{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T09:26:57Z","timestamp":1790846817390,"version":"4.1.0"},"reference-count":46,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2025,9,12]],"date-time":"2025-09-12T00:00:00Z","timestamp":1757635200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100006108","name":"National Center for Advancing Translational Sciences","doi-asserted-by":"publisher","award":["UM1TR004405"],"award-info":[{"award-number":["UM1TR004405"]}],"id":[{"id":"10.13039\/100006108","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000054","name":"National Cancer Institute","doi-asserted-by":"publisher","award":["P30-CA077598"],"award-info":[{"award-number":["P30-CA077598"]}],"id":[{"id":"10.13039\/100000054","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>Although skin cancers are considered mostly preventable, more people in the US are diagnosed with skin cancer than all other cancers combined. Sun safety recommendations include wearing sun-protective clothing, a wide-brimmed hat, seeking shade, and using sunscreen. Some evidence exists that sun risk behaviors and skin cancer rates are more frequent among rural than urban US populations, raising questions about underlying factors. We conducted a belief elicitation survey on these four sun protection behaviors among 278 adults (aged 18\u201360 years) living in rural Minnesota, a state with high sunburn rates and UV-attributable melanoma cases. These qualitative data were analyzed using content analysis, and the identified codes ranked by frequency. Almost all participants emphasized that spending time outside was important to them. The most frequently reported sun protection behaviors were wearing sunscreen and protective clothing. The primary outcomes were obtained from open-ended questions on outcome, normative, and control beliefs associated with each sun protection behavior. While many different beliefs were mentioned, reducing sunburn and skin cancer risk were commonly reported across all behaviors. Beliefs about negative aspects of each behavior (e.g., interference with being physically active or doing work outside, greasy\/sticky sunscreen, not getting a suntan, overheating in long clothes or when wearing hats, hats that blow off easily) typically outnumbered positive aspects (e.g., protective behaviors enabling being outside, staying cool in shade, reduced skin aging). The majority of participants believed that most people would approve of all protection behaviors, but many thought that age was a factor for behavior adoption, with young people typically thought to engage less in protective behaviors. Some commonly reported negative aspects of sun protective behaviors were related to activities more common in rural populations, such as working outside. This suggests that rural sun protection promotion may include structural interventions to make sun protection easy, convenient, and accessible without impeding rural lifestyles.<\/jats:p>","DOI":"10.1371\/journal.pone.0331685","type":"journal-article","created":{"date-parts":[[2025,9,12]],"date-time":"2025-09-12T17:58:48Z","timestamp":1757699928000},"page":"e0331685","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Sun protection behavior beliefs among adults living in rural United States: A qualitative study in Minnesota"],"prefix":"10.1371","volume":"20","author":[{"given":"Patricia","family":"Jewett","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matia","family":"Solomon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katherine","family":"Brown","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deveny","family":"Flanagan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emma","family":"Kelly","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelly","family":"Kunkel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Megan","family":"Schossow","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zora","family":"Radosevich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pamela","family":"Mason","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rehana","family":"Ahmed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rebekah","family":"Nagler","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carrie","family":"Henning-Smith","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"DeAnn","family":"Lazovich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Yzer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0149-8464","authenticated-orcid":true,"given":"Rachel