Melanoma prevention: behavioral and nonbehavioral factors in sunburn among an Australian urban population

A multicentre epidemiological study on sunbed use and cutaneous melanoma in Europe

A large European case-control study investigated the association between sunbed use and cutaneous melanoma in an adult population aged between 18 and 49 years. Between 1999 and 2001 sun and sunbed exposure was recorded in 597 newly diagnosed melanoma cases and 622 controls in Belgium, France, The Netherlands, Sweden and the UK. Fifty three percent of cases and 57% of controls ever used sunbeds. The overall adjusted odds ratio (OR) associated with ever sunbed use was 0.90 (95% CI: 0.71-1.14). There was a South-to-North gradient with high prevalence of sunbed exposure in Northern Europe and lower prevalence in the South (prevalence of use in France 20%, OR: 1.19 (0.68-2.07) compared to Sweden, prevalence 83%, relative risk 0.62 (0.26-1.46)). Dose and lag-time between first exposure to sunbeds and time of study were not associated with melanoma risk, neither were sunbathing and sunburns (adjusted OR for mean number of weeks spent in sunny climates >14 years: 1.12 (0.88-1.43); adjusted OR for any sunburn >14 years: 1.16 (0.9-1.45)). Host factors such as numbers of naevi and skin type were the strongest risk indicators for melanoma. Public health campaigns have improved knowledge regarding risk of UV-radiation for skin cancers and this may have led to recall and selection biases in both cases and controls in this study. Sunbed exposure has become increasingly prevalent over the last 20 years, especially in Northern Europe but the full impact of this exposure on skin cancers may not become apparent for many years.

Reducing ultraviolet radiation exposure to prevent skin cancer methodology and measurement

Skin cancer is the most common type of cancer, and is also one of the most preventable. This paper builds on an evidence review of skin cancer prevention interventions that was conducted for the Guide to Community Preventive Services (n=85 studies), and summarizes the state of knowledge about research methodology and measurement in studies of the effectiveness of interventions to reduce ultraviolet radiation (UVR) exposure. As this field advances, researchers should strive to minimize threats to validity in their study designs, as well as to consider the balance between internal and external validity. There is a need for more longer-duration interventions, and follow-up periods that make possible conclusions about the potential of these interventions to affect intermediate markers of skin cancer or at least sustained behavior change. Also, more work is needed to minimize attrition and characterize nonresponders and study dropouts. Verbal report measures of behavior are the most widely used measures of solar protection behavior. Given their limitations, investigators should routinely collect data about reliability and validity of those measures. They should also increase efforts to complement verbal data with objective measures including observations, skin reflectance, personal dosimetry, skin swabbing, and inspection of moles. Measures of environments and policies should incorporate observations, documentation, and direct measures of ambient UVR and shade. This article places the data derived from the evidence review in the context of needs and recommendations for future research in skin cancer prevention.

Sun protective behaviors and sunburn experiences in parents of youth ages 11 to 18

BACKGROUND

Recent studies suggest that parental sun protective behaviors and communication influence their adolescents. However, there is limited information on sun protection for parents of adolescents.

METHODS

A telephone-based, nationally representative prevalence study of sun exposure among youth, aged 11-18, and their parents living in households was conducted in 1998. Separate, independent responses were collected. Weighted prevalence estimates and 95% confidence intervals were estimated and presented for parents only (n = 1187).

RESULTS

Approximately one-third of parents planned activities to avoid the sun and used sunscreen. Among parents who used sunscreen, 70% applied it while at the beach or pool, but not as often during other outdoor activities. Almost one-third of parents were participating in water or non-water recreational activities during their most serious sunburn. Differences in sun protection and sunburn experiences were observed by age, gender, sun sensitivity, race and ethnicity, and educational attainment.

CONCLUSIONS

Parents have adopted sun protection habits, but have not surpassed national sun-protection goals. Combined use of sun protection behaviors may reduce sunburn prevalence and number of incident skin cancers. These data may be useful for developing or enhancing current sun protection programs for effective sun protection that include parents and their adolescents.

Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review

The relationship between skin cancer and ultraviolet radiation is well established. Behaviors such as seeking shade, avoiding sun exposure during peak hours of radiation, wearing protective clothing, or some combination of these behaviors can provide protection. Sunscreen use alone is not considered an adequate protection against ultraviolet radiation. This report presents the results of systematic reviews of effectiveness, applicability, other harms or benefits, economic evaluations, and barriers to use of selected interventions to prevent skin cancer by reducing exposure to ultraviolet radiation. The Task Force on Community Preventive Services found that education and policy approaches to increasing sun-protective behaviors were effective when implemented in primary schools and in recreational or tourism settings, but found insufficient evidence to determine effectiveness when implemented in other settings, such as child care centers, secondary schools and colleges, and occupational settings. They also found insufficient evidence to determine the effectiveness of interventions oriented to healthcare settings and providers, media campaigns alone, interventions oriented to parents or caregivers of children, and community-wide multicomponent interventions. The report also provides suggestions for areas for future research.

