Moderating influences on parents’ fatalistic beliefs about cancer and their association with sun safety behaviors among children of melanoma survivors: Implications for treatment

The purpose of this study is to examine the association between parents’ fatalism about melanoma and their children’s sun protection, and the potential moderating role of parent-child communication. In this observational study of N = 69 melanoma-surviving parents of children ages 8–17, parents reported on their own melanoma fatalism, as well as their children’s sun safety behaviors and parent-child discussion about sun safety. Parent gender, family history of melanoma, and frequency of parent-child discussions moderated the relationship between parents’ fatalism and children’s sun safety behaviors. Among mothers and parents with a family history of melanoma, high fatalism was associated with lower child sunscreen use, especially when discussions were less frequent. Melanoma surviving parents’ fatalistic beliefs about cancer indirectly influence their children’s health behavior and are a risk factor for unsafe sun behavior. Attending to parent gender, family history, and their communications about protective behaviors as co-factors of this risk could inform future intervention targeting.

over 325,000 new melanoma cases were diagnosed worldwide in 2020 and this number is expected to increase to more than 500,000 cases globally by 2040 (Arnold et al., 2022).Globally, regions with higher levels of social and economic development (e.g.North America, Australia, New Zealand, Western Europe) have higher incidence of melanoma (Siotos et al., 2022).Behaviors to prevent melanoma should begin in childhood and include limiting ultraviolet radiation (UVR) exposure through the use of sun safety methods such as protective clothing (e.g.long sleeved shirts, long pants or skirt, wide-brimmed hat), sunscreen application and re-application, avoiding outdoor time during peak UVR hours (10 am-4 pm), and avoidance of any tanning, including indoor tanning (Cust et al., 2011;Grossman et al., 2018;Watts et al., 2018;Wojcik et al., 2019).Family history is a significant risk factor for melanoma and children who have a parent with melanoma are at increased risk for developing the disease later in life (Cho et al., 2005).In this context of intergenerational cancer risk (Coffin et al., 2019), evaluating individual and family level factors that influence child melanoma prevention strategies is crucial to better inform interventions aiming to address barriers to preventive behavior implementation in at-risk families (Hay et al., 2007;Wu et al., 2019).
Prior studies of melanoma survivors have predominantly focused on theory-driven predictors of sun protection behaviors on the individual level, including family history of melanoma, survivors' perceived self-efficacy for helping their children use sun protection, perceived risk of their child to develop melanoma, and perceived barriers to child sun protection use (Glenn et al., 2012(Glenn et al., , 2015;;Tripp et al., 2016).These factors, while important, do not account for how the parent's cancer experience has shaped their attitudes and beliefs.One relevant factor is cancer fatalism, which is defined as the extent to which one believes that the development of cancer is not in one's personal control and that if one were to receive a cancer diagnosis, one will inevitably die.Cancer fatalism has been linked to negative health behaviors among individuals with and without a personal cancer history (Befort et al., 2013;Bottaro et al., 2023;Espinosa de Los Monteros and Gallo, 2011;Fenton et al., 2019;Powe and Finnie, 2003).Lower cancer fatalism predicted increased likelihood to followthrough with melanoma genetic testing among adults in a primary care setting (Hay et al., 2019) whereas higher skin cancer fatalism among Hispanic adults was associated with lower use of certain sun protection strategies (Coups et al., 2014;Rodríguez et al., 2017).However, it remains unknown to what extent cancer fatalism impacts intergenerational sun protective practices among families with elevated skin cancer risk.
Family-level factors are also important to consider in the context of child cancer prevention behaviors in high risk families.Drawing from risk communication frameworks for cancer prevention (Hay et al., 2007), parent-child discussions about melanoma preventive behaviors may promote child preventive behaviors.However, it is possible that parent-child discussions may have interactive effects with cancer fatalism, such that families that have more frequent parent-child discussions about preventive behaviors would buffer the effects of cancer fatalism on sun protection behaviors.
The aim of the current study is to examine the intergenerational impact of parent cancer fatalism on the sun protection behaviors of children of melanoma survivors and to identify potential individual and family-level factors that may moderate the relationship between cancer fatalism and child sun protective behaviors.Moderators to be examined include parentchild discussions about melanoma preventive behaviors, parent gender, and additional family history of melanoma.We hypothesized that lower melanoma fatalism and increased parentchild discussions about melanoma preventive behaviors would independently predict greater engagement in child sun protection behaviors and lower child tanning behaviors.Additionally, we hypothesized that increased parent-child discussions about melanoma prevention would moderate the relationship between parent fatalism and child sun protection behaviors.We also explored the potential moderating effects of parent gender and additional family history of melanoma on the relationship between fatalism and child sun protection behaviors based on literature suggesting these factors influence sun protective practices among children of melanoma survivors (Bowen et al., 2012;Gritz et al., 2013;Tripp et al., 2016).The ultimate goal of this work is to identity targets for intervention to improve sun safety practices in this high risk group.