I.","family":"Vogel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,9,12]]},"reference":[{"issue":"10","key":"pone.0331685.ref001","doi-asserted-by":"crossref","first-page":"1435","DOI":"10.1001\/jamainternmed.2016.5008","article-title":"Skin cancer-the importance of prevention","volume":"176","author":"E Linos","year":"2016","journal-title":"JAMA Intern Med"},{"issue":"1","key":"pone.0331685.ref002","doi-asserted-by":"crossref","DOI":"10.1016\/j.jaad.2016.07.045","article-title":"Impact of skin cancer screening and secondary prevention campaigns on skin cancer incidence and mortality: a systematic review","volume":"76","author":"A Brunssen","year":"2017","journal-title":"J Am Acad Dermatol"},{"key":"pone.0331685.ref003","volume-title":"Cancer facts and figures 2025","author":"American Cancer Society","year":"2025"},{"issue":"17","key":"pone.0331685.ref004","doi-asserted-by":"crossref","first-page":"1341","DOI":"10.1056\/NEJM199904293401707","article-title":"The pathogenesis of melanoma induced by ultraviolet radiation","volume":"340","author":"BA Gilchrest","year":"1999","journal-title":"N Engl J Med"},{"issue":"9","key":"pone.0331685.ref005","doi-asserted-by":"crossref","first-page":"978","DOI":"10.1111\/j.1365-4632.2010.04474.x","article-title":"Ultraviolet radiation and skin cancer","volume":"49","author":"DL Narayanan","year":"2010","journal-title":"Int J Dermatol"},{"issue":"1","key":"pone.0331685.ref006","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.ejca.2004.10.016","article-title":"Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure","volume":"41","author":"S Gandini","year":"2005","journal-title":"Eur J Cancer"},{"issue":"3","key":"pone.0331685.ref007","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1016\/j.jaad.2018.10.044","article-title":"Sunburn prevalence among US adults, National Health Interview Survey 2005, 2010, and 2015","volume":"80","author":"DM Holman","year":"2019","journal-title":"J Am Acad Dermatol"},{"key":"pone.0331685.ref008","doi-asserted-by":"crossref","DOI":"10.1158\/1055-9965.EPI-17-0430","volume-title":"Rural\u2013urban differences in cancer incidence and trends in the United States","author":"WE Zahnd","year":"2018"},{"issue":"3","key":"pone.0331685.ref009","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1001\/jamadermatol.2016.4625","article-title":"Comparison of regional and state differences in melanoma rates in the United States: 2003 vs 2013","volume":"153","author":"JS Mounessa","year":"2017","journal-title":"JAMA Dermatol"},{"issue":"5","key":"pone.0331685.ref010","doi-asserted-by":"crossref","first-page":"1385","DOI":"10.1002\/ijc.32921","article-title":"Cutaneous melanomas attributable to ultraviolet radiation exposure by state","volume":"147","author":"F Islami","year":"2020","journal-title":"Int J Cancer"},{"issue":"3","key":"pone.0331685.ref011","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1016\/j.jaad.2018.10.044","article-title":"Sunburn prevalence among US adults, National Health Interview Survey 2005, 2010, and 2015","volume":"80","author":"DM Holman","year":"2019","journal-title":"J Am Acad Dermatol"},{"issue":"7","key":"pone.0331685.ref012","doi-asserted-by":"crossref","first-page":"992","DOI":"10.1158\/1055-9965.EPI-17-0092","article-title":"Making the case for investment in rural cancer control: an analysis of rural cancer incidence, mortality, and funding trends","volume":"26","author":"KD Blake","year":"2017","journal-title":"Cancer Epidemiol Biomarkers Prev"},{"key":"pone.0331685.ref013","volume-title":"Greater minnesota refined & revisited","year":"2017"},{"key":"pone.0331685.ref014","author":"Centers for Disease Control and Prevention","year":"2024"},{"issue":"6","key":"pone.0331685.ref015","doi-asserted-by":"crossref","first-page":"950","DOI":"10.1016\/j.jaad.2009.08.058","article-title":"Rural-urban differences in behaviors to prevent skin cancer: an analysis of the Health Information National Trends Survey","volume":"62","author":"WE Zahnd","year":"2010","journal-title":"J Am Acad Dermatol"},{"issue":"11","key":"pone.0331685.ref016","first-page":"1251","article-title":"Differences in reported sun protection practices, skin cancer knowledge, and perceived risk for skin cancer between rural and urban high school students","volume":"30","author":"ES Nagelhout","year":"2019","journal-title":"Cancer Causes Control"},{"issue":"2","key":"pone.0331685.ref017","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1111\/jrh.12350","article-title":"Differences in sun protection behaviors between rural and urban communities in Texas","volume":"35","author":"SA Cunningham","year":"2019","journal-title":"J Rural