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.

KEYWORDS:

• sun-safety
• Theory of Planned Behavior
• beliefs
• winter sports
• gender

Introduction

Ultraviolet (UV) radiation can cause early skin ageing and skin cancer (D’Orazio et al., 2013; Gonzaga, 2009). Skin cancer’s incidence rate increases yearly and its prevalence is expected to double from 2009 to 2030 in Austria (Statistik Austria, 2015). As skin cancer is preventable (Linos et al., 2016), it is important to understand the psychological mechanisms of sun-safe behavior to develop health education.

Austria is known for summer and winter sports (Statistik Austria, 2020). While sun-safe behavior during summer sports is well studied (Bruce et al., 2017), sun-safety in winter sports needs further investigations. As UV-radiation raises with altitude (Blumthaler et al., 1997) and snow reflects up to 90% of the UV-radiation (Chadyšienė & Girgždys, 2008), people who engage in winter sports are at higher risk for skin damage.

Little is known about perceptions and beliefs about sun-safe behavior in winter sport settings. An early study in New Zealand revealed that 48% of winter athletes previously had sunburn experience (Price et al., 2006). Similarly, a study undertaken in winter sport resorts in North America found that only 4.4% fully complied to sun-protection advice (Buller et al., 2012). A more recent study from the Netherlands found that male and younger participants reported less use of sunscreen and more frequent sunscreen use was associated with higher self-efficacy levels, higher sun-safe intention, more knowledge about sunscreen use, and higher risk perception (Janssen et al., 2015).

The Theory of Planned Behavior (TPB; Ajzen, 1991) is a plausible framework to examine health-related behaviors. According to the TPB, behavior is determined by intention (i.e. one’s readiness to perform a behavior) and perceived behavioral control (PBC). Intention is influenced by attitude (formed by underlying behavioral beliefs, i.e. advantages and disadvantages), subjective norm (formed by underlying normative beliefs, i.e. important others), and PBC (formed by underlying control beliefs, i.e. barriers and facilitators). The TPB has not yet been applied specifically to sun-safe behavior in winter sport scenarios.

The present study aimed to examine the psychological mechanisms underlying sun-safe behavior among people engaging in winter sports. As risk perception has been found as an associate of sunscreen use (Janssen et al., 2015), we hypothesized that adding it would further explain sun-safe intention. Moreover, previous studies suggest that men use less sunscreen than women (Buller et al., 2012; Janssen et al., 2015), we would also examine the gender differences.

Methods

This study includes a belief elicitation study and a questionnaire survey. The elicitation study was conducted to elicit detect salient beliefs among the target group, as used in previous TPB-based health studies (Leske et al., 2014; Nguyen et al., 2019; Zhao et al., 2018). Thirty people with previous winter sports experience were surveyed Table 7). Content analysis was then conducted based on the data so as to develop the questionnaire scales. Participants were approached at the city center of Klagenfurt and invited to answer our survey after having fully understood the research project and signed the consent form. This study was approved by the university’s ethics committee and the data collection was completed during the winter of 2019.

As shown in Table 1, six constructs were measured following the guidelines of the TPB (Fishbein & Ajzen, 2010; White et al., 2019). Intention, subjective norm, PBC, and risk perception were examined using a 7-point Likert scale. Attitude was measured using four semantic scales. All measures showed a good internal consistency (Table 1). Gender, age, educational level, income, and previous winter sports experience were accessed as background information.

Table 1. Scale items and internal consistency for the constructs.