Evaluation of sun-protective practices of organ transplant recipients

The incidence, morbidity and mortality of skin cancer are markedly increased in organ transplant recipients. Efforts aimed at reducing sun exposure through sun avoidance, sunscreens and sun-protective clothing are the most effective means to reduce the risk of skin cancer. We evaluated the sun-protective behaviors of 205 transplant recipients. Twenty-three percent of transplant patients continued to seek a tan. Thirty percent of patients did not use sunscreens, and of those patients who did, less than 5% were committed to using them daily. Thirty-seven percent of patients frequently wore hats and 39% of patients frequently wore additional clothing to block the sun. When data were stratified according to patient age, gender or skin phototype, we identified preferences for specific sun-protective methods. These data strongly suggest that many transplant recipients do not use adequate sun protection. Further study of strategies to encourage the use of sun protection among transplant patients is needed to reduce the incidence of skin cancer.

Predictors of sun protection in northern Australian men with a history of nonmelanoma skin cancer

BACKGROUND

It is important to understand what predicts regular use of sun protection in men susceptible to skin cancer.

METHODS

A questionnaire survey of men with previous nonmelanoma skin cancer (n = 300) was conducted.

RESULTS

Participants who typically used sunscreen tended to be younger, have fewer excised skin lesions, work indoors, and have spent most of their life in the tropics. Predictors of wearing a long-sleeved shirt with a wide-brimmed hat were not enjoying sun exposure, not having barriers to using sun protection, having more skin lesions previously excised, working for a company with a mandatory policy of sun protection, attitudes that the benefits of a suntan do not outweigh the risks and that skin cancers cannot be easily treated, and age over 50.

CONCLUSIONS

Men who adequately protect themselves from the sun and who have better attitudes to sun exposure were more often those with a high level of negative experience with skin cancer. Therefore, the sun protection attitudes and behaviors of some men may only improve after significant sun damage. This study recommends that the use of appropriate sun protective clothing should be made mandatory for all who work outdoors in high-sun-exposure occupations.

Environmental conditions and variation in levels of sun exposure among children in child care

Sun exposure in childhood is 1 of the risk factors for developing skin cancer, yet little is known about levels of exposure at this age. This is particularly important in countries with high levels of ultraviolet radiation (UVR) such as Australia. Among 49 children 3 to 5 years of age attending child care centers, UVR exposure was studied under 4 conditions in a repeated measures design; sunny days, cloudy days, teacher's instruction to stay in the shade, and a health professionals instruction to apply sunscreen. Three different data collection methods were employed: (a) completion of questionnaire or diary by parents and researcher, (b) polysulphone dosimeter readings, and (c) observational audits (video recording). Results of this study indicated that more than half the children had been sunburnt (pink or red) and more than a third had experienced painful sunburn (sore or tender) in the last summer. Most wore short sleeve shirts, short skirts or shorts and cap, that do not provide optimal levels of skin protection. However, sunscreen was applied to all exposed parts before the children went out to the playground. Over the period of 1 hr (9-10 a.m.) the average amount of time children spent in full sun was 22 min. On sunny days there was more variation across children in the amount of sun exposure received. While the potential amount of UVR exposure for young children during the hour they were outside on a sunny day was 1.45 MED (Minimum Erythemal Dose), they received on average 0.35 MED, which is an insufficient amount to result in an erythemal response on fair skin even without the use of sunscreen.

Campaigning for melanoma prevention: a model for a health education program

Melanoma incidence and mortality rates are rising in many countries. This has led to the development of a variety of education programs designed for either early detection of melanoma when it can be easily cured, or prevention by taking a long term approach. Australia has been leading in these areas running programs such as Slip! Slop! Slap! for over 20 years. Data now show that attitudes towards sunlight and suntans have changed substantially. Sunburn rates have decreased as photoprotection has increased. Melanoma mortality rates are decreasing in the younger cohorts as a result of earlier detection of tumours that can be easily cured. Finally, incidence rates for melanoma in the younger cohorts are starting to level out and go down. Thus health education programs can be successful if they are well-designed and evaluated. In Australia we are now extending these programs beyond melanoma and into education programs on other common skin diseases such as acne, atopic dermatitis, warts, tinea, and a variety of other common conditions, depending on the level at which the education program is being delivered. This is the first time that coordinated public education programs on skin diseases, apart from skin cancer, have occurred anywhere in the world.

Correlates of sunburn experiences among U.S. adults: results of the 2000 National Health Interview Survey

OBJECTIVE

The purpose of this study was to determine the rate of sunburns in the U.S. adult population and the correlates of sunburns.