Participants and procedures
Parents were eligible to participate if they were the primary caregiver to one or more children under the age of 18 whose parent (alive or deceased) had melanoma and/or three or more second or third-degree relatives with a history of melanoma.The participating parent did not need to be the melanoma survivor.Potential participants were recruited through letters sent to melanoma patients at an NCI-Designated Comprehensive Cancer Center and approached at clinic appointments, letters sent to individuals in a research study about familial melanoma risk, and advertisements through the cancer center's clinics, free skin cancer screening, social media, and through a local melanoma advocacy group.Altogether, 69 parents out of 140 eligible (49% recruitment rate) participated in the current study.One parent with a personal history of melanoma had a spouse who also participated.We randomly selected one parent from this family to be included in analyses to maintain statistical independence.Parents provided informed consent and children provided assent.Questionnaires were completed in person or via mail.If parents had more than one child between the ages of 8 and 17, they were asked to report on all their children as a group.Participants received a gift card in appreciation for their time.All procedures were approved by the relevant Institutional Review Board (IRB 00072947).

Measures Demographic characteristics.
Parents were asked to report on their age, sex, race/ethnicity, education attained, marital status, household income, personal and family history of melanoma, number of minor children living in the home, and their relationship to the child(ren) participating in the study.They were also asked to report on children's race/ethnicity and insurance status.Children were asked to report on their sex and age.
Sun protection behaviors, tanning, and sunburn occurrence.Parents were asked items from the Sun Habits Survey for children's behaviors and sunburn occurrence (Glanz et al., 2008).Reported use of eight sun protection behaviors (e.g.sunscreen use and re-application, shadeseeking, avoidance of peak UVR exposure) and outdoor tanning in the past month using a 5-point Likert-type scale ranging from "never" to "always," and reported sunburn occurrence in the past month (from "0 times" to "5 or more times") (Glanz et al., 2008).A sun protection behavior index score was also created by summing the eight sun protection behaviors assessed.
Cancer fatalism.Ten items adapted from the Powe fatalism inventory (Powe, 1995) were used to assess parent-reported melanoma fatalism, both one's personal control over melanoma development and perceived inevitability of death if one is diagnosed with melanoma (see Supplemental Material Table 1).Items were rated on a 5-point Likert-type scale from "strongly disagree" to "strongly agree."An overall cancer fatalism score after reverse coding relevant items and creating a sum score, whereby higher scores corresponded with higher fatalism.
Parent-child discussions about melanoma preventive behaviors.Investigator-designed items were used to assess parent-report of their discussions with their children about sun protection (e.g."How much do you discuss protecting skin from the sun (using sunscreen, wearing protective clothing, and avoiding peak hours) with your children?") (see Supplemental Material Table 2).Responses for the seven items were on a 5-point Likert-type scale from "not at all" to "a lot."An overall sum score was calculated for use in analyses, with higher scores indicating more frequent discussions about sun protections.

Statistical analyses
Descriptive statistics (means, standard deviation, range, median) were calculated to summarize participant demographic characteristics and outcomes of interest.Linear regressions were conducted with child sun protection behavior as the outcome and fatalism, parent-child discussion about melanoma prevention, and their interaction as the independent variables.Separate regressions were conducted for each sun habit behavior outcome.Additional regressions were conducted with child sun protection behavior as the outcome and fatalism, a demographic variable (parent gender, number of family members diagnosed with melanoma), and their interaction as the independent variables.Significant interactions were probed and plotted using post-hoc probing procedures (Holmbeck, 2002).To help control for type 1 errors, the Benjamini-Hochberg procedure was used to determine statistical significance.