Construct	Item	Scale	Internal consistency^a
Sun safe behavior	How often do you use sunscreen when you do winter sports?	[1] never to [5] always	Single-item
Intention	I expect to apply sunscreen when I do winter sports next time. I want to apply sunscreen when I do winter sports next time I intend to apply sunscreen when I do winter sports next time	[1] strongly disagree to [7] strongly agree	0.99
Attitude	Applying sunscreen when I do winter sports next time is/feels … for me.	[1] harmful to [7] beneficial [1] worthless to [7] useful [1] bad to [7] good [1] unpleasant to [7] pleasant	0.90
Subjective norm	Most people who are important for me think that I should apply sunscreen when I do winter sports next time It is expected of me that I should not apply sunscreen when I do winter sports next time I feel under social pressure to apply sunscreen when I do winter sports next time People who are important to me want me to apply sunscreen when I do winter sports next time	[1] strongly disagree to [7] strongly agree	0.84
Perceived behavioral control	I am confident that I could apply sunscreen if I wanted to when I do winter sports next time For me applying sunscreen when I do winter sports next time is easy if I want to	[1] strongly disagree to [7] strongly agree	0.43***
Risk perception	If I don’t use any sunscreen when I do winter sports, it is likely for me to get serious skin problems (e.g. skin cancer, early aging) in my later life Having serious skin problems (e.g. skin cancer, early aging) is a very serious problem for me.	[1] strongly disagree to [7] strongly agree	0.50***

^aInternal consistency was not calculated for single-item constructs. Spearman’s ρ was used for constructs measured with two items. All construct scores were summed and averaged based on the item scores. *** p < 0.001.

Descriptive analyses were first performed among sun-safe behavior and perceptions. To test the utility of the TPB, hierarchical regression analyses were undertaken using both sun-safe behavior and intention in separate models. To examine gender differences, F-tests were used. Data analysis was conducted with IBM SPSS 25.

Results

Demographic profile and sunscreen use

Among 114 participants (51.8% female; M_age = 29.54 years; SD_age = 11.27), the majority (98.6%) had at least a secondary education level. 91.2% of participants had engaged in winter sports more than 5 times previously. Regarding sunscreen use, most participants had experience of using sunscreen during winter sports, only 14.0% respondents did not.

Predicting intention of using sunscreen during winter sports

Table 2 demonstrates descriptive outcomes of sun-safe variables. All variables are inter-correlated, with the association between intention and sun-safe behavior being the strongest (r = .86, p < .001). Following the TPB, model results from the multiple regression indicated that both intention (B = .78, p < .001) and PBC (B = .14, p = .023) significantly related to sun-safe behavior; two predictors explained 74.7% in the variance of sun-safe behavior (Table 3).

Table 2. Descriptive analysis of sunscreen use during winter sports.

Variable	1	2	3	4	5	6
1. Sunscreen use	-
2. Intention	.86***	-
3. Attitude	.72***	.82***	-
4. Subjective norm	.60***	.60***	.48***	-
5. Perceived behavioral control	.58***	.57***	.61***	.32**	-
6. Risk perception	.54***	.64***	.66***	.50***	.51***	-
Mean	3.13	4.77	5.48	3.94	5.79	6.04
SD	1.40	2.28	1.34	1.67	1.28	1.16

** p < 0.01. *** p < 0.001.

Table 3. Multiple regression analyses predicting sunscreen use during winter sports.

Variable	B	95% CI	SE	sr^2	R^2	Adjusted R^2
Intention	.78***	[0.41, 0.55]	0.78	0.62	0.75	0.74
Perceived behavioral control	.14*	[0.02, 0.28]	0.14	0.05

B = standardized coefficient. sr² = squared semi-partial correlation. * p < 0.05. *** p < 0.001.

When three standard TPB-variables were entered in the regression model (Table 4; Set 1), only attitude (B = .62, p < .001) and subjective norm (B = .27, p < .001) were significant, with PBC showing weak evidence (B = .11, p = .086) as a model predictor of sun-safe intention. These three variables explained 72.8% of the variance of intention. By adding risk perception (Set 2), attitude (B = .59, p < .001) and subjective norm (B = .25, p < .001) remained significant, PBC (B = .10, p = .133) and risk perception (B = .08, p = .269) were both nonsignificant. The latter failed to improve the model performance (∆F_(1,109) = 1.24, p = .269).

Table 4. Hierarchical regression predicting sunscreen use intention during winter sports.

