**3. Results**

A total of 1284 valid responses were included in the analysis. The mean age of the sample was 50.2 ± 18.1 years. Nearly 86% participants reported living in zip codes not touching an ocean or gulf area (Table 1). About 75 percent of the sample population reported having no college level education or degree. White respondents represented nearly half of the sample population. Six out of 10 respondents reported being employed and having an annual income under USD 100,000 (Table 1). About 13 percent of respondents had a history of skin cancer. Noticeably, 4 in 10 respondents had a family history of skin cancer (Table 1). Sunscreen users had a statistically significant higher mean scores for initiation (2.10 ± 1.49 vs 0.41 ± 1.2) and sustenance (1.82 ± 1.46 vs 0.36 ± 0.74) compared to sunscreen non-users (Table 2).

**Table 1.** Demographic characteristics of the sample population of Floridians (*N* = 1284).


Note: Percentage may not add to 100%, due to some missing data.


**Table 2.** Possible and observed range and mean scores of multi-theory model constructs of behavior change across participants who engaged in sunscreen usage behavior and those who did not engage in sunscreen usage behavior (*n* = 1284).

> Among participants who were engaged in sunscreen usage behaviors, the final model containing the demographic variables and all three constructs to predict initiation was statistically significant (adjusted R<sup>2</sup> = 0.736, F = 113.572, *p* < 0.001; Table 3). In the same group, constructs of emotional transformation, practice for change, and changes in social environment (besides family history of skin cancer) were significant predictors of the sustenance of sunscreen usage behavior (adjusted R<sup>2</sup> = 0.590, F = 59.565, *p* < 0.001; Table 3). Among participants who were not engaged in sunscreen usage behaviors, the model containing all constructs of initiation that were significant predictors of initiation was statistically significant; adjusted R<sup>2</sup> = 0.500, F = 61.305, *p* < 0.001; Table 4. In the sustenance model, emotional transformation, practice for change, and changes in the social environment explained 23.9% of variance in sustaining sunscreen usage behaviors among those who did not engage in sunscreen usage behavior (adjusted R<sup>2</sup> = 0.239, F = 19.80, *p* < 0.001; Table 4).

**Table 3.** Hierarchical multiple regression (HRM) predicting likelihood of initiation and sustenance among respondents who used sunscreen (*n* = 523).



**Table 3.** *Cont*.

B (Unstandardized coefficient); β (Standardized coefficient), \* *p*-value < 0.05; \*\* *p*-value < 0.001; Adjusted R<sup>2</sup> of initiation = 0.736; Adjusted R <sup>2</sup> of sustenance = 0.590.

**Table 4.** Hierarchical Multiple Regression (HRM) predicting likelihood of initiation and sustenance among respondents who did not use sunscreen (*n* = 761).


B (Unstandardized coefficient); β (Standardized coefficient), \* *p*-value < 0.05; \*\* *p*-value < 0.001; Adjusted R<sup>2</sup> of initiation = 0.500; Adjusted R <sup>2</sup> of sustenance = 0.239.

*Construct Validation through Structural Equation Modeling*

The structural equation modeling results (e.g., χ 2 [252] = 1511.870 (*p* < 0.001), CFI = 0.93, TLI= 0.92, and RMSEA = 0.08) for the initiation model demonstrated the goodness of fit of the data. Standardized effects of latent variables on the factor loading indicators were observed. The factor loadings of all the subscales of initiation are shown in Figure 2. *Healthcare* **2021**, *9*, x 9 of 13

**Figure 2.** Structural equation modeling for initiation of sunscreen use behavior among Florida residents. **Figure 2.** Structural equation modeling for initiation of sunscreen use behavior among Florida residents.

The sustenance model fit the data well (e.g., χ 2 [30] = 193.871 (*p* < 0.001), CFI = 0.98, TLI = 0.97, and RMSEA = 0.07). The factor loadings for emotional transformation, practice for change, and changes in the social environment were statistically significant. The factor loadings for all the subscales of sustenance are shown in Figure 3. The between construct correlations and standardized regression coefficients for emotional transformation showed moderate direct effects on the sustenance of sunscreen behavior, with β ranging from 0.12 to 0.51. However, both practice for change and changes in the social environment did not have any significant effects on the sustenance of sunscreen use behavior. **Figure 2.** Structural equation modeling for initiation of sunscreen use behavior among Florida residents.

proportion of variance in the dependent variables. In our sample, 40.7% of the **Figure 3.** Structural equation modeling for sustenance of sunscreen use behavior among Florida residents. **Figure 3.** Structural equation modeling for sustenance of sunscreen use behavior among Florida residents.

The purpose of this study was to identify the correlates of sunscreen use, based on the fourth-generation multi-theory model (MTM) of health behavior change among Florida residents. MTM has been tested or applied to explain various health behaviors in community settings [37–43]. The results of the study were encouraging; the contribution of MTM constructs in all four models tested were significant and accounted for a substantial proportion of variance in the dependent variables. In our sample, 40.7% of the

**4. Discussion** 
