Skin cancer is the most common form of cancer in the USA, accounting for half of all human malignancies, with over two million new cases diagnosed yearly [1]. The incidence of skin cancer has been rising faster than that of any other cancer [2]. In recent years, the incidence of melanoma, the most deadly form of skin cancer, has more than doubled among young women aged 15–29 years, from 5.5 to 13.9 cases per 100,000 [3]. While most skin cancers are not fatal, they are becoming increasingly common, costly, and can have devastating effects on health and appearance.

Sixty to ninety percent of all melanomas can be attributed to ultraviolet (UV) radiation [4,5], and UV is considered the single most significant modifiable risk factor in the prevention of melanoma [2]. Sunburns increase the risk of melanoma, particularly repeated blistering sunburns during childhood and adolescence [6,7]. Sunburn during childhood can double the risk for the development of melanoma in adulthood [8,9]. A recent review of national studies found that the incidence of past year sunburn among adolescents ages 11–18 years was 68.7% [10]. One in three US adults also reports burning during the past year, with rates being highest among young adults aged 18–29 years (57.5%) [10].

Studies of the correlates of sunburn have focused on demographic variables such as gender, race, and age, with most of these studies finding that young white women are most likely to report a history of sunburns [10,11,12,13]. Few studies have examined psychosocial correlates of sunburn. Studies of USA and European adolescents and adults found associations between more frequent sunburn and positive attitudes towards tanning and tanned skin, as well as having a social network who tans [14,15,16,17]. A national study of US adolescents found a positive association between sunburn and sunscreen use [18]. A recent study found that perceived susceptibility to burns was associated with burning during indoor tanning [19].

No study, to our knowledge, has applied a theoretical model to predicting sunburns. The Health Belief Model addresses motivational factors for behaviors associated with disease risk, such as perceived susceptibility to and severity of diseases such as skin cancer, perceived benefits of and barriers to associated behaviors (e.g., tanning and skin protection), self-efficacy and control over behaviors, and behavioral intentions [20]. HBM variables have been used to predict sunbathing and sun protection behaviors but not sunburn per se [21,22,23]. Examining psychosocial variables associated with sunburn may be valuable given the prevalence of sunburns and the increased risk of melanoma in those who have experienced sunburn, particularly during childhood and early adulthood [6].

The purpose of the current study was to explore potential correlates of sunburn in a high risk population of young adult women. The variables included in the analyses were biological (fair skin, family history of skin cancer), attitudinal from the HBM (perceived benefits of tanning and barriers to sunscreen use, perceived severity of and susceptibility to skin cancer and damage, self-efficacy for skin protection, perceived control over tanning and skin protection, and intentions to avoid tanning and protect the skin), and behavioral (sunbathing and sunscreen use).

Table 1 displays frequencies for each variable by number of sunburns (i.e., three or fewer versus four or more). Compared to individuals who had sunburned three or fewer times, those who sunburned four or more times were more likely to report being fair-skinned, χ²(1, N = 509) = 50.81, p < 0.001, having a family history of skin cancer, χ²(1, N = 509) = 28.94, p < 0.001, sunbathing at least one day per week on average, χ²(1, N = 499) = 17.48, p < 0.001, using sunscreen more often, t(505) = −3.16, p < 0.01, perceiving greater susceptibility to skin cancer, t(506) = −5.92, perceiving greater benefits of tanning, t(494) = −6.78, p < 0.001, perceiving fewer barriers to using sun protection, t(507) = 2.87, p < 0.01, p < 0.001, perceiving lower control over tanning, t(506) = 5.43, p < 0.001, and reporting fewer intentions to avoid tanning, t(501) = 3.66, p < 0.001.