METHODS

Data from the 2000 National Health Interview Survey Cancer Control Module were used to calculate the number of sunburns (0, 1, 2, or > or = 3) experienced during the past year by age, sex, race/ethnicity, and skin sensitivity to sun exposure. The relationship between no sunburns vs. one or more sunburns and additional demographic, health, and behavioral factors for adults who self-identify as white Hispanic or white non-Hispanic was assessed using general linear contrasts. Multivariate logistic regression modeling was conducted to determine the most important covariates associated with sunburns. All analyses were weighted for the complex sampling design.

RESULTS

The study data suggest that overall, 18.5% (95% confidence interval [CI] 17.9, 19.1) of U.S. adults experience one sunburn a year, 9.7% (95% CI 9.3, 10.1) experience two, and 8.0% (95% CI 7.6, 8.4) experience > or = 3 sunburns. The data also indicate that adults who self-identify as white non-Hispanic experience sunburns more frequently than (in order of prevalence) those who identify as American Indian/Alaska Native, white Hispanic, Asian/Pacific Islander, or black. Sunburns were found to be more common among men than among women, more common among younger age groups than among older age groups, and more common among those with skin more prone to sunburn than among those with skin less prone to sunburn. Among individuals who self-identify as white Hispanic or white non-Hispanic, protective behaviors associated with lower rates of one or more sunburns in multivariate analyses are staying in the shade (odds ratio [OR] 0.73, 95% CI 0.66, 0.80) and wearing long-sleeved shirts (OR 0.86, 95% CI 0.75, 0.99).

CONCLUSIONS

Many American adults have one or more sunburns per year. Methods to protect from sun exposure may not be used as needed to prevent sunburn.

Correlates of sunburn experiences among U.S. adults: results of the 2000 National Health Interview Survey

OBJECTIVE

The purpose of this study was to determine the rate of sunburns in the U.S. adult population and the correlates of sunburns.

METHODS

Data from the 2000 National Health Interview Survey Cancer Control Module were used to calculate the number of sunburns (0, 1, 2, or > or = 3) experienced during the past year by age, sex, race/ethnicity, and skin sensitivity to sun exposure. The relationship between no sunburns vs. one or more sunburns and additional demographic, health, and behavioral factors for adults who self-identify as white Hispanic or white non-Hispanic was assessed using general linear contrasts. Multivariate logistic regression modeling was conducted to determine the most important covariates associated with sunburns. All analyses were weighted for the complex sampling design.

RESULTS

The study data suggest that overall, 18.5% (95% confidence interval [CI] 17.9, 19.1) of U.S. adults experience one sunburn a year, 9.7% (95% CI 9.3, 10.1) experience two, and 8.0% (95% CI 7.6, 8.4) experience > or = 3 sunburns. The data also indicate that adults who self-identify as white non-Hispanic experience sunburns more frequently than (in order of prevalence) those who identify as American Indian/Alaska Native, white Hispanic, Asian/Pacific Islander, or black. Sunburns were found to be more common among men than among women, more common among younger age groups than among older age groups, and more common among those with skin more prone to sunburn than among those with skin less prone to sunburn. Among individuals who self-identify as white Hispanic or white non-Hispanic, protective behaviors associated with lower rates of one or more sunburns in multivariate analyses are staying in the shade (odds ratio [OR] 0.73, 95% CI 0.66, 0.80) and wearing long-sleeved shirts (OR 0.86, 95% CI 0.75, 0.99).

CONCLUSIONS

Many American adults have one or more sunburns per year. Methods to protect from sun exposure may not be used as needed to prevent sunburn.

Can an hour or two of sun protection education keep the sunburn away? Evaluation of the Environmental Protection Agency's Sunwise School Program

BACKGROUND

Melanoma incidence is rising at a rate faster than any other preventable cancer in the United States. Childhood exposure to ultraviolet (UV) light increases risk for skin cancer as an adult, thus starting positive sun protection habits early may be key to reducing the incidence of this disease.

METHODS

The Environmental Protection Agency's SunWise School Program, a national environmental and health education program for sun safety of children in primary and secondary schools (grades K-8), was evaluated with surveys administered to participating students and faculty.

RESULTS

Pretests (n = 5,625) and posttests (n = 5,028) were completed by students in 102 schools in 42 states. Significant improvement was noted for the three knowledge variables. Intentions to play in the shade increased from 68% to 75%(p < 0.001) with more modest changes in intentions to use sunscreen. Attitudes regarding healthiness of a tan also decreased significantly.

CONCLUSIONS

Brief, standardized sun protection education can be efficiently interwoven into existing school curricula, and result in improvements in knowledge and positive intentions for sun protection.

Evaluation of the SunWise School Program

Melanoma, the most fatal form of skin cancer, is rising at rates faster than all other preventable cancers in the United States. Childhood exposure to ultraviolet (UV) light increases the risk for skin cancer as an adult, therefore, starting positive sun protection habits early may be key to reducing the incidence of this disease. The Environmental Protection Agency's SunWise School Program, a national environmental and health education program for sun safety of children in primary and secondary schools (Grades K-8), was evaluated. Pretests (n = 4,559) and posttests (n = 4,016) were completed by students from 85 schools in 35 states. Significant increases were noted for the three knowledge variables. Intentions to play in the shade increased from 70% to 76% (p < 0.001) with more modest changes in intentions to use sunscreen. Attitudes regarding the healthiness of a tan also decreased significantly. Brief, standardized sun protection education can be efficiently interwoven into existing school curricula and result in increases in knowledge and positive intentions for sun protection.

