Health Psychology 2007, Vol. 26, No.

3, 350 360

Copyright 2007 by the American Psychological Association 0278-6133/07/$12.00 DOI: 10.1037/0278-6133.26.3.350

Long-Term Effects of Appearance-Based Interventions on Sun Protection Behaviors

Heike I. M. Mahler
University of California, San Diego, and California State University, San Marcos Iowa State University
Objectives: To examine the longer term efficacies of exposure to UV photographs and photoaging information (e.g., wrinkles and age spots) for increasing sun protection intentions and behaviors of young adults. Design: Randomized controlled trial with 4- to 5-month and 12-month follow-ups. Main Outcome Measures: Participants self-reported sun protection intentions assessed immediately after the interventions, and both self-reported sun protection behaviors and an objective assessment (via spectrophotometry) of skin color change measured at the end of summer (4 5 months following interventions) and 1 year following interventions. Results: Both interventions resulted in immediate positive effects on future sun protection intentions. Both interventions showed objective evidence of less skin darkening at the postsummer follow-up, with those in the photoaging information condition also reporting more sun protective behavior and continuing to show less skin darkening 1 year after intervention. There was also evidence that effects of photoaging information on subsequent skin color change were mediated by the earlier positive effect photoaging information had on participants intentions to sun protect and their subsequent sun protection behaviors. Conclusions: UV photo and photoaging-information interventions each show promise as a brief and relatively inexpensive approach for motivating sun protection practices that may reduce skin cancer risk. Keywords: skin cancer, sun protection, photoaging, UV photos, spectrophotometry

James A. Kulik
University of California, San Diego

Meg Gerrard and Frederick X. Gibbons

Skin cancer is the most common type of cancer, with approximately 1.3 million new cases diagnosed annually in the United States (American Cancer Society, 2004). The incidence of the deadliest form of skin cancer (melanoma) is increasing more rapidly than that of any other type of cancer (Rigel, Friedman, & Kopf, 1996; Weinstock, 1998), and sun exposure is implicated in over 80% of all skin cancers (Parker, Tong, Bolden, & Wingo, 1997). Thus, interventions that decrease sun exposure or increase sun protection behaviors have the potential for significant impact on skin cancer incidence.

Heike I. M. Mahler, Department of Psychology, University of California, San Diego, and California State University, San Marcos (CSUSM); James A. Kulik, Department of Psychology, University of California, San Diego; Meg Gerrard and Frederick X. Gibbons, Department of Psychology, Iowa State University. This research was supported by grants from the Cancer Research and Prevention Foundation, the National Cancer Institute, and CSUSM Research, Scholarship, and Creative Activity grants to Heike I. M. Mahler. We thank Jody Harrell, Kathy Herbst-Damm, Alma Correa, Emily Gray, Karen Lee, Crystal Winters, Angela Gorezman, and Jaimi Martsoff for their help in carrying out this project. We also thank Richard E. Fitzpatrick and Betsy Fizpatrick for their advice and assistance with this project. Finally, we thank John Homann of Neutrogena Corp. and Donna Gabriel of the Boston Dermatology and Laser Center who provided the sunscreen samples. Correspondence concerning this article should be addressed to Heike I. M. Mahler, Department of Psychology 0109, University of California, San Diego, La Jolla, CA 92093. E-mail: hmahler@ucsd.edu 350

Although knowledge regarding the skin cancersun exposure link and risk reduction behaviors has increased in the past 1520 years (Baum & Cohen, 1998; Robinson, Rigel, & Amonette, 1997), many Americans continue to receive large amounts of intentional and incidental sun exposure without adequate protection (Hoegh, Davis, & Manthe, 1999; Robinson et al., 1997). Because most intentional ultraviolet (UV) exposure is directed at getting a tan to improve appearance (Hillhouse, Stair, & Adler, 1996; Hoegh et al., 1999; Jones & Leary, 1994; Miller, Ashton, McHoskey, & Gimbel, 1990; Robinson et al., 1997; Turrisi, Hillhouse, & Gebert, 1998), interventions that focus exclusively on the health risks of sun exposure may not be maximally effective. Several recent studies have demonstrated the promise of appearance-based interventions, which instead highlight the link between sun exposure and appearance detractors such as wrinkles, age spots, and uneven pigmentation, for motivating UV protection behaviors (Gibbons, Gerrard, Lane, Mahler, & Kulik, 2005; Jones & Leary, 1994; Mahler, Fitzpatrick, Parker, & Lapin, 1997; Mahler, Kulik, Gibbons, Gerrard, & Harrell, 2003; Mahler et al., 2005). Compared with a health-based message, emphasizing negative appearance consequences may better counteract the primary (appearance-based) motivation for sun exposure, namely, getting a tan. Individuals also may feel more vulnerable to developing wrinkles and age spots than to cancer, because the former are more common and easily noticed. UV photography has been used in several recent appearance-based interventions to highlight the negative appearance consequences of UV exposure (Gibbons et al., 2005; Mahler et al., 2003; Pagoto,

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McChargue, & Fuqua, 2003). Chronic UV exposure can produce uneven epidermal pigmentation that, when photographed through a UV filter, appears as brown blotches. Viewing a photo of ones face with such blotches can be quite dramatic and may make the negative appearance consequences of sun exposure more salient, immediate, and certain. In two studies, Gibbons et al. (2005) found that college students who had versus had not viewed their UV photos reported less tanning booth use 3 4 weeks later. In a study of beachgoers, Mahler et al. (2003, Study II) also found that sun protection intentions were greater if participants did versus did not view their UV photo, and separately, if participants received versus did not receive photoaging information about wrinkles and age spots caused by UV exposure; both interventions either separately or in combination also increased self-reported sun protection behaviors during the subsequent 12 months. These recent findings, although clearly promising, are limited to immediate intentions and self-reported behaviors over brief periods of time (e.g., 12 months). The primary purpose of the present study therefore was to determine if appearance-based interventions also affect more objective assessments of sun exposure over substantially longer periods of time.1

of susceptibility to photoaging, sunbathing/tanning rewards, sun protection costs, and sun protection intentions.

