*2.5. Survey Instrument*

The initial draft of the survey was sent to seven panelists (including three authors). All were experts in instrumentation in social and behavioral health sciences, five were experts on MTM, two were experts in sun protection research, and three were chosen from the target population. The instrument was validated for face and content validity, along with readability, in two rounds. A total of 16 changes were made during two rounds. Consensus was reached between the experts after two rounds, to finalize the survey instrument. To minimize observer bias, all reviewers were blinded. A 51-item survey MTM based questionnaire was created to examine determinants of sunscreen use among Florida residents. The Flesch reading ease of the entire scale was 66.9 and the Flesch–Kincaid grade level was 5.7 (or less than sixth grade). The survey was composed of 20 questions related to demography, outdoor activities, sunscreen use, and medical history. In addition, 31 items were related to two primary MTM theoretical constructs (initiation and sustenance). The initiation component comprised three constructs which included participatory dialogue, behavioral confidence, and changes in physical environments. "Participatory dialogue" between interventionist and subject evaluates the advantages

and disadvantages of initiating an action [28–30]. "Behavioral confidence" is like selfefficacy but with subtle differences, it focuses on the self-confidence of the individual in acting. "Changes in physical environment" emphasizes the need for the subject to modify available resources and settings for a behavior to occur. The other component, sustenance (a continuation of behavior) comprises another three constructs: emotional transformation, practice for change, and changes in social environment. "Emotional transformation" involves changes in feelings and attitude and in this process, an individual prepares mentally to sustain the action [28–30]. "Practice for change" is a reflective process that continues while person is in action phase. The individual monitors behavioral progress and brings needed changes to sustain the behavior. "Changes in social environment" captures the available support around the individual that is conducive to sustaining the behavior [28–30]. A visual representation of MTM constructs is provided in Figure 1. vantages of initiating an action [28–30]. "Behavioral confidence" is like self-efficacy but with subtle differences, it focuses on the self-confidence of the individual in acting. "Changes in physical environment" emphasizes the need for the subject to modify available resources and settings for a behavior to occur. The other component, sustenance (a continuation of behavior) comprises another three constructs: emotional transformation, practice for change, and changes in social environment. "Emotional transformation" involves changes in feelings and attitude and in this process, an individual prepares mentally to sustain the action [28–30]. "Practice for change" is a reflective process that continues while person is in action phase. The individual monitors behavioral progress and brings needed changes to sustain the behavior. "Changes in social environment" captures the available support around the individual that is conducive to sustaining the behavior [28–30]. A visual representation of MTM constructs is provided in Figure 1.

based questionnaire was created to examine determinants of sunscreen use among Florida residents. The Flesch reading ease of the entire scale was 66.9 and the Flesch–Kincaid grade level was 5.7 (or less than sixth grade). The survey was composed of 20 questions related to demography, outdoor activities, sunscreen use, and medical history. In addition, 31 items were related to two primary MTM theoretical constructs (initiation and sustenance). The initiation component comprised three constructs which included participatory dialogue, behavioral confidence, and changes in physical environments. "Participatory dialogue" between interventionist and subject evaluates the advantages and disad-

*Healthcare* **2021**, *9*, x 4 of 13

**Figure 1.** Multi-theory model framework. **Figure 1.** Multi-theory model framework.

#### *2.6. Statistical Analysis 2.6. Statistical Analysis*

Participants' responses were first preprocessed and then exported to IBM SPSS version 27.0 (IBM Corp. Armonk, NY, USA) for statistical analyses. Incomplete responses and those with invalid data entries were excluded. Mean and standard deviation were used to represent continuous variables. Counts and proportions were used to express categorical variables. Inferential statistics were conducted through independent samples-*t*-tests to perform group-wise comparisons. Cronbach's alpha values were computed for the entire scale and subscales to assess the internal consistency. Two hierarchical regression models (HRM) were fit to explain the variance in the likelihood of initiation and sustenance of sunscreen use behavior by MTM individual constructs, besides the demographic variables. Structural equation modeling (SEM) was utilized for the construct validation. The Participants' responses were first preprocessed and then exported to IBM SPSS version 27.0 (IBM Corp. Armonk, NY, USA) for statistical analyses. Incomplete responses andthose with invalid data entries were excluded. Mean and standard deviation were used torepresent continuous variables. Counts and proportions were used to express categorical variables. Inferential statistics were conducted through independent samples-*t*-tests to perform group-wise comparisons. Cronbach's alpha values were computed for the entire scale and subscales to assess the internal consistency. Two hierarchical regression models (HRM) were fit to explain the variance in the likelihood of initiation and sustenance of sunscreen use behavior by MTM individual constructs, besides the demographic variables. Structural equation modeling (SEM) was utilized for the construct validation. The Analysis of Moment Structure, AMOS (Chicago, IL, USA) was used for SEM [27]. We used indices such as chi-square (χ 2 ), root mean square error of approximation (RMSEA), comparative fit index (CFI), and Tucker–Lewis (TLI) to assess how well our models fit the data [31–33]. Models were considered to have adequate fit if they met the less stringent, but traditionally accepted, values of 0.90 or greater for CFI and TLI, and values less than 0.08 for RMSEA. *P*-values less than 0.05 were considered statistically significant.