Spectral UV in public shade settings

The protective nature of specific shade environments was investigated by measuring the spectral UV in the shade for the three planes (horizontal, 45 degrees and vertical) and comparing this to that on a horizontal plane in full sun. Spectral UV irradiance measurements were made under clear sky conditions at a sub-tropical southern hemisphere site. The solar UV in the shade of a shade umbrella, covered verandah, covered sand pit and covered walkway were measured for an increasing solar zenith angle, between March and August, for the times of 11:30 a.m.-12:30 p.m. and 2:30-3:30 p.m. The ultraviolet protection factors provided ranged from 1.4 to 10. This research shows that there is sufficient UV in the shade to cause erythema on the human body in a short period of time. For the shade umbrella placed on dry grass the time able to be spent in the shade in the middle of the day before experiencing mild erythema increased from 35 to 60 min as the solar zenith angle increased from 33 to 52 degrees. Erythemal UV levels in the shade of a northern facing covered verandah, with trees in close proximity, were approximately up to five times less than the erythemal UV beneath the shade umbrella that had no surrounding trees. Shade structures must be given careful consideration when construction occurs. Even though the UV transmission through the materials may be very low, it is the construction of the entire shade setting that determines the exposure beneath the shade structure.

The changing incidence and mortality of melanoma in Australia

For many years Australia has had the highest incidence and mortality rates in the world for melanoma. The incidence rate has been increasing at around 5% per year and the mortality rate, at a rate slightly lower than that. Epidemiology studies have shown clearly that there is both a constitutional and an environmental contribution to melanoma risk, with sunlight being the major risk factor in the environment. The data also clearly show that the thickness of a melanoma at the time it is removed is one of the major determinants of the likelihood of metastasis and thus of the long-term prognosis. Both of these components have been incorporated into major public health programmes aimed at melanoma control in Australia over the last 25 years. Primary prevention programmes have been aimed at reducing the desire for a tan and subsequent overexposure to sunlight. Secondary prevention (early detection) programmes have encouraged people in the community to seek early attention if they notice a new or changing pigmented lesion. Although the age-adjusted incidence and mortality rates for Australia continue to rise, cohort analysis of both incidence and mortality rates reveals that the overall rise is not reflected in all age groups. In the younger cohorts--groups that it has been possible to influence by our public health campaigns in recent decades--both incidence and mortality rates are dropping.

Positive changes in sun-related behavior in Israel (1994-1998)

BACKGROUND

Current preventive measures against skin cancer focus on individual sun protection and early detection. Solar radiation in Israel is powerful, and about one-half of its population is fair skinned. We investigated whether public awareness efforts yielded changes in sun-related behaviors in Israel from 1994 to 1998.

METHODS

The Department of Health Promotion in the Ministry of Health in Israel has been conducting an ongoing research on health knowledge, attitude, and practice, including six closed questions about sun-related behaviors in a general questionnaire. Independent samples of about 3,000 people representing the adult Jewish population (18 years old and above) were surveyed in 1994, 1996, and 1998. Response rates in 1994 and 1996 were about 85 and 80% in 1998.

RESULTS

The number of people reporting sun protection behaviors increased from 34% in 1994 to 41% in 1996 and to 46% in 1998. Periodic medical skin examination increased from 9% of the responders in 1994, to 13% in 1996 and to 16% in 1998. The number of people reporting having fair skin increased from 28% in 1994 to 41% in 1996 and to 43% in 1998.

CONCLUSIONS

There were positive changes in sun-related awareness and behaviors in Israel between 1994 and 1998. These findings support the conclusion that positive gains were associated with the health promotion efforts conducted by the Israel Cancer Society, Ministry of Health, and other Israeli organizations throughout these years.

Sun-related behaviors of outdoor working men with a history of non-melanoma skin cancer

The present study describes sun exposure and sun protection behaviors of northern Australian outdoor workers with previous non-melanoma skin cancer (NMSC). In 1999 a cross-sectional study of northern Australian men with previous NMSC was conducted by self-administered questionnaire. Compared to other men, outdoor workers spent more time in the sun on average working days and days off (P < 0.0001, respectively), and outdoor workers with sun-sensitive skin reported that more skin lesions had been removed (P = 0.0461). The workplace did not reinforce sun-safe practices of 36.8% of workers who spent half their time or more outdoors. Sun-protective behaviors were not different between in- and outdoor workers. Outdoor workers experienced high levels of sun exposure, however, sun-protective behavior was similar to other workers. Workplaces should be targeted to reinforce sun-safe policies.