Results
In total, 69 parents (mean age = 40 years, SD = 6.8) participated in the current study (see Table 1).Almost all children (94%) had a living first degree relative with melanoma who participated as a parent in the study.In addition, 13 parents (19%) reported their child had a second degree relative with melanoma, 7 (10%) reported the child had a third degree relative with melanoma.Most participating parents (77%) were mothers.On average, parents had two children under the age of 18. Parents reported that on average, their children used recommended sun protection behaviors "sometimes" (see Table 2).Regression analyses indicated that there was no main effect of melanoma fatalism on child melanoma preventative behaviors overall (i.e.Sun Habits Index scores) or for most specific behaviors (Table 3).Greater parent-child discussions consistently predicted higher child sun protection use (i.e.overall sun habits index score, avoiding UVR during peak hours, wearing sunglasses; Table 3).Parent-child discussions about melanoma preventive behaviors were also a significant moderator of the relationship between parent melanoma fatalism and child sunscreen use (p = 0.02; see Figure 1(a)) and child long pants or skirt wearing (p = 0.04; see Figure 1(b)).Specifically, when parentchild discussions about melanoma preventive behaviors were low, greater melanoma fatalism was associated with lower child sunscreen use (B = −0.133,p < 0.001) and unrelated to child long pants or skirt wearing.In contrast, when parent-child discussions about melanoma preventive behaviors were high, melanoma fatalism was unrelated to child use of sunscreen and had a marginal effect on child long pants or skirt wearing (B = −0.085,p = 0.054).Additional regression analyses assessing the impact of demographic moderators indicated that the effect of parent melanoma fatalism on child sun protection behaviors was influenced by parent gender (p < 0.001; see Figure 1(c)).Specifically, higher fatalism predicted lower child sunscreen use among mothers (B = −0.156,p < 0.001), but not among fathers (B = 0.053, p = 0.240).There was a marginal effect of family history of melanoma as a moderator of the effect of melanoma fatalism on child sunscreen use (p = 0.056; see Figure 1(d)).Among families with a high number of family members with a history of melanoma, melanoma fatalism predicted lower child sunscreen use (B = −0.141,p < 0.001).

Discussion
The current study illustrated that among families with intergenerational risk for melanoma, the potential negative effects of parent melanoma fatalism on child melanoma preventative behaviors are mitigated by more frequent conversations between parents and children about melanoma prevention and key demographic factors of parent gender and number of additional family members with melanoma.While previous studies have demonstrated that higher fatalistic beliefs are negatively associated with adults' own skin cancer prevention and early detection behaviors (Coups et al., 2014;Merten et al., 2022;Michielutte et al., 1996), the present study builds on the current knowledge by demonstrating a link between parents' melanoma fatalism on their children's sun protective practices.
Our results indicate that more frequent parent-child discussions about melanoma preventive behaviors are protective against the negative effects of parent melanoma fatalism on  child sun protective behaviors.In terms of parent and family-level demographic factors, the findings suggest that children's sun protection use, particularly their use of sunscreen, can be negatively impacted when they have a mother with high melanoma fatalism, as opposed to a father with high melanoma fatalism.This is consistent with other studies that have found differences in sunburn occurrence among children of female survivors (Tripp et al., 2016).Furthermore, higher parent melanoma fatalism predicted lower child sunscreen use in families with a greater number of members who had history of melanoma, who may be a more vulnerable group due to the greater familial risk of melanoma.Together, these findings highlight the importance of modifiable family factors such as parent-child discussions about melanoma preventive behaviors that can be targeted in melanoma prevention interventions, and non-modifiable family factors such as parent gender and extent of the family history of melanoma that can be used to identify families who may benefit from interventions.

