Sun Safety Behaviors Research Articles

Comparison of Patient and Provider Practices between Bone Marrow and Solid Organ Transplantation Programs for Patient Education on Increased Risk of Skin Cancer

Patients receiving immunosuppressive therapy following transplantation are at risk for skin cancer owing to dampened tumor surveillance. As long-term immunotherapy is necessary to prevent graft rejection, transplantation providers and recipients are expected to perform regular surveillance for the development of suspicious lesions, and recipients are encouraged to practice preventative sun safe behaviors. No consensus exists regarding the timing of full body skin exams, and despite the well-established risk, patient education is not always prioritized. We investigated whether differences exist between bone marrow transplant (BMT) and organ transplant (OT) recipients and their providers regarding prevention and screening. We distributed surveys to adult and pediatric BMT and OT recipients, as well as their providers, at a single academic institution. Results were evaluated using the chi-square test. The survey results show that most BMT recipients (69%) and OT recipients (77%) were aware of their increased risk for skin cancer, but despite this knowledge, only 13% of patients overall reported using sunscreen, 29% reported reapplying sunscreen, and 48% reported wearing sun protective clothing. Most OT recipients (63%) reported never having a total body skin exam, whereas only 34% BMT recipients reported having a total body skin exam every 6 months (P=.006). BMT providers recommended a total body skin exam every 6 or 12 months (44.4% each), and OT providers recommended a total body skin exam every 12 months (58.3%). Only 11.1% of BMT providers and 8.3% of OT providers reported performing a total body skin exam at each visit. Despite results indicating widespread patient knowledge of skin cancer risk, most patients do not practice adequate prevention. Inclusion of a transplantation dermatologist in the care team or use of risk stratification tools by providers may help streamline timely referrals to Dermatology.

Association of Sun Safety Behaviors and Barriers with Sunburn History in College Students in a Region with High UV Exposure.

Over five million cases of skin cancer are diagnosed each year in the United States with melanoma the third most common cancer in young adults. While publications have shown that sunburns increase the risk of developing melanoma throughout the lifetime including in adolescence and adulthood showing the importance of altering sun exposing behaviors throughout the lifetime, use of sun protection in college students remails low. In Fall 2019, an online survey of undergraduate students living on campus at a large southwestern university was conducted to determine the frequency of recent sunburns as well as sun protective behaviors and perceived knowledge of and barriers to sun protection. Associations between knowledge, behaviors, and barriers with self-reported sunburn were evaluated using logistic regression. Over 46% of 458 students reported at least one sunburn in the past three months and 21% reported having multiple sunburns in that period. Furthermore, 53% reported that they intentionally tanned their skin outdoors occasionally or more frequently, while 6.4% reported using an indoor tanning bed occasionally or more. Adjusted for skin sensitivity, recent sunburn history was associated with higher tanning activity scores and with high agreement that tanning was attractive (p < 0.01). This information can inform a more targeted series of intervention programming on the university campus.

Sun Safety: Knowledge and Behavior among Egyptian Farmers—a Multicomponent Intervention Study

The purpose of study was to screen for health hazards related to sun exposure and to examine the effectiveness of a sun safety multicomponent intervention designed specifically for the Egyptian farmers. A multicomponent interventional study was conducted among 128 farmers from three villages in Zagazig district, Sharkia Governorate, Egypt, from January to July 2022. It passed through three phases: phase 1: assessment of participants’ risk of skin cancer and vision screening; phase 2: filling a semi-structured questionnaire assessing sun exposure hazards and sun safety knowledge, behavior, and barriers; and phase 3: conducting multicomponent intervention composed of education session, providing sun safety supplies and reminders then evaluate the effect of this intervention after one month. Most of participants had moderate risk for skin cancer (69.0%), history of photokeratitis (77.3%), cataract (15.6%), and bad/very bad self-reported overall eyesight (43.0%). After intervention, there was a statistically significant improvement in the participants’ awareness regarding sun exposure-related hazards, all knowledge items about sun safety measures (p < 0.01) and some sun safety behaviors (p < 0.05) including wearing protective clothing, minimization of direct sunlight exposure, taking breaks, plentiful water intake, regular self-checking of skin, wearing wide brimmed hats, and job rotation. Furthermore, there was a statistically significant improvement in all sun protection barriers (p < 0.01) except sunscreen and sunglasses related barriers (p ˃ 0.05). The multicomponent intervention composed of education session, providing sun safety supplies and reminders was effective in increasing awareness of farmers with sun exposure hazards and improving their knowledge and behavior towards sun safety measures.