Sunburn prevalence among adults in the United States, 1999

BACKGROUND

Exposure to high levels of sunlight, such as a sunburn, is a strong determinant of melanoma risk.

METHODS

To describe statewide and U.S. estimates of sunburn prevalence in the United States and determine demographic and behavioral predictors of sunburn, we analyzed data from the 1999 Behavioral Risk Factor Surveillance System, a population-based telephone survey conducted in all 50 states, the District of Columbia, and Puerto Rico.

RESULTS

Of 156,354 adults aged > or =18 years, 31.7% (95% confidence interval, 31.3%-32.1%) reported a sunburn in the past year; of adults aged 18 to 29 years, 57.5% reported such a sunburn. Reporting was highest among white, non-Hispanic males (44.1%), followed by white non-Hispanic females (35.3%), and lowest among black non-Hispanic males and females (5.1% and 5.3%, respectively). Statewide period prevalence of sunburn among whites was highest (>45%) in Wisconsin, Utah, Wyoming, Washington, DC, and Indiana, and lowest (<30%) in Puerto Rico, Arizona, Tennessee, Oklahoma, and New York.

CONCLUSIONS

Nationwide and statewide skin cancer prevention efforts should target young adults. Periodic monitoring of sunburn is important in evaluating the effectiveness of those efforts.

Sunbed use at home: risk behaviour and psychosocial determinants

The objective of this study was to analyse the behaviour of people with regard to sunbed use at home, and to analyse the psychosocial determinants of intention and behaviour with regard to limiting the health risk of using sunbeds at home. Data were collected by means of a telephone survey among 349 adults from the Dutch general public who use sunbeds at home (response=95%). Determinants that were assessed were: attitude with respect to safer use and the use of sunbeds in general, the social influences people encounter to use sunbeds in a safer way, and the self-efficacy expectations people have of their ability to use sunbeds more safely. The results showed that there were great differences between people's perceptions of their safe sunbed behaviour, and their actual safety behaviour. Almost all respondents (94%) thought that their sunbed behaviour was safe, while in reality only 37% of the respondents used the sunbed in accordance with the safety guidelines. The safer users of sunbeds differed on many determinants from the unsafe users. Intention to minimize the health risk when using sunbeds could be predicted by a person's perceived self-efficacy, the overall attitude and anticipated regret beliefs (R2=0.52). Sunbed users should be made aware of their risk behaviour with regard to sunbeds as well as providing information on changing determinants, in order to positively change people's intentions and behaviour with regard to the safer use of sunbeds.

Summer sunburn and sun exposure among US youths ages 11 to 18: national prevalence and associated factors

OBJECTIVE

Epidemiologic evidence suggests that ultraviolet radiation (UVR), from sun exposure and sunburns during early life, is associated with increased risk of melanoma and other skin cancers in adulthood. The objective of this study was to gather national, population-based data on sun exposure and protection behaviors among US youths ages 11 to 18 to quantify the magnitude and patterns of sun exposure and establish baselines for continued surveillance.

METHODS

A nationwide survey based on random-digit dialing and stratified, 2-stage national probability sampling was conducted of households with telephones in the 48 contiguous states of the United States during July through October of 1998; a population-based sample of 1192 youth ages 11 to 18 was studied to measure weighted prevalence estimates of summer sunburn and sun exposure and adjusted prevalence odds ratios and 95% confidence intervals from logistic regression analyses of sunburn.

RESULTS

Among youths ages 11 to 18, 72% reported having had at least 1 summer sunburn, 30% reported at least 3, and 12% reported at least 5 sunburns. Before receiving their most serious summer sunburn, 39% of youths reported having applied sunscreen. Factors associated with increased odds of sunburn included greater sun sensitivity, white race, age younger than 16 years, more hours spent outdoors, and high desirability of a tan.

CONCLUSIONS

Summer sunburn was the norm among US youths ages 11 to 18. The high frequency of sunscreen use during the sunburning episodes suggests the need to educate youth and parents better about proper use of these agents, as well as the importance of practicing other sun protection behaviors, such as wearing hats and protective clothing and avoiding the sun during peak exposure times. These data may serve as a baseline for tracking progress in skin cancer prevention efforts and will inform the crafting of future public health campaigns.

The Environmental Protection Agency's National SunWise School Program: sun protection education in US schools (1999-2000)

BACKGROUND

Melanoma, the most fatal form of skin cancer, is rising at a rate faster than that of all preventable cancers except lung cancer in the United States. Childhood exposure to ultraviolet (UV) light increases the risk for skin cancer as an adult; thus starting positive sun protection habits early may be key to reducing incidence.

METHODS

We evaluated the US Environmental Protection Agency's SunWise School Program, a national, environmental education program for sun safety of children in primary and secondary schools (kindergarten through eighth grade). The program was evaluated with surveys administered to participating students. An identical 18-question, self-administered survey was completed by students (median age, 10 years) in the classroom before and immediately after the SunWise educational program.