Method Participants
Undergraduate students from the University of California, San Diego (107 women, 26 men) received course credit for their participation. Ages ranged from 18 to 44 years (M 20.13, SD 3.38), and 45% described themselves as Caucasian, 35.3% as Asian, 11.3% as Hispanic, 1.5% as both Asian and Caucasian, 0.8% as both Hispanic and Caucasian, 0.8% as both Asian and Hispanic, and 5.3% as other. At baseline, participants reported sunscreen use on their face 74.2% and 45.1% of the time while sunbathing and during incidental exposure (time in the sun engaged in activities other than sunbathing), respectively. In contrast, they used sunscreen on their body 58.3% and 21.5% of the time while sunbathing and during incidental exposure, respectively. Twenty-three percent reported spending at least 30 min sunbathing, and 93.9% reported at least 3 hr of incidental sun exposure during the prior week. None had a personal history but 27.1% had a positive family history of skin cancer.

Overview of Current Experiment

Participants were college students randomly assigned to one of four conditions: control, UV photo, photoaging information, or UV photo plus photoaging information. The first follow-up occurred after a period of very high risk for sun exposure, namely, immediately following the summer break (4 5 months after the intervention). A second, final follow-up occurred 1 year after the intervention. Objective assessment of skin color changes (i.e., tanning) was accomplished via skin reflectance spectrophotometry. Of primary interest was whether the two appearance-based interventions (photoaging information and UV photo) would separately increase sun protection intentions and behaviors, and if so, how long any such effects on behavior would last. We also sought secondarily to examine possible mediators of the anticipated intervention effects. Health behavior models such as the health belief model (HBM; Becker, 1974), protection motivation theory (PMT; Rogers, 1983), and the theory of planned behavior (TPB; Ajzen & Madden, 1986) posit various cognitions that theoretically mediate the relationship between a prevention message and a health behavior. For example, the HBM suggests that engaging in a particular preventive behavior is determined by perceived susceptibility to the health threat and by perceived costs versus benefits of the recommended behavior (Becker, 1974). The PMT likewise posits a role for perceived susceptibility (Rogers, 1983), whereas the TPB emphasizes behavioral intentions as a proximal determinant of behavior (Ajzen & Madden, 1986). Either of our interventions might be expected to raise participants perceived susceptibility to photoagingthe UV photo directly by showing that underlying damage already exists, and the photoaging information more indirectly by linking the majority of wrinkles and age spots to chronic sun exposure. Seeing the underlying brown blotches on ones face and learning that most wrinkles and age spots are caused by sun exposure also could decrease the perceived rewards of tanning and costs of sun protection. Thus, we expected that the effects of either intervention on participants subsequent sun-related behavior might be mediated by perceptions

Intervention Materials
Photoaging information. Photoaging information was presented via an 11-min videotaped slide show that had been developed and evaluated previously (Mahler et al., 1997). The video depicted photoaging (including graphic photos of extreme cases of wrinkles and age spots), described how sun exposure and UV radiation from any source leads to photoaging, and discussed effective practices for minimizing photoaging (e.g., wearing protective clothing and applying a sunscreen with a sun protection factor [SPF] of at least 15 to protect against both UVB and UVA rays). The video also provided general information about sunscreen, such as the meaning of the SPF number, when to use sunscreen, and how much to apply. UV photographs. UV facial photographs were taken with an instant Polaroid camera modified to include a 315- to 390-mm UV filter. Because filtered UV light is selectively absorbed by the melanin in the skin, a photograph taken with a UV filter dramatically highlights the nonuniform epidermal pigmentation that results from chronic sun exposure (Fulton, 1997). Each person who had a UV photo taken also had a natural-light, instant photograph taken for comparison. In all cases, participants were first shown the natural-light, black-and-white photograph and were told that it depicted what can be seen with the naked eye. Then the UV
1 Although no previous appearance-based interventions have assessed longer term outcomes, we were able to locate one health-based intervention that included a 1-year follow-up (Robinson, 1990) and a multicomponent intervention that included both a 1- and a 2-year follow-up (Weinstock, Rossi, Redding, & Maddock, 2002). Both of these studies demonstrated improved long-term sun protection efforts in the intervention group compared with controls. However, both studies relied exclusively on selfreported outcomes and also included boosters for the intervention group (i.e., provision of additional information during the follow-up period), making interpretations of the long-term effects of the interventions somewhat problematic.

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photograph was placed adjacent to the natural-light photo. Participants were told that any dark, freckled, or pitted areas in the UV photo that did not appear in the natural-light photo indicate existing underlying skin damage that would continue to get worse if they continued their current sun exposure levels without additional sun protection.

were assessed.2 Most of those who did not participate in this follow-up were not reachable because of incorrect telephone numbers and e-mail addresses (78%). The remainder were studying abroad or no longer living in the area.