32741 Investigating sun safety behaviors, beliefs, and skin cancer-related knowledge and risk factors in the Canadian population

Introduction: In Canada, cutaneous melanoma (CM) is the 8th most diagnosed malignancy and incidence rates for CM have increased steadily over the past years. However, despite this increase, there are only limited CM public health awareness campaigns in Canada. This translated into a decreased awareness of the seriousness of CM.

Stimulating Sunscreen Use Among Outdoor Construction Workers: A Pilot Study.

BackgroundOutdoor workers (OW) receive a higher dose of ultraviolet radiation (UVR) compared to indoor workers (IW) which increases the risk of non-melanoma skin cancer (NMSC). Regular sunscreen use reduces the NMSC risk, however, adequate sun-safety behavior among OW is poor. The main objective was to conduct method- and intervention-related elements of a future intervention trial among OW, based on providing sunscreen and assessing sunscreen use on group- and individual level.MethodsThis pilot study was conducted at a construction site in the Netherlands from May-August 2021. Nine dispensers with sunscreen (SPF 50+) were installed at the worksite. OW (n = 67) were invited to complete two (cross-sectional) questionnaires on sun-safety behavior, before and after providing sunscreen. Stratum corneum (SC) samples for the assessment of UV-biomarkers were collected from the forehead and behind the ear from 15 OW and 15 IW. The feasibility of the following elements was investigated: recruitment, (loss to) follow-up, outcome measures, data collection, and acceptability of the intervention.ResultsThe first questionnaire was completed by 27 OW, the second by 17 OW. More than 75 percent of the OW were aware of the risks of sun exposure, and 63% (n = 17) found sunscreen use during worktime important. The proportion of OW never applying sunscreen in the past month was 44.4% (n = 12) before, and 35.3% (n = 6) after providing sunscreen. A majority of OW (59.3%, n = 16) found sunscreen provision encouraging for sunscreen use, the dispensers easy to use (64.7%, n = 17) and placed in practical spots (58.8%, n = 18). Collecting SC-samples was fast and easy, and several UV-biomarkers showed higher levels for sun-exposed compared to less exposed body parts. There was no significant difference in UV-biomarker levels between OW and IW.ConclusionsThis pilot study revealed low sunscreen use among OW despite providing sunscreen, overall satisfaction with the sunscreen, and the sufficient awareness of the risks of UVR-exposure. Collecting SC-samples at the workplace is feasible and several UV-biomarkers showed to be promising in assessing UVR-exposure. The low participation rate and high loss to follow-up poses a challenge for future intervention studies.

Sun-safe behavior and perceptions during winter sports: an Austrian study based on the Theory of Planned Behavior

ABSTRACT As a preventable disease, skin cancer is a public health issue in Austria. Most sun-safety studies focus on people’s activities in summer, but little is known about sun-protective behavior in winter. Based on the Theory of Planned Behavior (TPB), this study examines psychological perceptions among people who engage in winter sports in Austria. Following a TPB-based belief elicitation study, a consequent survey was conducted among 114 participants (51.8% female; M age = 29.54 years) in South Austria. Intention, attitude, subjective norm, perceived behavioral control, and risk perception showed strong and significant associations with sun-safe behavior among people who engage in winter sports. The TPB framework explained a large portion of variance in sun-safe behavior (75%) and intention (73%). Gender differences have been identified in TPB-variables as well as several beliefs. Based on the utility of the TPB, our findings suggest guidelines for sun-safety in winter sports settings. Gender differences are in line with previous research, highlighting the vulnerability of men to sun damage during winter sports.

Assessment of sun-safety education behavior via spectrophotometric evaluation: A preliminary study.

