Globally, the most commonly diagnosed cancer is that of the skin and its incidence is increasing, including the deadliest form, melanoma [1, 2]. Melanoma is the third most common cancer among young populations [3]. Most melanomas are caused by ultraviolet radiation (UVR), predominately from sun exposure, but also from artificial sources such as indoor tanning beds [4–6]. Young adults do not consistently use recommended sun protection methods and consequently receive substantial UVR exposure. Among college students, up to 50% report outdoor intentional tanning [7]. Prevention of skin cancer by targeting sun protection and risk behaviors among young adults is therefore essential.

Most skin cancer prevention interventions for college students have relied on appearance-focused appeals, such as providing information about the damaging effects of UVR exposure (e.g., wrinkles, age spots) and ultraviolet (UV) photos that show underlying skin damage and thus modifiable, environmental contributors to skin cancer risk [8, 9]. These interventions have shown promise for improving some but not all sun protection outcomes. Other studies have tested alternative risk communication interventions including messages about personal cancer risk based on non-modifiable family history or biological factors, and have shown that these types of interventions also improve sun protection outcomes [10, 11]. Innovative, multi-component interventions that convey personalized risk from both environmental contributors and biological risk could be ideal for reaching young populations but have not yet been tested.

The current study extends existing work by examining the combined impact of a personalized UV photo conveying environmental contributors to skin cancer and the results of genetic testing or a biological vulnerability for developing skin cancer. The latter is a form of risk communication that leverages inherited variation in the melanocortin-1 receptor (MC1R) gene to motivate sun protection and tanning avoidance. A subset of MC1R variants is associated with a clinically significant, modest, 1.3–twofold, increased risk for melanoma. These variants are common and relevant to melanoma risk even in carriers with low risk based on skin phenotype [12, 13]. Building on the Elaboration Likelihood Model [14] and extensions of the common sense model of self-regulation theories that describe ways individuals process, react to, and cope with risk information [15], it is unknown to what extent UV photos and other risk communication strategies could have unique or complementary effects on skin cancer prevention behaviors. The current pilot study sought to examine the overall and unique effects on the primary outcomes of sun protection and tanning and the secondary outcome of sunburn of skin cancer prevention education, information on environmental contributors to skin cancer risk (UV photo), and genetic risk communication among young people in a college setting. We hypothesized that young people who received both the UV photo and genetic risk communication interventions would report improved sun protection and less tanning and sunburn compared to those who received only one or a control intervention. We also hypothesized that young people who received only the UV photo or genetic risk communication intervention would report improved sun protection and less tanning and sunburn compared to those who received a control intervention. Seasonality of sun protection has been documented [16]; however, the role that season has on skin cancer prevention intervention effects among college students has not yet been examined. We examined the potential role of season of intervention delivery to help guide decisions around seasonal timing of future interventions for this population.

In total, 92 students participated in the current study (mean age =22.4 years, SD =5.2; Table 1). Table 2 contains descriptive statistics for sun protection behaviors, tanning, and sunburn. At baseline, participants reported wearing shirts with sleeves and long pants most frequently. Participants reported an average of slightly more than 0 sunburns in the last month (17.4% had 1 or more sunburns in the past month) and slightly fewer than 2 in the last year (84.8% had 1 or more sunburns in the past year).

The current pilot study findings indicate that the combination of personalized risk information about both environmental contributors to and biological risk can benefit young adults’ skin cancer prevention and risk behaviors. Combined effects of UV photograph plus MC1R testing generally showed the most consistent change toward increased sun protection and skin cancer risk reduction. Further, seasonal effects were complex, and indicate that season is an important consideration for future intervention planning. Findings of significant increases in avoiding peak hours and sun protection usage among those who received all types of intervention argue for the receptivity of college students to skin cancer risk reduction intervention and their ability to respond within a few weeks. Some of the changes were in the direction of increased risk behavior, indicating sun protection and skin cancer risk behaviors assessed are complex.

No specific intervention component provided a clear efficacy benefit for all behaviors. All components had some demonstrated effects; however, the combined UV photo plus MC1R test appeared to be slightly more active than separate delivery. This novel combination capitalizes on promising effects of appearance-focused appeals [24], delivered via UV photos emphasizing skin damage [9], and health behavior-focused messaging that sun protection during younger years mitigates risk for skin cancer, as well as developing evidence for the role of skin cancer genetic feedback via MC1R testing in motivating sun protection and skin cancer screening [25]. Here, as with the changes overall in the cohort, there remained counterintuitive effects requiring additional inquiry for larger samples.

Our study found delivery of the intervention components in the fall semester resulted in a general trend to increase behaviors that are logical in cooler weather such as decreased outdoor tanning. In contrast, delivery of the intervention components in the spring led to a general trend to increase protection that might be logical as weather becomes hotter. Seasonality of sun protection has been documented [16], but we are unaware of other work in college students comparing intervention effects across season of the year. Overall, the different trends in the fall and spring indicate that timing of sun protection intervention matters, and that skin cancer risk reduction interventions may hasten the effects of natural changes in outdoor exposure, sun protection, and risk behaviors in young people as temperature and forms of outdoor recreation and work change. Further examination of these effects in future studies may help to optimize existing interventions or to further specify intervention components to specific seasons.

There are several limitations of the current study to note. The study recruited from a single geographical location, and included participants with similar education level, socioeconomic status and age. In addition, the sample’s racial and ethnic diversity was limited; however, non-Hispanic Whites face the highest risk of skin cancer and our recruitment rate for non-White college students was relatively high (57%). There was limited reported sunburn in the month prior to study recruitment, so future work could recruit higher risk samples during high UVR seasons. And finally, given the pilot nature of this work, the sample size was limited and thus we were not able to examine differences between those who received increased versus average MC1R risk feedback.

We conducted a rigorous pilot investigation examining sun protection and tanning outcomes associated with provision of environmental risk feedback and skin cancer genetic risk feedback with young adults with recent histories of higher risk behavior. Our findings are promising indications that students are responsive to these interventions and motivated to change short-term skin cancer risk behavior, and that provision of intervention components in different seasons may have distinct impacts. Future work could test these intervention components in larger samples and test different mechanisms of their effects, and examine student characteristics such as typical patterns of sun exposure and protection that may impact outcomes.