Measures
Cognitions. Immediately following administration of the intervention conditions, several scales were used to assess potential cognitive mediators of interest (see Mahler et al., 1997, 2003). On separate 5-point scales (1 strongly disagree, 5 strongly agree), perceived rewards of sunbathing/tanning were indexed by averaging 10 items ( .90; e.g., I have more self-confidence when I have a tan), costs of using sun protection by averaging 12 items ( .72, e.g., Using sunscreen regularly is just too much trouble), perceived susceptibility to photoaging by averaging 9 items ( .70; e.g., I dont spend enough time in the sun to be concerned about getting wrinkles and age spots; reverse scored), and sun protection intentions by averaging 18 items ( .91; e.g., I plan to always use sunscreen on my face when I sunbathe and I plan to avoid being outdoors between the hours of 10 a.m. and 2 p.m. whenever possible). Skin color. Skin color was assessed at baseline and at both follow-ups using skin reflectance spectrophotometry, which enables objective, reliable, in vivo quantification of human skin color (Bjerring & Andersen, 1987). The Minolta CM-2600d spectrophotometer used is a handheld instrument that measures the color of objects on three dimensions, two of which, L* and b*, are sensitive to tanning (Levine et al., 1991; Seitz & Whitmore, 1988).3 L* indexes lightness from black to white, with higher values indicating lighter coloring (i.e., less tan), whereas b* indexes saturation in terms of blue to yellow, with higher values indicating more yellow (i.e., more tan). At each assessment period, three consecutive readings of L* and of b* were taken from one higher exposure site (4 in. [10.16 cm] above the wrist on outer side of the forearm) and from one lower exposure site (4 in. above the wrist on underside [palm side] of the same forearm). The three readings from each site were averaged for analysis. Sun exposure and protection behaviors. Previous work has indicated that intentional (e.g., sunbathing) and incidental sun exposure involve distinguishable behaviors (e.g., Mahler et al., 2003), as do sun exposure and sun protection behaviors (e.g., Jackson & Aiken, 2001). Prior to the interventions, we therefore assessed baseline intentional and incidental UV exposure in addition to sun protection behaviors. Specifically, we asked participants to indicate their number of hours of sunbathing during the previous week and weekend. These items, as in other work (e.g., Mahler et al., 2003), were only modestly
2

Procedure
Initial session. The initial session was conducted during the spring term (AprilMay; average temperatures 62 F [16.7 C] and 64.1 F [17.8 C], respectively). Participants signed up for a study titled Health Attitudes through the Psychology Department human participant pool. The sign-up sheet specified only that participants had to be at least 18 years old and should not be graduating seniors (to ensure they would be more readily available for the follow-ups). Participants were tested individually or in pairs (separated by a partition), and each session was assigned randomly to a 2 (photoaging video vs. no video) 2 (UV photo vs. no UV photo) factorial design (resulting in 30 participants in the photo video, 35 in the photo-only, and 34 each in the video-only and control conditions). On arrival, participants completed a consent form that described the study as an attempt to learn more about college students sun exposure and sun protection behaviors. Participants were further informed that they might be contacted for a follow-up study in the fall and were asked to provide their current telephone number and e-mail address as well as a permanent contact (e.g., parents) telephone number. All of the participants then completed a questionnaire that assessed demographic information and baseline UV exposure and protection behaviors. Depending on condition, participants then either did or did not view the photoaging videotape and, separately, either did or did not have their UV photo taken and shown to them. All of the participants then completed a questionnaire that assessed their future intentions to use sun protection and several additional potential cognitive mediators, after which their baseline skin color was measured using skin reflectance spectrophotometry (described below). Thereafter participants were partially debriefed and received a sunscreen sample as a thank-you gift. Postsummer follow-up. At the beginning of the following fall term (late September; average temperature 71.4 F [21.9 C]), participants were contacted by telephone or e-mail, reminded of their participation during the previous spring term, and offered course credit or $10 to return to the lab. Eighty-five percent of the original sample participated in this follow-up, which occurred an average of 20.30 (SD 2.56) weeks following the intervention and 2.79 (SD 2.13) days after being contacted. Of the 15% who did not participate, half were studying abroad or no longer living in the area, 40% were not reachable, and 10% refused. Current skin color was assessed via spectrophotometry, and both sun exposure and sun protection behaviors during the summer months were assessed by questionnaire. 1-year follow-up. The 1-year follow-up occurred on average 54.12 (SD 2.69) weeks after the intervention and 4.83 (SD 3.42) days after being reached to schedule the follow-up. Participants were unaware that there would be a 1-year follow-up. Eighty percent of our original sample participated in this surprise follow-up, during which current skin color and self-reported sun exposure and sun protection behaviors (for the previous month)

Ten percent of the sample for the surprise 1-year follow-up had to be interviewed by telephone, because they no longer lived in the area. For these people, self-reported sun protection reports were obtained but not spectrophotometry readings. 3 Like others (e.g., Buller, Buller, Beach, & Ertl, 1996; Mayer et al., 1997), we did not use a third (a* scale) measure, because it indicates skin erythema or redness (i.e., sunburn). Skin darkening is considered a better measure of cumulative UV exposure from baseline to follow-up, because cumulative exposure is more likely to produce changes in tanning. Also, skin reddening (sunburn) typically subsides within 48 72 hr following UV exposure (Muizzuddin, Marenus, Maes, & Smith, 1990).

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interrelated, but for simplicity they were separately z scored and averaged to index baseline intentional exposure ( .50).4 We also assessed participants number of hours of sun exposure while doing other (nonsunbathing) activities during the previous workweek and weekend. These items too were separately z scored and averaged to index baseline incidental exposure ( .84). Finally, to assess baseline sun protection behaviors, we asked participants to indicate their frequencies of sunscreen use on face and body during both intentional and incidental exposure (on scales ranging from 0% to 100%) and also the SPF levels of sunscreen they used on face and body during both intentional and incidental exposure, respectively. A baseline sun protection index was then created by z scoring and averaging these 8 items ( .72), with higher values indicating greater protection. Postsummer follow-up sun exposure and protection questions were asked in reference to the past summer (June 15September 15), whereas the 1-year follow-up questions were asked in reference to the preceding month (April 15May 15). To index intentional exposure, participants estimated the number of hours they spent sunbathing during the relevant period. For comparability, these values were separately z scored within the follow-up period for analyses. Participants also indicated the number of hours they had spent in the sun doing other (nonsunbathing) activities on a typical weekday and weekend day. These items were separately z scored and averaged within the follow-up period to index incidental exposure ( .70 and .75 for the postsummer and 1-year follow-ups, respectively). Finally, participants indicated the frequencies of sunscreen use on their face and body during intentional and, separately, during incidental sun exposure (ranging from 0% to 100%), in addition to the SPF levels of sunscreen used on their face and body during both intentional and incidental sun exposure. Separate postsummer and 1-year sun protection indices were created subsequently by z scoring and averaging these items ( .85 and .88, respectively), with higher values indicating greater protection. Manipulation checks. Finally, participants completed three manipulation-check items at both follow-ups. Specifically, participants rated their agreement with the statement I currently have significant underlying sun damage to my face (1 strongly disagree, 5 strongly agree), and they provided open-ended responses to questions asking What percentage of wrinkles and age spots are caused by the sun (or other UV exposure) rather than the natural aging process? and How much sunscreen should be used to cover the entire body? We expected that those who had versus had not seen their UV photo would more strongly agree that they had significant sun damage. Separately, we also expected that viewers compared with nonviewers of the photoaging video would be more accurate in their estimates of the percentage of wrinkles and age spots caused by sun exposure and of how much sunscreen should be used (because both pieces of information were twice mentioned in the video but are not common knowledge).5