Biases inherent in self-assessment of sun exposure and sun-safe behavior may lead to inaccurate conclusions about the effectiveness of sun-safety educational programs. We aimed to compare self-reports to objective measures of sun exposure, when examining the effectiveness of passive versus active educational interventions. From May to June 2018, 73 participants recruited at a dermatology clinic were sequentially assigned to receive sun-safety education through one of 3modes: interactive online module, video, or no education. A baseline Sun Exposure and Behavior Inventory (SEBI) questionnaire was administered, and spectrophotometric measurements of sun-exposed and sun-protected areas were taken and reported in the CIE L*a*b* color space. Participants were followed 4-8 and 16weeks after the initial visit where the SEBI was re-administered, and serial measurements of skin color were taken. The change in SEBI scores and L*a*b values, as calculated by the individual typology angle (ITA°), was analyzed. There was a significant increase in skin darkening in all the groups at 4-8 and 16weeks follow-up. There was no statistically significant difference between the groups in the magnitude of color change. However, subjectively at 4-8 weeks post-intervention, participants in the interactive module and video groups had significantly improved self-reported SEBI scores compared to control (p<.05, Kruskal-Wallis). By 16weeks, only the interactive module group showed significant improvement in SEBI scores compared to control (p<.05, ANOVA). In determining the effectiveness of sun-safety programs, spectrophotometric evaluation of sun-induced skin pigmentation can allow for a more complete evaluation of self-reported sun exposure and sun-protective behavior.

“Let’s Talk about Skin Cancer”: Examining Association between Family Communication about Skin Cancer, Perceived Risk, and Sun Protection Behaviors

Family communication about skin cancer risk may motivate protective behaviors. However, it is unclear how widespread such communication might be. In this study, we describe prevalence and patterns (across environmental, personal, and behavioral factors) of family communication about skin cancer across N = 600 diverse (79% female, 48% Hispanic, 44% non-Hispanic White) primary care patients from Albuquerque, New Mexico, a geographical location with year-round sun exposure. Over half reported discussing general cancer (77%) and skin cancer risks (66%) with their families. The most frequent target of skin cancer risk communication included doctors (54%), followed by friends/coworkers (49%), spouse/partner (43%), other family members (38%), sisters (36%), mothers (36%), daughters (33%), sons (32%), father (24%), and brothers (22%). On average, participants reported having talked to three family members about skin cancer risks. The most frequently discussed content of skin cancer risk communication was the use of sun protection (89%), followed by the personal risk of skin cancer (68%), who had skin cancer in the family (60%), family risk of skin cancer (59%), time of sun exposure (57%), and skin cancer screening (57%). A family or personal history of cancer, higher perceived risk, higher health literacy, being non-Hispanic, having higher education or income, and proactive sun protective behavior were associated with greater family communication about general cancer and skin cancer risks. These study findings have implications for interventions that encourage discussions about skin cancer risk, sun protection, and skin cancer screening that lead to adoption of sun-safe behaviors.

Golfers' Interest in Multilevel Sun-Protection Strategies.

Active adults accumulate more ultraviolet (UV) radiation exposure and are at greater risk of skin cancer than inactive adults. Golf is a popular sport that increases UV exposure because it is played outdoors in daylight. This study evaluated adult golfers’ interest in multilevel sun-protection strategies and characterized differences in interest as a function of golfer characteristics. Adult golfers (N = 347) completed a web survey to rate their interest in 20 sun-protection strategies. We estimated descriptive statistics and evaluated differences in interest as a function of demographics, perceived risk, sun-protective behavior, and golf exposure. Golfers reported the greatest interest in environmental supports for sun protection, but these ratings were driven by golfers who already perceived golf as a risk behavior and used sunscreen diligently. Vulnerable golfers—those with a golf-related sunburn in the past year or who spend more time golfing—expressed interest in a broader range of intervention components, including education, family support, and text messages. Multilevel skin cancer prevention interventions are needed for golfers. Intervention components of interest involved support and reminders, which suggests they are open to sun-safety behaviors but need help executing them.

Sunburn, Sun Safety and Indoor Tanning Among Schoolchildren in Ireland.

Objectives: We present patterns of sunburn, sun safety behaviors and indoor tanning bed use in a nationally representative sample of schoolchildren aged 10–17. These behaviors were explored across gender, age, and social class groups.Methods: Within the Health Behaviour in School-aged Children (HBSC) Ireland study, 10,271 young people (aged 13.54 ± 1.92, percentage girls 53.3%) reported frequency of sun safety behaviors, sunburn, and frequency and circumstances of indoor tanning bed use.Results: Children frequently experienced sunburn (90% lifetime, 74% last year), and 3% reported never using any sun protection. Applying sunscreen and wearing sunglasses were the most commonly used sun safety measures; other ways of sun protection were less popular. Indoor tanning bed use was reported by around 5%, and a large proportion of users were not advised of any indoor tanning safety measures. Sun safety behaviors varied by age and gender, with some socio-economic differences in tanning bed use. An association was found between frequency of family holidays abroad and sunburn.Conclusion: Targeted interventions are needed to increase sun safety behaviors and eliminate tanning bed use among children in Ireland.

