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.


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), sunsafety 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.
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.

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. Table 2 demonstrates descriptive outcomes of sun-safe variables. All variables are intercorrelated, 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).

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, 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).

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 . 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 sunsafe 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 genderassociated 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).

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