icant differences or trends in age, gender, ethnicity, or education level. There also were no differences in terms of intentional or incidental sun exposure at baseline, skin type (Fitzpatrick, 1988), personal history of skin cancer, or the frequencies of sunscreen use on either the face or body during incidental or intentional sun exposure. We did find that those assigned to the UV photo condition compared with those assigned to the no-photo condition reported having fewer family members with a history of skin cancer (Ms 0.34 vs. 0.85, p .02). To statistically control for its potentially confounding influence, we included family history of skin cancer as a covariate in the analyses of any outcome with which it was at least marginally related ( p .10). Manipulation checks. The manipulation checks collected at both follow-ups indicate that the interventions provided differential information as intended. Separate Photoaging Video UV Photo ANOVAs indicated that participants who did versus did not view their UV photo believed they had significantly more underlying skin damage from the sun: M 3.27, SD 0.91 versus M 2.77, SD 1.03, F(1, 106) 7.06, p .01, for postsummer; M 3.40, SD 0.75 versus M 2.69, SD 1.07, F(1, 87) 12.94, p .001, for 1-year follow-ups. As expected, there were no separate or interactive effects with the photoaging video condition for this item at either time. In addition, viewers of the photoaging video compared with nonviewers provided higher (i.e., closer to correct) estimates of the percentage of wrinkles caused by sun exposure: M 74.48, SD 19.95 versus M 61.69, SD 21.58, p .002, for postsummer follow-up; M 71.26, SD 17.53 versus M 57.36, SD 21.24, p .001, for 1-year follow-up. As expected, there were no significant effects involving the UV photo on this item. Finally, participants who had viewed the photoaging video also were significantly more likely than their nonviewer counterparts to indicate accurately (0 incorrect, 1 correct) the amount of sunscreen necessary to cover the body: M 0.25, SD 0.44 versus M 0.09, SD 0.28, p .03, for postsummer follow-up; M 0.32, SD 0.47 versus M 0.14, SD 0.35, p .05, for 1-year follow-up. Again, as expected, there were no UV photo main effects or interactions for this item at either time.

Primary Analyses
None of the primary analyses indicated any significant interactions between the two interventions. For simplicity, therefore, all tables and figures are presented in terms of the respective intervention main effects. To assist in interpretation of the significance of primary findings of interest, we also list effect sizes using Cohens d statistic (small 0.20, medium 0.50, large 0.80; Cohen, 1988). In addition, in all instances in which analysis of covariance (ANCOVA) is used, preliminary analyses indicated that all assumptions were met.
4

Results Preliminary Analyses

Group equivalence. To determine the initial equivalence of the groups, we performed separate 2 (photoaging video) 2 (UV photo) analyses of variance (ANOVAs) on the demographic and baseline sun protection variables. The results indicated no signif-

Analyses that use the intentional exposure items individually yield the exact same conclusions as those involving the composite index. 5 Responses regarding the amount of sunscreen needed to cover the body were coded as either incorrect (0) or correct (1). Because the goal was to determine whether participants had paid attention to the information provided in the photoaging video, we adopted a very strict accuracy criterion. Specifically, for an answer to be coded as correct, participants had to indicate one of the following: (a) 1.2 ounces, (b) one shot-glass full, or (c) a palm full.

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Table 1 Means (and Standard Deviations) of Cognitions as a Function of Phototaging Video and UV Photo Conditions
Measure Intentions to sun protecta,b Susceptibility to photoaginga Rewards of tanningc Costs of sun protection Photoaging video (n 64) 3.30 (0.69) 3.70 (0.53) 2.35 (0.92) 2.87 (0.60) No video (n 69) 2.79 (0.75) 3.54 (0.55) 2.55 (0.72) 2.98 (0.51) UV photo (n 65) 3.18 (0.76) 3.72 (0.47) 2.46 (0.82) 2.90 (0.52) No photo (n 68) 2.91 (0.69) 3.52 (0.61) 2.44 (0.81) 2.95 (0.59)

a UV photo main effect: p .05. b Photoaging video main effect: p .001. cControlling for a significant effect of skin cancer in family history ( p .03).

Immediate cognition outcomes. The proposed cognitive mediators that were assessed immediately after the interventions (perceived susceptibility to photoaging, perceived rewards of sunbathing, perceived costs of sun protection, and sun protection intentions) were analyzed using a Photoaging Video UV Photo multivariate analysis of variance (MANOVA). The MANOVA results indicated that the overall effect of the photoaging video was significant, F(4, 126) 4.25, p .003, whereas the overall UV photo condition effect was not ( p .13). Subsequent univariate analyses indicated that those who viewed compared with those who did not view the photoaging video had significantly greater intentions to engage in sun protective behavior, F(1, 129) 15.65, p .001, d 0.70, and felt marginally more susceptible to photoaging, F(1, 129) 2.98, p .09, d 0.30, but did not differ with respect to perceived rewards of tanning or costs of sunscreen use. These univariate analyses separately indicated that those who viewed their UV photo compared with those who did not also had significantly greater intentions to engage in sun protective behavior, F(1, 129) 4.59, p .03, d 0.38, and felt more susceptible to photoaging, F(1, 129) 4.64, p .03, d 0.38, but did not differ in perceived rewards of tanning or costs of sun protection (see Table 1 for means). Longer term outcomes. To enable direct comparisons of changes over time in longer term outcomes, we focus here on the participants (n 84) who completed both follow-ups. Analyses of participants who did versus did not complete both follow-ups revealed no significant differences in age, education, gender, ethnicity, skin type, personal skin cancer history, family history of skin cancer, perceived susceptibility to photoaging, perceived costs of sun protection, sun protection intentions, baseline hours of intentional and incidental sun exposure, frequencies of sun protection behaviors during intentional and incidental sun exposure, or spectrometer readings. The only significant difference found was for those lost to follow-up to perceive the rewards of tanning as somewhat greater than did those who completed both followups, Ms 2.64 versus 2.33, F(1, 129) 4.64, p .04, d 0.38. Intercorrelations among the primary outcome measures are presented in Table 2.6 Skin color changes. Separate 2 (photoaging video) 2 (UV photo) 2 (follow-up time, postsummer vs. 1 year) ANCOVAs, with repeated measures on the last factor and controlling for the relevant baseline skin color assessment, were performed on the change (follow-up minus baseline) in L* and b* readings at the higher and lower exposure sites, respectively.7 As would be expected, each of these analyses revealed strong effects of time