The Context of Sunburn Among U.S. Adults: Common Activities and Sun Protection Behaviors

Sunburn increases skin cancer risk and is common among U.S. adults. However, little is known about the contexts in which sunburns often occur. The purpose of this study is to examine the contextual factors surrounding sunburns among U.S. adults. Cross-sectional data from a 2018 online panel survey were analyzed. A total of 4,088 panel members were recruited by mail using probability-based, random sampling by address. Respondents were asked about their most recent sunburn, and analyses were limited to those who remembered their most recent sunburn (N=3,106). Data were weighted to match the U.S. Current Population Survey proportions; analyses were conducted in 2018 and 2019. Participants' age ranged from 18 to 93 years. About half (50.8%) were women, and most (82.3%) were non-Hispanic White adults. Swimming or spending time in water (32.5%), working outside at home (26.2%), traveling/vacationing (20.7%), and engaging in nonswimming physical activity (14.2%) were the most frequently reported activities. Using sunscreen on the face, neck, and chest (38.8%) and on the body (19.9%) and wearing sunglasses (34.2%) were the most frequently reported sun safety behaviors. Wearing clothes to the ankles (6.6%) and a long-sleeved shirt (4.5%) were least frequently reported. This study provides new information about the contexts in which adult sunburns often occur, especially about contexts unrelated to intentional tanning, which was relatively infrequent. The results suggest the need to promote multiple forms of sun protection tailored to specific outdoor activities and develop innovative solutions for outdoor physical and aquatic activities, which present unique sun safety challenges.

Does it matter if a story character lives or dies?: a message experiment comparing survivor and death narratives

Objective In narratives, characters often face threats where they either live (survivor narratives) or die (death narratives). Both outcomes have the potential to persuade, and are frequently utilised in mass communication campaigns, yet more research is needed examining the relative effectiveness and underlying mechanisms of each strategy. Design U.S. adults (N = 1010) were randomly assigned to a 2 (survivor, death) × 2 (non-foreshadowed, foreshadowed) × 2 (within-study replication: narrative 1, narrative 2) between-participants experiment with melanoma stories as stimuli. Main Outcome Measures Intentions to engage in sun safe behaviour and skin self-examination behaviour were assessed in the pre- and posttest, and then transformed into change scores. Results Death narratives increased sun safe behaviour intentions. Consistent with the entertainment overcoming resistance model, foreshadowed death narratives were found to increase sun safe behaviour intentions via increased transportation and decreased counterarguing. Conclusion Compared to survivor narratives, death narratives increase intentions to engage in sun safe behaviour. The findings offer support for character death as a key feature of narrative persuasion, and narrative transportation and counterarguing as important mediational pathways.

Sun Exposure and Black Skin.

Black skin, compared with white skin, is generally assumed to be more resistant to the consequences of sun exposure due to its epidermal melanin content. However, recent scientific evidence shows that black skin is not completely impervious to sunlight. Both clinical and -experimental data have reported sun-induced effects on black skin. Black skin can warm, burn and peel when -exposed to the sun. Exposure to the sun can also cause hyperpigmentation and photoageing manifestations. The current misconceptions expressed by most black individuals about their resistance to sun-induced effects prevent their engagement in sun safe behaviours. Therefore, the demystification of the harmful effects of the sun needs to be supported by more research studies showing the effectiveness of sun protection strategies for the black population.

14188 Wearable UV/HEV light sensor and smartphone application for personal monitoring and personalized recommendations

Prolonged exposure even to suberythemal UV doses has many associated risk factors, including skin cancer and photo-aging. Recent studies also indicate that high-energy visible light (HEV) induces oxidative stress in the skin which is ultimately linked to visible signs such as pigmentation and aging. Personalized monitoring of UV/HEV radiation is necessary for recommendations of personal sun-safe behaviors. Here, we demonstrate a wireless, battery-free, miniature, wearable UV/HEV sensor that can be mounted on t-shirt, sunglasses, wristband, shoes or necklace.