Clinical implications
These findings have several implications for the design of interventions for families affected by melanoma.Addressing melanoma survivor's cancer fatalism could have an important positive downstream effect on their children's risk of skin cancer by improving their sun protection behaviors.Our results expand prior work showing that cancer fatalism is associated with lower engagement in preventive health behaviors (Befort et al., 2013;Bottaro et al., 2023;Espinosa de Los Monteros and Gallo, 2011;Fenton et al., 2019;Jun and Oh, 2013;Kim and Lwin, 2021;Powe and Finnie, 2003;Welch and Ellis, 2018) to include sun protection behaviors.Thus, addressing cancer fatalism may be an important strategy to promote healthy behaviors among survivors (Powe and Finnie, 2003).
Psychosocial care providers such as social workers, counselors, and psychologists could assess survivor's cancer fatalism routinely as part of survivorship care.While attending to culturally and spiritually relevant factors (Powe and Finnie, 2003), these providers could help survivors reframe their own experience with melanoma to focus on what factors they do have control over, such as decreasing their children's skin cancer risk by facilitating their use of sun protection strategies.Given our results that more frequent discussions of sun protection behaviors were associated with higher engagement in sun protective behaviors even in the context of high fatalism, survivors can be encouraged to regularly discuss and reinforce their children's use of sun protection.Familybased interventions focusing on improving communication about these behaviors may be helpful.
Our results also suggested factors to identify families in greatest need of interventions.Specifically, female melanoma survivors with high cancer fatalism and families with a higher number of members with melanoma seem to be at greater risk for poor child sun protection, especially when the survivor's cancer fatalism is high.Directly addressing cancer fatalism with melanoma survivors may be improve upon prior interventions that were less effective for female survivors and those who had a family history of melanoma (Gritz et al., 2013).

Study limitations
The results of this study are limited by the relatively homogenous study sample, modest sample size (including a smaller proportion of fathers relative to mothers), and single geographic location for recruitment of participants.Future work could expand the sample to other geographic locations and investigate whether environmental factors such as ambient UVR levels impact outcomes such as sun protection behaviors and sunburn occurrence.In the current study, the reliance on self-report methods to assess sun protective behaviors could introduce bias to the results and may not be as accurate as more objective measures of these behaviors.Despite these limitations, our findings are consistent with previous studies demonstrating that fatalist beliefs can negatively impact cancer preventative behaviors (Befort et al., 2013;Bottaro et al., 2023;Coups et al., 2014;Espinosa de Los Monteros and Gallo, 2011;Fenton et al., 2019;Hay et al., 2019;Powe and Finnie, 2003) and indicate potential intervention targets (i.e.parent-child discussions of sun protective behaviors) to prevent fatalistic beliefs from impacting sun protective behaviors in children of melanoma survivors.Future studies could also seek to expand knowledge on how cancer fatalism fits within existing health behavior theories and how it may be related to the outcomes and both modifiable and non-modifiable constructs within those theories.

Conclusion
Future research should build on these findings by exploring the specific ways in which cancer fatalism impacts survivors' facilitation of sun protection behaviors among their children, who are at increased risk of developing melanoma.Given that cancer fatalism may be more prevalent among individuals of lower socioeconomic status, lower education levels, and ethnic minority groups (Kobayashi and Smith, 2016;Powe and Finnie, 2003), these findings should be replicated in larger, more diverse study populations.Female survivors of melanoma with high cancer fatalism and families with a high family history of melanoma should be targeted for intervention.Interventions should include strategies to promote parentchild discussions about melanoma preventative behaviors.It is hoped that addressing cancer fatalism in the context of melanoma prevention interventions will lead to better outcomes.

Data sharing statement
The current article is accompanied by the relevant raw data generated during and/or analysed during the study, including files detailing the analyses and either the complete database or other relevant raw data.These files are available in the Figshare repository and accessible as Supplemental Material via the Sage Journals platform.Ethics approval, participant permissions, and all other relevant approvals were granted for this data sharing.

Figure 1 .
Figure 1.(a) Parent-child discussion as a moderator of survivor melanoma fatalism on child sunscreen use, (b) parent-child discussion as a moderator of survivor melanoma fatalism on child long pants use, (c) parent gender as moderator of survivor melanoma fatalism on child sunscreen use, and (d) family history of melanoma as a moderator of survivor melanoma fatalism on child sunscreen use.

Table 2 .
Descriptive statistics for outcomes of interest (parent-report).

Table 3 .
Regression models examining the influence of fatalism, parent-child discussion about melanoma prevention, and their interaction on child sun protection outcomes.