period, such that controlling for baseline skin assessments, participants skin colors were significantly darker (L* readings) and more yellow saturated (b* readings) immediately after the summer months than they were 1 year after the springtime interventions (all Fs 61.47, ps .0001, ds 1.852.10). No separate effects of the interventions on b* readings were significant ( ps .12; see Table 3 for means), whereas analyses of the change in L* readings at the higher exposure site indicated that the skin of those who viewed the photoaging video was significantly lighter than the skin of those who had not viewed the photoaging video, F(1, 79) 7.34, p .01, d 0.61; this effect was consistent across both follow-up periods, as evidenced by the lack of any interaction with time period (F 1) and by subsequent analyses that revealed significant differences both at the postsummer and 1-year followups ( ps .02, ds 0.56 and 0.57, respectively; see Figure 1). Separately, the higher exposure skin sites of those who viewed their UV photos also tended to be lighter than those of their non-UV photo counterparts, F(1, 79) 3.58, p .06, d 0.43, but this effect was qualified by a significant UV Photo Time effect, F(1, 80) 4.54, p .04, d 0.48. Subsequent analyses indicated the UV photo participants were lighter at both follow-ups but that the difference was significant at the postsummer follow-up ( p .01, d .60) but not at the 1-year follow-up ( p .39, d 0.19; see Figure 1). Analyses of change in L* readings at the lower exposure site of the arm revealed very similar effects of the photoaging video, in that those who had viewed the video had significantly lighter skin than those who had not, F(1, 79) 5.24, p .03, d 0.52. Again, this difference was consistent and significant at both follow-up periods ( ps .04, ds .49 and .47, respectively; see Figure 2). Separately, those who viewed their UV photo were also lighter at this skin site, but the difference was not significant ( p .15, d 0.33; see Figure 2). No other effects involving L* readings approached significance. When the 7.6% of participants who purchased sunless tanning lotion during the follow-up period were
6 Correlations of these outcomes that include everyone who participated in either the postsummer follow-up (n 110) or the 1-year follow-up (n 91), but not necessarily both, yielded results that are virtually identical to those reported; therefore, they are not presented to avoid redundancy. 7 ANCOVAs performed on change scores yield statistical tests that are identical to ANCOVAS performed on the raw outcome values but have the desirable advantage here of also conveying the direction (lighter or darker) of skin color changes from baseline.

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Table 2 Correlations Between Primary Outcome Measures (n 84)

Variable 1. 2. 3. 4. 5. 6. 7. 8. Sun protection intentions L* higher exposure L* lower exposure b* higher exposure b* lower exposure Sunbathing hours Incidental exposure hours Sun protection index 1 .31** .21* .23* .19 .23* .03 .35*** 2 .36 .81*** .55*** .64*** .25* .06 .11
***

3 .31 .85*** .46*** .82*** .22* .03 .03

**

4 .28 .33** .43*** .75*** .29** .21 .08

**

5 .24 .58*** .80*** .73*** .19 .12 .05

*

6 .29 .08 .07 .29** .15 .34** .06

**

7 .19 .07 .18 .18 .12 .13 .08

8 .37*** .42*** .32** .07 .16 .04 .22*

Note. Sun protection intentions were assessed immediately after the interventions. With that exception, correlations above the diagonal depict postsummer follow-up relationships, whereas those below the diagonal depict 1-year follow-up relationships. Higher values of L* indicate lighter skin color; higher values of b* indicate greater yellow saturation. Sites were higher (outer side of the forearm) and lower exposure (underside of the same forearm) areas. * p .05. ** p .01. *** p .001.

removed from the analyses of skin color change reported above, the pattern of findings remained the same and all significant effects remained significant. Sun exposure and protection behavior. Because the follow-up indices of reported sun exposure and protection behaviors were not identical to their respective baseline indices, direct change scores could not be computed. Therefore intentional exposure, incidental exposure, and sun protection behavior reports were analyzed with separate 2 (photoaging video) 2 (UV photo) 2 (follow-up time, postsummer vs. 1 year) ANCOVAs, with repeated measures on the last factor and controlling for the relevant baseline index. The analyses of intentional exposure indicated that people who reported higher intentional exposure levels at baseline also reported higher levels across the follow-up assessments, F(1, 78) 14.34, p .001, d 0.86. Separately, those who did versus those who did not view their UV photo reported somewhat more intentional exposure (z-score Ms 0.13 vs. 0.17), but this difference was not significant, F(1, 78) 2.95, p .09, d 0.39. No other effects involving intentional exposure approached significance (see Table 3). More interesting, the analyses of incidental exposure indicated that controlling again for a significant positive relationship with relevant baseline exposure, F(1, 78) 5.46, p .025, d 0.53, participants who had viewed the photoaging video reported significantly lower incidental sun exposure levels than did those who had not viewed the video, F(1, 78) 6.62, p .02, d 0.58 (z-score Ms 0.20 vs. 0.25). This effect held across follow-up periods (see Table 4 for means), as indicated by the absence of any interaction involving time period (Fs 1.21). Separately, there was a significant UV Photo Time effect, F(1, 79) 4.96, p .03, d 0.50, which indicated that those who viewed their UV photo reported less incidental exposure at the postsummer follow-up but more incidental exposure at the 1-year follow-up than their non-UV photo counterparts (see Table 3). Analyses within follow-up periods indicated that these differences were not individually significant, however, either at postsummer ( p .15, d 0.33) or at 1 year ( p .29, d 0.24). Finally, analyses of the sun protection behavior index indicated that, controlling for a highly significant positive relationship with baseline sun protective behavior, F(1, 78) 66.06, p .001, d 1.84, there was a marginal Video Time effect, F(1, 79) 3.12, p .08, d 0.40. Analyses of the individual follow-ups indicated