Health"},{"issue":"1","key":"pone.0331685.ref018","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1016\/j.jaad.2021.01.095","article-title":"Comparison of sun exposure and protection behaviors between urban and rural residents without a history of melanoma in the Midwestern United States","volume":"86","author":"RI Vogel","year":"2022","journal-title":"J Am Acad Dermatol"},{"issue":"4","key":"pone.0331685.ref019","doi-asserted-by":"crossref","first-page":"608","DOI":"10.1158\/1055-9965.EPI-23-1264","article-title":"Rural-urban differences in sun exposure and protection behaviors in the United States","volume":"33","author":"AC Dona","year":"2024","journal-title":"Cancer Epidemiol Biomarkers Prev"},{"issue":"6","key":"pone.0331685.ref020","doi-asserted-by":"crossref","first-page":"1727","DOI":"10.1016\/j.jaad.2020.08.092","article-title":"Rural health disparities in melanoma staging and prognostic outcomes in Iowa","volume":"84","author":"FS Zafar","year":"2021","journal-title":"J Am Acad Dermatol"},{"key":"pone.0331685.ref021","doi-asserted-by":"crossref","first-page":"105881","DOI":"10.1016\/j.ypmed.2019.105881","article-title":"Financial hardship among rural cancer survivors: an analysis of the Medical Expenditure Panel Survey","author":"CL Odahowski","year":"2019","journal-title":"Prev Med"},{"issue":"1","key":"pone.0331685.ref022","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1111\/1753-6405.12012","article-title":"Seven-year trends in sun protection and sunburn among Australian adolescents and adults","volume":"37","author":"A Volkov","year":"2013","journal-title":"Aust N Z J Public Health"},{"key":"pone.0331685.ref023","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1016\/j.ypmed.2014.02.018","article-title":"The association between demographic and behavioral characteristics and sunburn among U.S. adults - National Health Interview Survey, 2010","volume":"63","author":"DM Holman","year":"2014","journal-title":"Prev Med"},{"issue":"5","key":"pone.0331685.ref024","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1001\/jamadermatol.2018.0028","article-title":"Prevalence of sun protection use and sunburn and association of demographic and behaviorial characteristics with sunburn among US adults","volume":"154","author":"DM Holman","year":"2018","journal-title":"JAMA Dermatol"},{"issue":"5","key":"pone.0331685.ref025","doi-asserted-by":"crossref","DOI":"10.1016\/j.amepre.2020.12.011","article-title":"The context of sunburn among U.S. adults: common activities and sun protection behaviors","volume":"60","author":"DM Holman","year":"2021","journal-title":"Am J Prev Med"},{"key":"pone.0331685.ref026","doi-asserted-by":"crossref","first-page":"101914","DOI":"10.1016\/j.pmedr.2022.101914","article-title":"Outdoor activities and sunburn among urban and rural families in a Western region of the US: implications for skin cancer prevention","volume":"29","author":"YP Wu","year":"2022","journal-title":"Prev Med Rep"},{"key":"pone.0331685.ref027","volume-title":"Predicting and changing behavior: the reasoned action approach","author":"M Fishbein","year":"2010"},{"issue":"11","key":"pone.0331685.ref028","doi-asserted-by":"crossref","first-page":"1272","DOI":"10.1080\/08870446.2016.1204449","article-title":"Predicting sun-protective intentions and behaviours using the theory of planned behaviour: a systematic review and meta-analysis","volume":"31","author":"LC Starfelt Sutton","year":"2016","journal-title":"Psychol Health"},{"issue":"2","key":"pone.0331685.ref029","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1111\/j.1468-2885.2003.tb00287.x","article-title":"Using theory to design effective health behavior interventions","volume":"13","author":"M Fishbein","year":"2003","journal-title":"Commun Theory"},{"key":"pone.0331685.ref030","article-title":"The role of theory in developing effective health communications","volume":"56","author":"M Fishbein","year":"2006","journal-title":"J Commun"},{"issue":"3","key":"pone.0331685.ref031","doi-asserted-by":"crossref","first-page":"756","DOI":"10.1093\/heapro\/dau005","article-title":"Development of theory-based health messages: three-phase programme of formative research","volume":"30","author":"T Epton","year":"2015","journal-title":"Health Promot Int"},{"issue":"6","key":"pone.0331685.ref032","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1007\/BF01904903","article-title":"Predictors of sunbathing and sunscreen use in college undergraduates","volume":"19","author":"JJ Hillhouse","year":"1996","journal-title":"J Behav Med"},{"issue":"8","key":"pone.0331685.ref033","doi-asserted-by":"crossref","first-page":"967","DOI":"10.1001\/archderm.141.8.967","article-title":"Sunscreen