RESULTS

Surveys were completed by students in 40 schools before (pretests; n = 1894) and after the program was presented (post-tests; n = 1815). Significant improvement was noted for the 3 knowledge variables: appropriate type of sunscreen to be used for outdoor play, highest UV Index number, and need for hats and shirts outside. Intentions to play in the shade increased from 73% to 78% (P <.001), with more modest changes in intentions to use sunscreen. Attitudes regarding healthiness of a tan also decreased significantly.

CONCLUSIONS

Brief, standardized sun protection education can be efficiently interwoven into school health education and result in improvements in knowledge and positive intentions for sun protection.

Predictors of sunburn among Canadian adults

BACKGROUND

Data from the 1996 National Survey on Sun Exposure & Protective Behaviors (4,023 respondents) were analyzed to identify independent predictors of sunburn among adult Canadians.

METHODS

Multivariate models predicting sunburn odds were developed using unconditional logistic regression. Backward elimination model selection was used to identify independent predictors of sunburn.

RESULTS

Nonbehavioral characteristics found to predict sunburn were younger age, male sex, light skin color, nonblack hair color, and birthplace in North America or Europe. Behavioral predictors of sunburn included high awareness of the UV Index, working outdoors in the summer, longer leisure time in the sun, forgetfulness about protecting oneself from the sun, and seeking a tan. Sun avoidance between 11 AM and 4 PM was associated with lower odds of sunburn, while seeking shade when outside and use of protective clothing showed nonsignificant associations with lower sunburn odds. Sunscreen use was found to have a nonsignificant positive association with sunburn.

CONCLUSIONS

These findings highlight risk factors to be considered in the targeting of sunburn reduction strategies to high-risk groups and suggest that sun avoidance, seeking shade, and use of protective clothing may be effective in preventing sunburn.

Sun exposure and sun-protection behaviors and attitudes among U.S. youth, 11 to 18 years of age

BACKGROUND

Adolescence is a high-risk period for the development of melanoma and nonmelanocytic skin cancers later in life. This study examines the prevalence and correlates of sun-protection practices among U.S. youth.

METHODS

During July-October, 1998, a national, population-based telephone survey was conducted (N = 1,192 paired interviews of youth and their parents). Weighted prevalence and adjusted prevalence odds ratios and 95% confidence intervals were estimated. Multiple logistic regression analyses examined associations between sociodemographics, attitudes, and other modifiable correlates to specific behaviors.

RESULTS

Routinely practiced sun-protection behaviors among youth on sunny days were wearing sunglasses (32%) or long pants (21%), staying in the shade (22%), and applying sunscreen (31%). Fifty-eight percent used a sunscreen with SPF > or =15 when at the beach or pool. Age, sex, and sun sensitivity were associated with substantial variation in some sun-protection behaviors. Factors associated with specific sun-protection behaviors included a lower appeal to tanning, a higher perceived benefit of sun protection, and information from family and friends about sun protection.

CONCLUSION

Effective sun protection is practiced by less than one-third of U.S. youth. This baseline survey will help to monitor progress in skin cancer prevention in this critical age group in the future.

Sunburn and sun protection among New Zealand adolescents over a summer weekend

OBJECTIVE

To examine predictors of sunburn and sun protection practices during summer weekends within a sample of NZ adolescents.

METHOD

Phone interviews were conducted with 203 participants aged 12-17 years. Questions were asked about behaviour from 11am to 4pm during the previous weekend.

RESULTS

Less than half of the sample outside during peak radiation hours wore sunscreen and only a quarter wore hats. Sunburn was experienced by 31% of adolescents and was associated with spending longer times outside and use of sunscreen without reapplication. Wearing a sunhat was predicted by being younger and male, while sunscreen use was predicted by being female.

CONCLUSIONS

There is a lack of appropriate sun protection among many NZ adolescents, and correspondingly high rates of sunburn. Possible opportunities to address this are through increasing the efficacy of sunscreen and sun hat use, and creating outdoor environments that support sun avoidance.

Slip! Slop! Slap! and SunSmart, 1980-2000: Skin cancer control and 20 years of population-based campaigning

The Anti-Cancer Council of Victoria has been running sun protection programs for more than 20 years: Slip! Slop! Slap! from 1980 to 1988 and SunSmart from 1988 to the present. The Victorian Health Promotion Foundation has provided funding for the SunSmart program for the past 13 years. These programs have played an important role in changing the whole society's approach to the sun and have resulted in marked reductions in sun exposure. This article describes the social, political, economic, and organizational context within which these programs developed. Then 10 areas are discussed that illustrate a critical aspect of the development and implementation of this successful systemwide health promotion program. These areas focus on key aspects of the context within which the program operates and on issues that derive from the experience of implementing program strategies. In summary, the success of the two programs is described as having been built on two key foundations: the vital integration of research and evaluation, on one hand, and a strong basis of consistency and continuity, on the other.

