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Decisional Balance and Self-Efficacy for Sun Protection: Measurement Among Turkish Adolescents

Aygun, Ozcan; Ergun, Ayse

doi: 10.1097/NNR.0000000000000048

Background Sun protection is important for skin cancer prevention, but many adolescents do not protect themselves from the sun. Instrumentation derived from the transtheoretical model (TTM) can be used to study the process of change in health behaviors like sun protection.

Objective The purpose of this study was to translate and adapt TTM-based decisional balance and self-efficacy for sun protection scales from English to Turkish and assess psychometric properties of scores when the scales are used among Turkish adolescents.

Methods The Decisional Balance Scale (DBS) and the Self-Efficacy Scale (SES) for sun protection were adapted to Turkish culture using translation and back-translation. The scales were administered to a total of 900 adolescents in two Turkish schools. Confirmatory factor analysis was used to assess dimensionality. External validity was evaluated by comparing subscale scores across reported stages of change for sun protection.

Results Reliability estimates for scores on the DBS Pros and DBS Cons and the SES Sunscreen Use scales were high and SES Hat Use and Sun Avoidance were moderate. The two-factor correlated model for the DBS and the three-factor correlated model for the SES reported in other studies were confirmed. Means increased across the stages of change for sun protection and sunscreen use for the DBS Pros and the SES subscales as predicted by the TTM, but the pattern of DBS Cons means did not.

Discussion Scores from the Turkish version of the DBS and SES for sun protection were valid, reliable, and appropriate for Turkish culture. The pattern of means for the SES and DBS Pros across the stages of change supported propositions of the TTM. Theoretical inconsistencies in the pattern of DBS Cons scores across the stages of change suggest that greater attention to conceptualization and measurement of the DBS Cons for sun protection and sunscreen use is needed.

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Ozcan Aygun, PhD, RN, is Teaching Staff, Fethiye High School of Health Nursing Department, Mugla Sitki Kocman University, Fethiye/Mugla, Turkey.

Ayse Ergun, PhD, RN, is Assistant Professor, Public Health Nursing Department, Division of Nursing, Faculty of Health Science, Marmara University, Istanbul, Turkey.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Accepted for publication April 4, 2014.

The authors acknowledge this study was supported by the Marmara University Scientific Research Projects Coordination Unit (Project Number SAG-C-DRP-210311-0050). Portions of this article presented a poster presentation at the 24th International Nursing Research Congress of the Sigma Theta Tau International in Prague, Czech Republic, 22–26 July, 2013. The authors also acknowledge the cooperation of the Turkish Ministry of Education as well as the many principals, teachers, parents, and students who participated in this study.

The authors have no conflicts of interest to report.

Corresponding author: Ozcan Aygun, PhD, RN, Fethiye High School of Health Nursing Department, Mugla Sitki Kocman University, Calica Mevkii, Karaculha, Fethiye/Mugla, Turkey (e-mail:

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.