendix 6: Text efficacy condition stimuli

There are a number of things that you can do to reduce your risk of skin cancer, including:

  • Wearing sunscreen.

  • Staying out of the sun between 10 AM and 4 PM.

  • Wearing protective clothing (e.g., long sleeves, long pants, a broad brimmed hat, sunglasses).

  • 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

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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)

  1. Means and standard errors (in parentheses)

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)

  1. Means and standard errors (in parentheses)
  2. Means with different superscripts are significantly different, p < .10. In Non-UV conditions, the means are not significantly different. In UV conditions, fear in the control efficacy condition is significantly greater than in the visual efficacy condition, p = .04 and approaching significance in the Visual +Text efficacy condition, p = .098

Appendix 10: Simple mediation—tests of indirect effects of EPPM variables (MolevsAll)

N = 2220

Models without mediator

Models with mediator

 

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

  1. Process Model 4 with 1000 bootstraps where each mediator was tested one at a time. Fear is the only significant mediator as the boot confidence interval does not overlap zero. The predictor is the MolevsAll contrast, outcome is behavior expectation
  2. B unstandardized regression weights, c total effect of predictor on outcome without the mediator in the model, c′ direct effect of predictor on outcome while controlling for the mediator, a the path between the predictor and the mediator, b the path between the mediator and the outcome, ab indirect effect of predictor on outcome thorough the mediator, R2 amount of variance explained by the model, CI confidence intervals, k2 effect size
  3. p < .10; * p <  .05; ***p < .001

Appendix 11: Simple mediation models of the EPPM

figure q

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

figure rfigure rfigure r

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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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