Trends in sun protection behaviour among Australian young adults

OBJECTIVE

To study changes in sun protection behaviour, exposure and sunburn that occur from late adolescence to young adulthood.

METHOD

A longitudinal design was used to survey a cohort on their sun-protection behaviour from the middle of their final year at school to more than three years after finishing school.

RESULTS

Males reported higher exposure, less use of sunscreen and deeper tans than females. Yet males wore hats more frequently. People with skin that just burnt were more likely to protect themselves from the sun than people with skin that tanned. Longitudinally, the level of reported exposure and the depth of tan declined, frequency of covering up, hat wearing and sunscreen use remained unchanged, and a slight U-shaped trend was observed for sunburn.

CONCLUSIONS

Young adulthood may be an important time where deteriorating trends for sun protection found in the teen years are averted. Males are at greater risk of sun exposure than females.

IMPLICATIONS

It is recommended that health promotion programs capitalise on the trend of improved sun-protective behaviours during the transition from adolescence to young adulthood, with a particular focus on young men.

A psychosocial model of sun protection and sunbathing in young women: the impact of health beliefs, attitudes, norms, and self-efficacy for sun protection

A psychosocial model of sun protection and sunbathing as distinct behaviors was developed on 202 young Caucasian women and replicated in an independent sample (n = 207). Proximal outcomes were intention to sun protect and intention to sunbathe; distal outcomes included sun protection and sunbathing behavior measured 5 months later. Objective risk for skin cancer plus 4 classes of psychosocial variables (sun-protective health beliefs, self-efficacy for sun protection, attitudes toward sunbathing, and norms for sunbathing and sun protection) served as predictors. Sun-protective norms and self-efficacy for sun protection predicted only intention to sun protect; sunbathing norms predicted only intention to sunbathe. Susceptibility and advantages of tanning predicted both intention constructs, which, in turn, predicted behavior. These findings distinguish sun protection from sunbathing and provide a basis for intervention design.

Evaluation of differences in ultraviolet exposure during weekend and weekday activities

The weekday UV exposures to anatomical sites were evaluated for outdoor workers, home workers, adolescents, indoor workers, school staff and students in south-east Queensland, Australia. Additionally, the UV exposures at weekends of school staff, school students, indoor workers and outdoor workers were evaluated. The weekday exposures per day ranged from 1.0 to 11.0 SED for winter to summer respectively. During spring, the ratios of the personal exposures divided by the ambient exposures at the weekend to the personal exposures divided by the ambient exposures on the weekdays to the neck, hand and left arm were at least 3.4, 2.0 and 0.67 for the indoor workers, school staff and students and outdoor workers respectively. The same ratios for the erythemal UV exposures over the year, estimated from the exposures on four days in each of the four seasons, were at least 2.3 for the school staff and at least 1.3 for the 13 to 19 year old school students. These results reinforce the importance of targeting prevention programmes to both weekend and weekday exposures.

Predictors of the use of sunscreen in dermatological patients in Central Europe

BACKGROUND

There is mounting evidence that sun exposure is a cause of skin cancer. Therefore, the focus of skin cancer prevention is on sun protection. The present study investigated the use of sunscreens in a sample from the adult Central European population.

METHODS

As part of a case-control study of cutaneous melanoma, a total of 498 controls with classical dermatological disorders were selected from hospitals in Central Europe. All people underwent whole-body skin examinations and were interviewed using a standardized questionnaire.

RESULTS

Overall, 40.8% of the people never used sunscreen and of the 281 persons who used sunscreen, 41.5% applied it only once per sun bath. Persons who did not use sunscreen tended to be older (P<0.0001) and of male gender (P = 0.0004). Young people, women, and people who expressed a positive attitude to the sun spent more time in the sun and were more likely to apply sunscreens. People who worked almost always outdoors had a six times increased odds ratio of not using sunscreens (P<0.0001) compared to people who worked always indoors.

CONCLUSIONS

Men, older people, and outdoor workers should be targeted in health education campaigns. On the other hand, people who apply sunscreen as a means of sun protection should be advised about adequate usage.

Structural interventions in public health

OBJECTIVE

To review structural interventions in public health, identify distinct approaches to structural interventions, and assess their implications for HIV-prevention interventions.

METHOD

The MEDLINE, HealthStar, PsychInfo and Sociofile databases were searched on specific health issues, types of public health interventions, and conceptual topics (e.g. empowerment, social structure, and inequality) to compile a list of public health interventions in the United States. We excluded interventions focused on testing and surveillance unless they specifically facilitated prevention, and educational or media campaigns focused on increasing individuals' level of knowledge about a particular health problem.

RESULTS

The term 'structural' is used to refer to interventions that work by altering the context within which health is produced or reproduced. Structural interventions locate the source of public-health problems in factors in the social, economic and political environments that shape and constrain individual, community, and societal health outcomes. We identified two dimensions along which structural interventions can vary. They may locate the source of health problems in factors relating to availability, acceptability, or accessibility; and they may be targeted at the individual, organizational, or environmental levels. All together, this framework suggests nine kinds of structural interventions, and it is possible to identify examples of each kind of intervention across a range of public health issues.