that those who had versus those who had not viewed the photoaging video reported significantly more sun protective behavior at the initial postsummer assessment, F(1, 78) 4.15, p .045, d 0.46, but there were no differences at the 1-year follow-up (F 1, d 0.00; see Table 3). No effects involving the UV photo condition were significant for this measure.

Mediation Analyses
Finally, we conducted a series of analyses to identify possible mediators of the obtained intervention effects on L* readings, the outcome of primary interest to us. Following Baron and Kenny (1986), evidence that a variable serves as a mediator is obtained when, in separate regression analyses, (a) the independent variable significantly affects the dependent variable; (b) the independent variable significantly affects the hypothesized mediator; and (c) the mediator has a significant unique effect on the dependent variable and reduces the previously significant effect of the independent variable on the dependent variable. With respect to possible mediators, we did not find that either intervention significantly affected the perceived rewards of tanning or the perceived costs of sun protection, but both interventions did increase immediate sun protection intentions. The UV photo condition additionally produced higher immediate perceptions of susceptibility to photoaging, whereas the photoaging video produced lower incidental exposure across follow-ups and greater sun protection behavior as assessed at the postsummer follow-up. We therefore explored the extent to which these immediate cognitions and later behaviors may have mediated the effects of the interventions on participants subsequent L* readings.8 Because the effects of the photoaging video on L* readings at the higher and lower exposure sites were both consistent across follow-ups, at each site we first separately averaged the L* differ8 As noted previously, the effect of UV photo condition on L* level was primarily evident at the higher exposure skin site at the postsummer follow-up (Figure 2). We found no evidence that either immediate sun protection intentions or perceived susceptibility to photoaging mediated this effect of UV photo condition. In the interest of space, therefore, we present only the specific mediation analyses of the photoaging video condition.

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Table 3 Spectrometer (b* Scale), Self-Reported Intentional and Incidental Exposure, and Sun Protection Means (and Standard Errors) at Postsummer Follow-Up and 1-Year Follow-Up as a Function of Photoaging Video and UV Photo Condition
Postsummer Measure Higher exposure site b* scalea Lower exposure site b* scalea Intentional exposureb Incidental exposureb Sun protection indexb Photoaging video 2.12 (0.28) 2.07 (0.28) 0.13 (0.16) 0.17 (0.16) 0.14 (0.10) No video 2.34 (0.25) 2.08 (0.25) 0.09 (0.14) 0.22 (0.15) 0.11 (0.09) UV photo 2.24 (0.26) 2.23 (0.26) 0.06 (0.15) 0.14 (0.15) 0.02 (0.09) No photo 2.23 (0.26) 1.88 (0.26) 0.10 (0.15) 0.19 (0.15) 0.02 (0.09) Photoaging video 0.82 (0.28) 0.32 (0.28) 0.12 (0.16) 0.23 (0.16) 0.02 (0.10) 1 year No video 0.90 (0.25) 0.39 (0.25) 0.10 (0.14) 0.28 (0.15) 0.07 (0.09) UV photo 1.03 (0.26) 0.51 (0.26) 0.21 (0.15) 0.15 (0.15) 0.05 (0.09) No photo 0.69 (0.26) 0.21 (0.26) 0.24 (0.15) 0.11 (0.15) 0.03 (0.09)

Note. Photoaging video (n 38) versus no video (n 46); UV photo (n 42) versus no photo (n 42). Higher values of b* indicate greater change toward yellow color. bValues are z scores adjusted for baseline status.

ence score readings for the two follow-up periods and then separately regressed these averaged L* readings on photoaging video condition (and baseline L*). As can be seen in Table 4 (Step 1), and in accord with the results of the ANCOVAs previously reported, these analyses indicated that the photoaging video significantly affected subsequent L* levels both at the higher ( p .009) and the lower exposure sites ( p .03). Also consistent with previously reported results, separate regressions of each potential mediator (sun protection intentions, incidental exposure averaged over follow-ups, and sun protection behavior reported at the postsummer follow-up, respectively) on the photoaging video condition indicated that each was significantly influenced by the photoaging video (see Table 4, Step 2). The critical analyses then

involved separate regressions of the L* readings simultaneously on photoaging video condition and each possible mediator. The results indicated that participants immediate sun protection intentions significantly predicted subsequent L* levels at both the higher and the lower exposure sites and that controlling for these immediate intentions reduced the photoaging video effect on L* readings at both sites to nonsignificance (Table 4, Step 3). The reduction was significant by Sobel z test (Preacher & Leonardelli, 2001) for L* readings at the higher exposure site (Sobel z 2.25, p .02) and borderline at the lower exposure site (Sobel z 1.87, p .06). These analyses suggest then that the effects of the photoaging video intervention on subsequent L* levels at both the higher and the lower exposure sites were mediated at least partially

Figure 1. Change in higher exposure site L* readings at postsummer and 1-year follow-ups as a function of photoaging video and UV photo conditions, controlling for baseline status (n 84). L* indexes lightness from black to white, with higher values indicating lighter coloring (i.e., less tan). Bars represent standard errors of the means.

