Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.



Degree Program

Nursing, PhD

Committee Chair

Hardin-Fanning, Frances

Committee Co-Chair (if applicable)

Witt, Cheryl

Committee Member

Witt, Cheryl

Committee Member

Sha, Shuying

Committee Member

LaJoie, Andrew

Author's Keywords

cancer prevention; skin cancer; outdoor worker; secondary; qualitative


Skin cancer, seemingly more innocuous than other cancers, maintains the highest incidence among cancers in the United States. While it is treatable early, metastasized melanoma or other carcinomas present severe illness with high mortality rates and disproportionate 5-year survival rates among ethnic/racial groups. Fortunately, most skin cancer is highly treatable when found in the early stages. However, this necessitates prevention tactics to avoid the causative agent, ultraviolet radiation, and regular skin screening to catch the disease in earlier stages. Unfortunately, these tactics are not widely conducted by adults, despite substantial skin cancer awareness. Therefore, motivating people to perform these health behaviors is vital, and their attitudes, norms, and self-efficacy influence this process. This dissertation examines the factors critical to skin cancer prevention behaviors, both primary and secondary, and comprises four chapters. Chapter One presents an Introduction to the dissertation. Chapter Two is a scoping literature review of sun protection behavior (SPB) studies, including those addressing a vulnerable population, outdoor workers. The study in Chapter Three sought to identify the factors influencing sun protection behaviors and sunburn incidence utilizing a nationally representative database, the National Health and Nutrition Examination Survey (NHANES) (U.S. Department of Health and Human Services, 2020). This secondary analysis was limited to participants ages 20 years and older answering dermatology questions (N=3404), providing a large sample size. Statistical procedures were then used with Holman’s Sunburn Risk Model as the theoretical framework (Holman et al., 2019). Finally, additional research recommendations are provided to understand further the demographic and perceived risk differences in SPBs and sunburn prevalence. Chapter Four presents a qualitative analysis investigating SC prevention among a vulnerable population, presenting a narrowed approach to the national findings in Chapter Two. Chapter Three presents the qualitative study that examined adult outdoor workers’ attitudes and perceptions about skin cancer prevention, including barriers and facilitators of these behaviors. Social constructivism provided the philosophical underpinnings for the grounded theory research process guided by the work of Kathy Charmaz. The primary data source was comprised of eighteen semi-structured interviews with outdoor workers. Facilitators for performing sun protective behaviors were attitudes shaped by the perceived risk of skin cancer, normative beliefs that skin cancer is a minor disease, shaped by healthcare experiences, and perceived control over their health outcomes. Barriers included fatalistic attitudes, lack of trust in healthcare providers and institutions, and lack of preventative healthcare experience. These thematic findings demonstrate that attitudes, norms, and self-efficacy are strongly associated with the performance of skin cancer prevention behaviors. Finally, recommendations are provided for healthcare providers and public health interventions aimed at OWs. Chapter Five summarizes the key findings derived from the studies and compares and contrasts themes with the current literature. Finally, the study's limitations, significance to nursing and public health, and implications for future research are presented. These studies illuminate the need for additional research on skin cancer prevention in adults, using interventions to affect both primary and secondary prevention behaviors. In addition, they provide a direction for future research.