Use of Electronic UV Dosimeters in Measuring Personal UV Exposures and Public Health Education

The performance limits of electronic ultraviolet (EUV) dosimeters, which use AlGaN Schottky photodiodes as the ultraviolet radiation (UVR) sensing element to measure personal erythemally weighted UVR exposures, were investigated via a direct comparison with meteorological-grade reference instruments. EUV dosimeters with two types of AlGaN Schottky photodiode were compared to second-generation ‘Robertson–Berger type’ broadband erythemal radiometers. This comparison was done by calculating correction factors for the deviations of the spectral responsivity of each instrument from the CIE erythemal action spectrum and for deviations in their angular response from the ideal cosine response of flat surfaces and human skin. Correction factors were also calculated to convert the output of these instruments to vitamin D-weighted UV irradiances. These comparisons showed that EUV dosimeters can be engineered with spectral responsivities and cosine response errors approaching those of Robertson–Berger type radiometers, making them very acceptable for use in human UVR exposure and sun safety behaviour studies, provided appropriate side-by-side calibrations are performed. Examples of these calibrations and the effect of EUV dosimeter sampling rates on the calculation of received erythemal UVR doses and erythemal UVR dose rates are provided, as well as brief descriptions of their use in primary skin cancer prevention programmes, handheld meters, and public health displays.

Sun-safe behaviours, personal risk, level of concern, and knowledge about cutaneous melanoma in italy: time for social marketing?

SummaryIntroductionThe incidence of cutaneous melanoma is increasing, although 80-95% of all deaths caused by melanoma can be avoided through protective behaviours. There is evidence that social marketing as an approach in public health can improve health-related behaviours and encourage sun-safe behaviours.MethodsA multicentre survey was conducted to collect and compare data about cutaneous melanoma risk, knowledge, concern, and protective behaviours across Northern, Central, and Southern Italy, and explore how these data could potentially inform a social marketing intervention to improve sun-safe behaviours. Data were analysed using descriptive and inferential statistics.ResultsA total of 1,028 questionnaires were collected. Apart from ‘Personal Risk’ no statistically significant differences were found between the three regions. About 30% (n = 344) of the total sample had high levels of personal risk, and low levels of concern and protective behaviour, and over 70% (n = 711) gave priority to sun tanning. The worst scores were related to knowledge about melanoma (30% wrong answers, and over 40% ‘don’t know’). Protective behaviour was moderately correlated with age (p = 0.03). Personal risk was significantly higher in women (10.84 vs 10.05), and lower in individuals with a degree (9.46 vs 11.38; p < 0.001).ConclusionsOver 70% of our sample gave priority to sun tanning, which combined with low levels of concern and knowledge about melanoma, and high levels of personal risk, confirm that much still needs to be done in terms of melanoma prevention, but all these are aspects that could be effectively addressed through social marketing interventions.

Parent reports of sun safety communication and behaviour for students in a randomised trial on a school policy implementation intervention

ObjectiveSchools are an important setting for skin cancer prevention. An intervention for implementation of school sun safety policy, Sun Safety Schools (SSS), was evaluated. MethodsPrimary schools (n=118) in California school districts that had already adopted a sun safety policy were enrolled in a study with a randomised controlled design. Half of the schools were randomised to SSS intervention (N=58). Parents completed an online post‐test. ResultsMore parents in intervention schools received information about sun safety (mean=26.3%, sd=3.1%, p=0.017) and children more frequently wore sun‐protective clothing when not at school (mean=2.93, sd=0.03, p=0.033) than in control schools (mean=18.0%, sd=2.5%; mean=2.83, sd=0.03, respectively). In schools where principals reported implementing sun safety practices, parents reported that children spent less time outdoors at midday (mean=14.78 hours, sd=0.25, p=0.033) and fewer were sunburned (mean=12.7%, sd=1.1%, p=0.009) than in non‐implementing schools (M=16.3 hours, sd=0.67; mean=21.2%, sd=3.8%, respectively). Parents who received sun safety information (mean=3.08, sd=0.04, p=0.008) reported more child sun protection than parents not receiving information (mean=2.96, sd=0.02). ConclusionsA school district sun protection policy and support for implementation increased dissemination of sun safety information to parents and student sun safety. Implications for public healthTechnical assistance for sun safety policies may increase sun protection of children.