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Figure 2. Change in lower exposure site L* readings at postsummer and 1-year follow-ups as a function of photoaging video and UV photo conditions, controlling for baseline status (n 84). L* indexes lightness from black to white, with higher values indicating lighter coloring (i.e., less tan). Bars represent standard errors of the means.

by the effects of the photoaging video on immediate intentions to sun protect. Similar evaluations of the possible mediational roles of incidental exposure and sun protective behavior revealed more differentiated patterns. Incidental exposure levels did not, but sun protec-

tion behavior did, significantly predict L* readings at the higher exposure site; further, controlling for sun protection levels reduced the effect of the photoaging video, though not to nonsignificance (Table 4, Step 3; Sobel z 1.60, p .11). In some contrast, sun protection behavior did not, but incidental exposure did, signifi-

Table 4 Mediational Analyses of Photoaging Video Condition Effects on Higher and Lower Exposure Site L* Readings
Step Step 1 Video-higher exposure L* Video-lower exposure L* Step 2 Video-sun protection intentions Video-incidental exposure Video-sun protection behavior Step 3 L* higher exposure Intentions Video Incidental exposure Video Sun protection Video L* lower exposure Intentions Video Incidental exposure Video Sun protection Video .21 .20 .45 .23 .27 .23 .11 .09 .19 .17 .16 .19 .11 .21 .15 .12 .16 SEb .78 .76 .15 1.39 .15 .58 .85 .06 .81 .59 .81 .57 .83 .06 .76 .58 .80 t 2.68 2.28 4.52 2.14 2.57 2.60 1.30 1.13 2.35 2.03 2.00 2.06 1.14 2.38 1.76 1.30 1.74 p .0089 .025 .0001 .035 .012 .011 .20 .26 .02 .045 .049 .04 .26 .02 .08 .20 .086 Sobel z, p

2.25, p .02

1.60, p .11 1.87, p .06 1.59, p .11

Note. Step 1 regression of L* levels on photoaging video condition (df 81); Step 2 regression of mediator on video condition (df 82); Step 3 regression of L* levels simultaneously on video condition and mediator (df 80).

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cantly predict L* readings at the lower exposure site while reducing the photoaging video effect to nonsignificance (Table 4, Step 3; Sobel z 1.59, p .11). Thus, this set of analyses suggests that the effect of the photoaging video on subsequent L* levels at the higher exposure site was also mediated somewhat by subsequent sun protection behavior, whereas the photoaging video effect on L* levels at the lower exposure site was mediated partially by the effect of the photoaging video on subsequent incidental sun exposure levels.

Discussion
Few prior studies have focused specifically on the effect of using UV photographs to show individuals their current, not-yetvisible skin damage from UV exposure, but the existing evidence suggests that doing so significantly increases future sun protection intentions (Mahler et al., 2003) and self-reported sun or UV protection 12 months later (Gibbons et al., 2005; Mahler et al., 2003). This study replicates the effects on intentions and extends these UV photo results by showing longer term (4 5 month) beneficial effects on objectively assessed changes in skin darkness (L* levels) following the summer months, the time when UV radiation from the sun is most intense. Participants who had viewed their UV photo continued to have lighter skin than their no-photo counterparts 1 year after the original intervention, but this difference was no longer reliable. The separate impact of the photoaging video information was even more impressive. Exposure to this information significantly increased immediate intentions to sun protect, reduced reported incidental sun exposure during the subsequent year, increased self-reported sun protection behaviors that occurred during the summer months following the intervention, and, most important, produced spectrophotometric evidence of significantly less skin darkening at higher and lower exposure areas of the arm at the postsummer follow-up and also a year after the original intervention.

more work to understand these elusive mediational mechanisms certainly is warranted. Like the UV photo intervention, the photoaging intervention produced significantly greater sun protection intentions. However, for the photoaging intervention, there was fairly strong evidence that these immediate sun protection intentions significantly mediated the effects of photoaging information on skin darkness levels assessed during the subsequent year at both exposure sites. Immediate perceptions of the costs of sun protection, benefits of tanning, and personal susceptibility were not significantly influenced by the photoaging intervention and thus were not implicated as mediators either directly or through their possible effects on intentions to sun protect. There was, however, additional evidence to suggest the photoaging video also affected subsequent skin darkness through its beneficial effects on subsequent sun protective behavior and incidental sun exposure (but not through intentional exposure, such as sunbathing). Specifically, there were indications that the effects of the photoaging video on subsequent sun protective behavior partially mediated skin lightness at the higher sun exposure site, whereas the photoaging video effect on subsequent incidental exposure partially mediated the effect on skin lightness at the lower sun exposure site. These patterns make sense in that sun protective behaviors (particularly the application of sunscreen) tend to be directed at relatively high exposure sites (i.e., people typically apply sunscreen directly to the outer side of the arm, but the underside of the arm only receives the small amount that remains on the palm after the outer arm has been covered), leaving lower exposure sites perhaps to be influenced more by the amount of incidental exposure one receives. That said, the strength of these mediational pathways was modest, so future work will need not only to try to replicate these important relationships but also to continue to identify additional mediators.

Methodological/Interpretive Issues
The present research has several important strengths. We were able to evaluate the separate effects that two orthogonally manipulated, appearance-based interventions have on the cognitions and subsequent sun protection behaviors and tanning of an important, at-risk group (college students). Unlike most previous sun protection interventions, which have assessed only immediate or shortterm effects of interventions (e.g., 1 month), our study also assessed longer term outcomes, first 4 5 months after the intervention and following the period of greatest sun intensity, and then again in an unanticipated, 1-year postintervention assessment. Also, unlike most previous sun protection interventions, which have relied on self-reports of intentions or behavior, our study used objective assessments of skin color changes at both follow-ups. One interpretive wrinkle that warrants comment concerns the fact that the UV photo and photoaging video interventions both had significant effects on L* readings (lightness in terms of black white) but not b* (saturation in terms of blueyellow) readings. As noted previously, prior work has indicated that L* and b* readings are sensitive to tanning (Levine et al., 1991; Seitz & Whitmore, 1988), and one might therefore also have expected significant effects on the b* readings. Consistent with our results, however, at least one other study that used a very different intervention and a shorter follow-up period likewise found effects on L* but not b* readings (Buller et al., 1996). Perusal of the correlations (Table 3)

