Melanoma is the most deadly form of skin cancer, accounting for more than 70% of skin cancer deaths in the United States . The incidence of melanoma is increasing rapidly  and faster than any other type of cancer . Family history of melanoma is a known independent risk factor for melanoma . While intense sun exposures and sunburns before the age of 18 are known risk factors, sun exposure during adulthood also impacts melanoma development [4, 5]. The American Academy of Dermatology , the American Cancer Society , the Centers for Disease Control and Prevention , and the Task Force on Community Preventive Services on Reducing Exposure to Ultraviolet Light  recommend sun avoidance during peak ultraviolet light (UV) hours and use of sun protective clothing for the general population. First degree relatives (FDRs) of individuals who receive a diagnosis of melanoma are at increased disease risk and should pay special attention to precautions to limit sun exposure (e.g., ).
Despite the increased level of familial risk, results of several studies indicate that family members of patients with melanoma engage in relatively low levels of UV protection and high levels of exposure. Bergenmaar and Brandberg  assessed young adults with a family history of melanoma and found that engagement in sun protection was low and that sun exposure was high. Almost a third of the sample reported sunbathing very often or often and 28% reported using a tanning bed at least once per month in the past year. Geller and colleagues  found that about half of the adult siblings of individuals diagnosed with melanoma did not report using sunscreen regularly. Manne and colleagues  reported that FDRs of individuals diagnosed with melanoma engaged in relatively low levels of sun protection. Sunbathing was not assessed in this study. Azzarello and colleagues  assessed sun protection practices among FDRs of individuals diagnosed with melanoma, and reported that more than one-third of relatives never or rarely used sunscreen, and more than 60% rarely or never wore protective clothing. Again, sunbathing was not assessed. Geller and colleagues  studied children of individuals diagnosed with all skin cancer types and found that use of sunscreen was relatively low (42%). Rates of frequent sunburn in the past year were also relatively high (39%), with particularly high rates of sunburn in the past year among female offspring of mothers who had received a diagnosis of skin cancer. Finally, Bishop and colleagues  studied sun protection and sun exposure individuals with a first degree relative with melanoma and found that about 33% of relatives had a sunburn in the previous summer and 64% reported getting a tan the previous summer. However, sunscreen use was high in this sample (90%) as was the use of other methods of sun protection.
Several studies have examined correlates of sun protection practices among relatives of individuals diagnosed with melanoma. These studies have focused on demographic, phenotypic, health care access, and attitudinal factors. In terms of demographic factors, some studies suggest that female gender  and a college education  are associated with greater sun protection, whereas other studies do not suggest these associations [11, 13]. In terms of phenotypic factors, a greater tendency to burn  and greater number of melanoma risk factors  have been associated with sun protection in some studies, but not in others . Health care access and knowledge factors such as having a dermatologist , a physician recommendation to engage in sun protection , and a greater knowledge level regarding what suspicious moles look like  have been associated with higher engagement in sun protection. Attitudinal factors such as a greater perceived risk  have been associated with greater sun protection habits in some studies  but not others [12, 13]. Greater self-efficacy has been consistently associated with engagement in sun protection [13, 14]. Fewer perceived barriers to using sunscreen  and lower normative influences for sunbathing [11, 13] have also been associated with sun protection. Appearance benefits and normative influences have been described as common reasons for sunbathing among relatives .
Although there have been several studies focusing on sun habits of family members of melanoma patients, there are two gaps in the literature. First, no study has evaluated the role of a comprehensive set of attitudinal and knowledge factors in both sun protection and sunbathing practices among family members and compared whether the correlates of each behavior differ. The majority of studies have studied sun protection with little attention paid to correlates of sunbathing. Second, little is known about the population of relatives who are the least compliant with skin protection behaviors. This is a little-studied population that is most reluctant to adopt sun protection. It is important to better understand their sun protection and sunbathing habits among these individuals because they are at higher risk for skin cancer due to their skin cancer surveillance habits, and are therefore an appropriate target for intervention to improve sun protection.
To select correlates for the current study, we integrated constructs from two conceptual models, the Preventive Health Model (PHM) [17, 18] and the Theory of Planned Behavior (TPB) . We also based our selection on findings from prior research on correlates of sun protection and sunbathing behaviors from studies of individuals at average risk for skin cancer [20–25]. From the TPB, we included the role of normative influences and considered them as part of broader social influence factors to be examined. Drawing from the PHM, we examined the degree to which background demographic and medical factors (including medical factors of both the FDR and the family member with melanoma), psychological factors, and social influence factors were associated with sun protection and sunbathing. Specific psychological factors we examined included sun protection benefits, sunscreen barriers, benefits of sunbathing, sunscreen self-efficacy, photo-aging concerns, perceived risk and severity of melanoma, and distress about melanoma. The social influence factors we examined included physician recommendation for sun protection, image norms for tanness (i.e., image norms for what is portrayed as attractive in the media), sun protection norms, and sunbathing norms. In addition, we examined whether knowledge variables (i.e., knowledge of sun-protection guidelines and knowledge about sunscreen and sun exposure) were associated with sun protection or sunbathing practices. Few previous studies have examined the association between knowledge and skin cancer prevention behaviors and results have been equivocal [13, 26].
The current study had two aims. The first aim was to evaluate demographic, medical, psychological, knowledge, and social influence correlates of sun protection and sunbathing practices among FDRs of melanoma patients. The second, exploratory aim was to examine whether there were unique correlates of sun protection and sunbathing practices. Specifically, we hypothesized that greater perceived sun protection benefits, sunscreen self-efficacy, photo-aging concerns, physician recommendation for sun protection, and sun protection norms would be associated with higher sun protection. In contrast, we hypothesized that greater perceived benefits of sunbathing, lower photo-aging concerns, greater image norms for tanness, and greater sunbathing norms would be associated with higher levels of sunbathing.