Multivariable logistic regression analyses showed that fairer skin (OR = 3.30, 95%CI = 2.17, 5.03), more frequent sunscreen use (OR = 1.34, 95%CI = 1.05, 1.71), greater perceived susceptibility of skin cancer (OR = 1.32, 95%CI = 1.07, 1.62), greater perceived benefits of tanning (OR = 1.39, 95%CI = 1.10, 1.76), and lower perceived control over using sun protection (OR = 0.86, 95%CI = 0.75, 0.98) were associated with being sunburned four or more times, when also taking into account family history of skin cancer, sunbathing, perceived skin cancer and damage severity, perceived barriers to using sun protection, sun protection self-efficacy, perceived control over tanning, and behavioral intentions. Results of regression analyses are reported in Table 2.

Skin cancer rates are increasing, particularly among young adult women [2,3,35]. Ultraviolet radiation, especially sunburns early in life, contribute to increased risk for skin cancer [6,7,8,9]. Despite the large literature on sun exposure and protection, the current study is one of the few to evaluate psychosocial correlates of sunburns among high risk young adult women. The data demonstrated that individuals who reported more sunburns were significantly more likely to report fair skin, higher perceived susceptibility to skin cancer and skin damage, higher perceived benefits of tanning, lower perceived control over using skin protection, and more sunscreen use. Variables not associated with greater number of sunburns were perceived severity of skin cancer and damage, sun protection self-efficacy, perceived control over tanning, intentions to avoid sunbathing or skin protection, and sunbathing. Family history of skin cancer and lower perceived barriers to skin protection were associated with a stronger history of sunburns, but these associations did not reach statistical significance in the multivariate model.

One wonders whether young adult women acquire sunburns due to biological or psychosocial factors. Based on the current data, it appears that both such factors contribute. Young women who acquire more sunburns do have fairer skin and are slightly more likely to have a family history of skin cancer but perceive greater benefits of tanning and do not engage in less sunbathing than lower risk women. Although young women who get more sunburns report lower perceived control over using skin protection, they report a higher susceptibility to skin cancer and skin damage, slightly lower perceived barriers to sun protection, and use sunscreen more often than women who get fewer sunburns. Thus, women’s sunbathing and sunscreen use behaviors may be counteracting one another in terms of sun safety. Even individuals trying to get a tan typically do not intend to burn and may be somewhat deterred from future burning [36], so the young women who are burning are likely not using sunscreen properly by applying enough broad spectrum sunscreen frequently enough, as has been shown in several prior studies [37,38,39]. In part, there may be a “teachable moment” when those who experience sunburn may initially make a greater effort to protect their skin from skin cancer and photo-aging, as was suggested by a study of students and staff at a university in Turkey [40]. However, some individuals may intend to burn in order to obtain a “base-tan,” which is not recommended.

Lower perceived control over sun protection suggests that young women who get more sunburns would like to use sunscreen more overall but do not follow through successfully when actually in a sunny environment such as a beach or pool. There seems to be a gap between education and awareness on the one hand and actual behavior on the other [41,42,43]. Future research and interventions should continue to explore this gap in order to reduce skin cancer risk among young women. Factors that may prevent behavioral follow-through could include peer pressure to sunbathe or not wear sunscreen or a lack of planning such as not purchasing or bringing sunscreen to sunny locations or reapplying after swimming [44,45]. Some studies have also used more comprehensive measures of sunscreen application that assesses amount used and re-application at appropriate intervals in order to further characterize sunscreen use behavior [25,46]. There also seems to be a conflict between the perceived benefits of tanning such as attractiveness and the desire to protect one’s health from skin damage [11]. This conflict between immediate appearance concerns and later health concerns is difficult to resolve, given that many young individuals prioritize the views of peers over authority figures and may perceive themselves as invulnerable to disease [47,48]. Further changes in societal norms regarding the attractiveness of tans and the importance of health may be required [21].

Strengths of the current study include the relatively large sample size and the use of the HBM. Limitations include the cross-sectional nature of the study and the inclusion of only psychology students from one US college, which may limit generalizability. However, many students are required to take psychology courses, and US college women are an appropriate study population due to their high levels of skin cancer risk behaviors and the increasing skin cancer rates among young women. An additional potential source of bias is that individuals may have been differentially motivated by the incentives provided.