Set	Variable	B	95% CI	SE	sr^2	R^2	Adjusted R^2
1	Attitude	0.62***	[0.83, 1.29]	0.12	0.43	0.73	0.72
	Subjective norm	0.27***	[0.21, 0.52]	0.08	0.17
	Perceived behavioral control	0.11	[−0.03, 0.42]	0.11	0.03
2	Attitude	0.59***	[0.75, 1.25]	0.13	0.36	0.73	0.72
	Subjective norm	0.25***	[0.18, 0.50]	0.08	0.14
	Perceived behavioral control	0.10	[−0.05, 0.40]	0.11	0.02
	Risk perception	0.08	[−0.12, 0.42]	0.14	0.01

B = standardized coefficient. sr² = squared semi-partial correlation. *** p < 0.001.

Gender differences

Females showed higher behavioral and intentional tendencies to use sunscreen during winter sports (Table 5) and reported a significantly higher level of frequency of sunscreen use compared to men (F_(1,111) = 6.55, p = .012). The only nonsignificant gender difference was found on subjective norm (F_(1,111) = .39, p = .534). In addition, women showed a stronger risk perception than men (F_(1,111) = 8.90, p = .004).

Table 5. Mean (SD) scores of sun safe constructs between men and women who engage in winter sports.

	Sunscreen use	Intention	Attitude	Subjective norm	Perceived behavioral control	Risk perception
Women (n = 59)	3.44(1.43)*	5.32(2.08)**	5.83(1.16)**	4.02(1.66)	6.06(1.13)*	6.34(0.81)**
Men (n = 54)	2.78(1.31)*	4.15(2.37)**	5.11(1.43)**	3.82(1.71)	5.48(1.38)*	5.70(1.40)**

* p < 0.05. ** p < 0.01.

Table 6 displays 21 specific beliefs from the elicitation study. Similar to the findings in Table 5, only beliefs underlying subjective norm (i.e. normative beliefs) showed similar levels between men and women. In contrast, four behavioral and four control beliefs had significant gender differences. Female participants agreed more on the protective functions of applying sunscreen. Similarly, women’s sun-safe behavior was more triggered by environmental factors (e.g. sunlight), product nature (e.g. product design), and their own skin condition (e.g. skin compatibility).

Table 6. Salient sunscreen use beliefs among people who engage in winter sports.

Beliefs	M (SD)		F^a
	Women	Men
Behavioral beliefs
If I apply sunscreen when I do winter sports next time, I …
… protect my skin from skin cancer	6.24 (1.09)	5.65 (1.58)	5.40*
… protect my skin from sunburn	6.22 (1.31)	5.63 (1.64)	4.50*
… protect my skin from early aging	5.95 (1.24)	4.94 (1.51)	15.07***
… take care of my skin (e.g. give hydration)	5.36 (1.60)	4.93 (1.54)	2.16
… have to put extra effort in it	3.67 (1.78)	2.78 (1.59)	7.84**
… would have sunscreen everywhere which is disturbing	4.66 (1.94)	3.94 (2.04)	3.56
… would have dirty ski gear	5.31 (1.71)	4.80 (1.89)	2.29
Normative beliefs
… think I should apply sunscreen when I do winter sports next time.
My friends …	4.03 (2.12)	3.74 (1.92)	0.59
My parents …	5.07 (2.06)	4.64 (2.18)	1.13
My partner …	3.96 (2.15)	4.46 (2.27)	1.32
My doctor …	5.30 (1.92)	4.87 (1.98)	1.34
Control beliefs
Would the following factors facilitate you to apply sunscreen when you do winter sports next time?
Facilitator: Having sunscreen with me	5.90 (1.74)	5.46 (1.99)	1.54
Facilitator: Strong sunlight	5.88 (1.60)	5.20 (1.86)	4.34*
Facilitator: My body tolerates the sunscreen	5.47 (1.84)	4.44 (2.17)	7.45**
Facilitator: Possibility to buy sunscreen on the mountain	2.75 (1.92)	2.54 (1.48)	0.41
Facilitator: Small package which does not disturb in my ski gear	5.19 (1.97)	4.43 (2.13)	3.88^†
Would the following factors stop you to apply sunscreen when you do winter sports next time?
Barrier: I left my sunscreen at home	2.63 (2.15)	2.06 (1.60)	2.54
Barrier: Cloudy weather	3.81 (1.98)	2.98 (1.73)	5.61*
Barrier: Allergic reactions of my skin	2.71 (2.15)	2.72 (2.38)	0.00
Barrier: No possibility to get it on the mountain	4.73 (2.32)	4.57 (2.00)	0.14
Barrier: Unhandy package which disturbs in my ski gear	3.83 (2.20)	3.93 (2.12)	0.06