Possible Mechanisms
The specific mechanism(s) by which the UV photo produced its effects on postsummer skin darkness remains unknown. Although the UV photo significantly affected sun protection intentions and perceptions of photoaging susceptibility, we found no evidence that these cognitions directly mediated the UV photo effects on postsummer skin darkness. Like other studies (e.g., Mahler et al., 2003), ours found no evidence that the perceived rewards of tanning or costs of sun protection mediated the UV photo effects on subsequent skin darkness. In a study of tanning booth use, Gibbons et al. (2005) found that UV photos influenced a tanning cognitions index (more negative general attitudes toward tanning; more negative views of the prototypical tanning booth user; less willingness to engage in impromptu risky UV exposure) and that this index partially mediated reductions in booth use during the subsequent 3 weeks. It is possible but unknown whether a similar index would likewise play a mediational role in the context of sun exposure over the longer durations involved in the present study. However, given the promise of the UV photo approach,

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indicates that L* and b* levels in the present study were related negatively to each other as expected, although the magnitude of their correlations suggests they do indeed tap different aspects of skin color. We are not in a position to resolve the question of why our interventions reliably affected L* but not b* aspects of skin color change. It is worth noting, however, that some experts on skin reflectance spectrophotometry now believe that L* readings are more sensitive than b* readings to change in UV exposure levels (personal communication, Nikiforos Kollias, Senior Research Fellow, Johnson & Johnson Consumer Products Worldwide, July 20, 2005), and others have noted that although b* readings may contribute to a tanning effect, the L* values are the most important to show darkness of skin due to tanning (Muizzuddin et al., 1990, p. 377). Additional caveats to note are that our study was conducted at only one site (San Diego, where the sun shines approximately 263 days per year), the volunteer sample was largely made up of women and included no African Americans, and the follow-up analyses included only individuals who returned for both followups. Thus, it is not possible to determine whether the interventions would have similar effects in areas with different climates or with different populations. Also, participants were aware at least of the possibility that there would be a follow-up at the end of summer. Thus, we cannot rule out the possibility that participants altered their sun exposure and protection behaviors in anticipation of that follow-up. However, participants were not told exactly when the follow-up would occur (only sometime in the fall), and when contacted many spontaneously remarked that they had forgotten about the follow-up. Further, all of the participants were sensitized to the issues being investigated. That is, even controls completed all of the measures of baseline sun exposure and sun protection, risk perceptions, and rewards of tanning and were debriefed regarding the general purpose of the study following the initial session.

possible to measure all potential effects. This may be particularly relevant for studies, such as this one, that involve potential behavior change. According to the transtheoretical model of behavior change (Prochaska & DiClemente, 1986), change in risk behavior progresses through a series of stages: precontemplation (no intention to alter behavior), contemplation (seriously considering altering target behavior), preparation (preparing to take action), action (currently modifying some aspect of target behavior), and maintenance (continuation of the modified behavior). Participants in this experiment were likely at various stages when first exposed to the interventions, but the measures used would only allow detection of intervention effects among individuals who were moved to action (or possibly to a higher form of action) or maintenance. Effects of the interventions that moved individuals from precontemplation to contemplation would not have been detected. As one participant remarked during debriefing,
Before this experiment I never even took a bottle of sunscreen when I went to the beach. Now I always take a bottle with me, but I dont always put it on. But I feel guilty when I dont put it onthat never would have happened before.

Coupled with these issues, it has been our experience that both interventions generate considerable interest and curiosity, and that individuals tend to share the information learned with friends and family members (Mahler et al., 2003, 2005). Whether such vicarious exposure to UV photo or photoaging information might also influence the contemplation or behavior of others is itself an interesting question, but regardless, we believe these interventions have considerable potential utility, perhaps even more than we were able to document.

Conclusions
The results of this experiment add to the growing literature demonstrating the efficacy of an appearance-based approach in general, and of separate photoaging information and UV photo interventions in particular, for motivating UV protection behaviors that may reduce skin cancer risk (Gibbons et al., 2005; Mahler et al., 1997, 2003). This is the first experiment to investigate the longer term effects of these interventions and to do so with objective indices of skin color change. Given the brevity of the interventions, their impact during the UV-intensive summer months is particularly remarkable and important. We believe it also may be possible to enhance the impact and duration of the intervention effects, without greatly undermining their practical utility. For example, it seems quite conceivable that if individuals were allowed to keep the intervention material for future reference (which would be particularly feasible in the case of the UV photo), even stronger, longer lasting effects could be realized with minimal increased cost. Likewise, combining the interventions with information about safe alternatives for obtaining a tan might enhance their benefits while maintaining their practicality (see Mahler et al., 2005).

Practical Implications
Given the role of sun exposure in the increasing incidence of skin cancer (American Cancer Society, 2004; Parker et al., 1997), an intervention that is effective in decreasing sun exposure has the potential for significant impact on skin cancer incidence. To the extent that any such intervention is not terribly expensive, it of course becomes all the more attractive from a cost benefit standpoint. The fact that single exposures to the UV photo and the photoaging video interventions separately demonstrated efficacy following the summer months, the period of greatest risk of harmful UV exposure, is therefore very encouraging. The fact that the photoaging video intervention continued to exert significant effects a full year later is even more remarkable. As we have noted previously (Mahler et al., 2003), both the photoaging video information and the UV photo intervention are relatively inexpensive, brief, and do not require trained staff to administer; in fact, both could be self-administered and could be made widely available in health clinics, physicians offices, and perhaps even pharmacies (much like automated blood pressure monitoring devices). We think there are also theoretical and anecdotal reasons to believe the measured results may actually have underestimated the impact of the interventions. We were able to assess a variety of outcomes that might be affected by the interventions, but it is never

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