The mediating role of constructs representing reasoned-action and automatic processes on the past behavior-future behavior relationship.

Past behavior has been consistently shown to predict and explain future behavior. It has been proposed that past behavior effects reflect both reasoned action and automatic processes. The current study sought to explore the mediation of past behavior-future behavior relationship via constructs reflecting these processes across three populations and behaviors: binge drinking in university students, flossing in adults, and parental sun safety behavior of children 2 - 5 years of age. Furthermore, this study used a measure of past behavior that combined long-term, recent, and routine patterns of behavioral engagement. A prospective design with two waves of data collection spaced six weeks apart was adopted. Participants (total N = 754) completed an initial survey containing measures of past behavior (frequency, recency, and routine), social cognition (attitudes, subjective norms, perceived behavioral control), and behavioral automaticity. Six weeks later, participants (N = 454) completed a self-report measure of behavior and behavioral automaticity. Structural equation modelling revealed that automatic, but not reasoned-action processes, mediated the past-to-future relationship, across the three behaviors. Results further revealed that long-term, recent, and routine patterns of behavioral engagement were highly correlated and indicated a second-order past behavior latent variable. While both reasoned-action and automatic factors can predict a range of health behaviors, automatic processes appear to explain the effect of past behavior on future behavior. Further investigations should focus on exploring the role of other non-conscious and automatic processes such as counter-intentional habits and implicit beliefs in explaining engagement in heath behaviors.

Parental and primary caregiver's attitudes towards sun safe hat and sunscreen use at a major national children's playground in Canberra, Australia.

The sun safety habits of children are developed throughout the childhood years under the influence of peers, parents, family members and other adult caregivers, as well as through education. This study assessed the sun safety attitudes and actual practices of parents and primary caregivers at a large public playground over a twelve-month period in 2019/2020. The desire to have an educational sun safety message at major playgrounds was also assessed. Parents and primary caregivers at our study playground in Canberra, Australia, were offered an eight-question survey. Data analysis compared the proportion of respondents who selected each sub-question. Surveys were conducted on a minimum of three days per week for a twelve-month period, excluding the period of May to the beginning of August when the ultraviolet radiation index (UVI) is typically below three in Canberra. Less than half of the children at the study playground wore a sun safe hat the whole of their playtime when the UVI≥3. Although 80.5% parents and primary caregivers acknowledged the importance of modelling good sun safety behaviours, most adults did not wear a sun safe hat or apply sunscreen. 93.3% of adult respondents desired some form of permanent educational message at playgrounds to encourage better sun safety. There is significant room for improvement in the sun safety practices of primary caregivers and children at our study playground. The vast majority of respondents desired a permanent sun safety message display at major playgrounds.

Patterns of sun safety behaviors in parents: Associations with physical activity, sedentary behavior, and access to neighborhood physical activity resources

Exposure to ultraviolet rays is associated with increased risk of sunburn – a biomarker of skin cancer risk – and physical activity can increase exposure. Sun safety behaviors can mitigate the increased risk of skin cancer. The objective of this cross-sectional study was to determine associations between physical activity behaviors, access to neighborhood physical activity resources, and sunburn across different patterning of sun safety behaviors. Data collected in 2014 from parents in the United States were analyzed (N = 1680; 75% female, primarily between the ages of 35–44 and 45–59, and 67% White). Latent class analysis was conducted to identify classes of sun safety behaviors based on engagement in sun protective behaviors (wearing a hat, shirt with sleeves, and seeking shade) and sun exposure (tanning outdoors). The latent classes were then examined as moderators of the association between physical activity related variables and sunburn. Three classes were identified corresponding to Low, Moderate, and High Risk for sunburn. There was no evidence of moderation, so equality constraints were imposed across the classes. Moderate-to-vigorous physical activity (MVPA) (odds ratio [OR] = 1.09) and neighborhood environments favoring physical activity (OR = 1.39) were associated with an increased likelihood of sunburn. Greater engagement in physical activity and access to built environments that favour activity are associated with a higher likelihood of sunburn, regardless of sun safety behaviors. Physically active parents are a vulnerable population for melanoma, and cancer prevention efforts focused on physical activity should also address sun safety.