^aF-tests show the comparisons between women and men. ^†p = 0.05. * p < 0.05. ** p < 0.01. *** p < 0.001.

Discussion

To authors’ knowledge, this is the first winter sports sun-safety study using the Theory of Planned Behavior. Over 70% of the variance in sun-safe behavior and intention has been explained, indicating the utility of the model. Findings from this study reveal important guidelines for sun-safety education for people who engage in winter sports.

Whereas the role of PBC has been found relevant for sun-safe intention (Starfelt Sutton & White, 2016), it was a nonsignificant predictor for sun-safe intention in our study. However, PBC was significantly associated with sun-safe behavior given the meaningful link between PBC and sun-safe behavior in our study. A similar pattern was seen in an Australian TPB-based sun-protective intervention, where PBC-intention link was nonsignificant in both intervention and control group at baseline, but emerged at post-intervention stage (White et al., 2019). Thus, promoting self-efficacy is likely to promote people’s winter sports sun-safe behavior.

Even though it has been suggested that including a measure for perceived susceptibility is reasonable in examining health behavior (Norman et al., 1999), risk perception is not a significant predictor in our study. The role of risk perception may be distal to one’s sun-safe intention and action.

Women showed higher values on every dimension of the TPB except for subjective norm. These gender discrepancies are in line with previous sun-safe studies targeting winter sports, consistently suggesting women show more sun-safe behaviors than men (Janssen et al., 2015; Price et al., 2006). Moreover, the similar level of subjective norm perceived by both genders importantly highlights the difference between summer sports (e.g. swimming) and winter sports (e.g. skiing). While female swimmers conduct their sun-safe behaviors according to social norms (Dixon et al., 2011), sun-protection seems to be unrelated to gender-associated norms for people who engage in winter sports. Health education using a population-based form may be effective for both genders.

Limitations of our study include the sample homogeneity as all participants were experienced in winter sports and were recruited from Carinthia, the southernmost Austrian state. Future studies with participants who have mixed winter sports experience and demographic background (e.g. different nationalities) are needed. For example, the beliefs and attitude of first-time skiers can be researched to develop better preventive strategies.

These limitations notwithstanding the study underlines the utility of the TPB as a potential useful framework to develop sun-safe health education among people who engage in winter sports. Brief information-based education via posters and smartphone apps can be implemented in winter sports areas to create people’s sun-safe attitude and controllability over sunscreen application. Given the direct link between PBC and sun-safe behavior, provision of free sunscreen can also be considered by skiing clubs. For foreign visitors, tailored and brief sun-safety tips via online booking procedures can be used to foster a stronger sun-portative attitude.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

Appendix

Table 7. Elicitation study based on the TPB guidelines.

We conduct a study to examine sun-safe behavior among people who engage in winter sports in Carinthia. We would appreciate your participation in our study by completing the following short survey. There are no right or wrong answers. Please tell us what you really think.
1	What do you believe are the advantages of using sunscreen during winter sports?
2	What do you believe are the disadvantagesof using sunscreen during winter sports?
3	Is there anything else you associate with your own views about using sunscreen during winter sports?
4	Are there any individuals or groups who would approve of your using sunscreen during winter sports?
5	Are there any individuals or groups who would disapprove of your using sunscreen during winter sports?
6	Is there anything else you associate with other people’s views about using sunscreen during winter sports?
7	What factors or circumstances would enable you to use sunscreen during winter sports?
8	What factors or circumstances would make it difficult or impossible for you to using sunscreen during winter sports?
9	Are there any other issues that come to your mind when you think about using sunscreen during winter sports?