use related to UV exposure, age, sex, and occupation based on personal dosimeter readings and sun-exposure behavior diaries","volume":"141","author":"E Thieden","year":"2005","journal-title":"Arch Dermatol"},{"issue":"5","key":"pone.0331685.ref034","doi-asserted-by":"crossref","first-page":"412","DOI":"10.1037\/0278-6133.13.5.412","article-title":"Predictors of Norwegian adolescents\u2019 sunbathing and use of sunscreen","volume":"13","author":"L Wichstr\u00f8m","year":"1994","journal-title":"Health Psychol"},{"issue":"2","key":"pone.0331685.ref035","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1016\/0277-9536(94)E0063-X","article-title":"Suntanning and sun protection: a review of the psychological literature","volume":"40","author":"S Arthey","year":"1995","journal-title":"Soc Sci Med"},{"issue":"2","key":"pone.0331685.ref036","first-page":"108","article-title":"Testing general versus specific behavioral focus in messaging for the promotion of sun protection behaviors","volume":"54","author":"A Bleakley","year":"2020","journal-title":"Ann Behav Med"},{"issue":"1","key":"pone.0331685.ref037","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1177\/0002716211425015","article-title":"Beliefs underlying eating better and moving more","volume":"640","author":"SE Middlestadt","year":"2012","journal-title":"Ann Am Acad Pol Soc Sci"},{"issue":"4","key":"pone.0331685.ref038","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1177\/1524839918811803","article-title":"A salient belief elicitation examining adolescents\u2019 meditation beliefs using the reasoned action approach","volume":"21","author":"RG Erbe","year":"2020","journal-title":"Health Promot Pract"},{"issue":"2","key":"pone.0331685.ref039","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1016\/j.shaw.2023.03.002","article-title":"Beliefs of university employees leaving during a fire alarm: a theory-based belief elicitation","volume":"14","author":"C Owens","year":"2023","journal-title":"Saf Health Work"},{"key":"pone.0331685.ref040","doi-asserted-by":"crossref","DOI":"10.1002\/9781394260645","volume-title":"Internet, phone, mail and mixed-mode surveys: the tailored design method","author":"D Dillman","year":"2014","edition":"4"},{"issue":"2","key":"pone.0331685.ref041","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1016\/j.jbi.2008.08.010","article-title":"Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support","volume":"42","author":"PA Harris","year":"2009","journal-title":"J Biomed Inform"},{"key":"pone.0331685.ref042","first-page":"18","article-title":"The use of theory based semistructured elicitation questionnaires: formative research for CDC\u2019s Prevention Marketing Initiative","author":"SE Middlestadt","year":"1996","journal-title":"Public Health Rep"},{"issue":"2","key":"pone.0331685.ref043","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1001\/archdermatol.2007.46","article-title":"Measures of sun exposure and sun protection practices for behavioral and epidemiologic research","volume":"144","author":"K Glanz","year":"2008","journal-title":"Arch Dermatol"},{"key":"pone.0331685.ref044","doi-asserted-by":"crossref","DOI":"10.1002\/9781394179909.ch27","volume-title":"A research protocol for determining depression help-seeking message content","author":"M Yzer","year":"In press"},{"issue":"3","key":"pone.0331685.ref045","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2016-014388","article-title":"Knowledge and attitudes of UK university students in relation to ultraviolet radiation (UVR) exposure and their sun-related behaviours: a qualitative study","volume":"7","author":"L Kirk","year":"2017","journal-title":"BMJ Open"},{"issue":"3","key":"pone.0331685.ref046","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1177\/0017896909345195","article-title":"Tanning behavior among young frequent tanners is related to attitudes and not lack of knowledge about the dangers","volume":"68","author":"LK Dennis","year":"2009","journal-title":"Health Educ J"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0331685","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,12]],"date-time":"2025-09-12T17:58:55Z","timestamp":1757699935000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0331685"}},"subtitle":[],"editor":[{"given":"Caroline","family":"Watts","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,9,12]]},"references-count":46,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2025,9,12]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0331685","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,12]]}}}