CONCLUSIONS

The relevance of this framework for developing HIV prevention interventions is considered.

Sun exposure and primary prevention of skin cancer for infants and young children during autumn/winter

OBJECTIVE AND METHOD

Excessive sun exposure in childhood has been associated with the development of skin cancer, and appropriate levels of sun protection during the early years of a child's life can significantly reduce the risks. A survey of 133 mothers was undertaken in south-east Queensland to examine the levels of sun exposure and skin protection of infants and young children.

RESULTS

Among this sample of 133 mothers, use of appropriate skin protection was relatively high for themselves and their children. However, even by six months of age, a third had been sunburnt and 15% had experienced painful sunburn. By three years of age, 82% had been sunburnt and one-third had experienced painful sunburn, though mothers' knowledge levels of sun safety issues were very high. The predictors associated with primary prevention varied across the type of prevention behaviour, but indicated that interventions should focus on susceptibility to sunburn and history of sunburn. Similar programs could be applicable across a broad range of socio-demographic groups, but require attention to mother's country of birth as a factor that significantly influences their use of protection for their young children.

CONCLUSIONS

Ongoing public education that targets specific groups and settings may contribute to adoption of appropriate sun protective behaviours for young children.

IMPLICATIONS

Results of the study provide some of the needed baseline data to assist future skin cancer prevention campaigns for young children and infants. A similar study of levels of sun exposure and skin protection for children during summer is under way.

Awareness and early detection of cutaneous melanoma: an analysis of factors related to delay in treatment

Factors associated with the detection of cutaneous melanomas and reasons for delay in diagnosis were investigated in 429 patients with histologically proven melanoma operated on between January 1993 and June 1996. Patients were interviewed using a standardized questionnaire. In 25% of patients, treatment was delayed for more than 1 year from the time they first noticed a suspicious pigmented lesion. Melanoma was detected by the patients themselves in 67% of women and 45% of men. The three predominant clinical symptoms of melanoma were change in colour (darker), increase in size and increase in elevation of a pigmented lesion. The role of sun exposure and of naevi as risk factors for melanoma, as well as the potential benefit of early treatment, were known by 87%, 66% and 82% of the patients, respectively. However, melanoma awareness had no impact on the time period between first observation of skin changes and treatment. Among the factors associated with delay in melanoma diagnosis, an initial incorrect diagnosis as a benign lesion by the physician first visited (in 18% of all cases) had the highest significance. Patients detecting their lesions themselves were treated significantly later than patients in whom others had remarked on changes in a naevus. Furthermore, melanomas of the head and neck were treated later than melanomas at other body sites. Further efforts to educate both the public and the medical profession are essential to ensure earlier treatment for cutaneous melanomas.

Examination of cognitive variables relevant to sunscreen use

The present study is an examination of the underlying psychological variables relevant to a sun-damage preventive behavior, sunscreen use. The focus of the research was to examine cognitive predictors of sunscreen use, utilizing a decision theoretic framework. Two hundred thirty subjects were recruited from psychology classes and administered questionnaires assessing sunscreen behavioral tendencies, attitudes toward sunscreen use, and internal- and external-based cognitions relevant toward sunscreen use. In contrast to previous work that had examined only one or two of these predictor variables in isolation, the present study evaluated the relative impact of these variables on sunscreen use tendencies. The findings revealed evidence of a multivariate model (using structural equation modeling; LISREL VIII) relating perceived need for, perceived efficacy of, perceived consequences of, and social normative influences on sunscreen use. The findings are discussed with respect to improving the effectiveness of short-term education efforts to increase sunscreen use.

Knowledge of sunlight effects on the eyes and protective behaviors in adolescents

The knowledge of the effects of sunlight on the eyes and protective behaviors were studied in an adolescent population. A group of 652 systematically sampled students aged between 13 and 17 years was surveyed with a standardized questionnaire in Brisbane, Australia in October-November, 1995. Survey data on the knowledge of sunlight effects on the eyes, ultraviolet light, eye and body protection as well as risk factors for ultraviolet (UV) exposure were relatively ranked and totalled to give overall scores. Of the 652 subjects, 330 (51%) were female. Most subjects (568 or 88%) were aged between 15 and 16 years. Overall, this group of subjects demonstrated a moderate level of knowledge with respect to UV, sunlight and the eyes. The knowledge of the effects of sunlight and body protection was higher than the knowledge of the effects of sunlight and eye protection. Almost three-quarters (462 or 71%) of the subjects owned a pair of sunglasses. The mean age at which subjects started to wear sunglasses was 10.4 years. However, most subjects (528 or 81%) only wore sunglasses occasionally or not at all. The reported frequency of wearing sunglasses was significantly related to personal, family and peer attitudes to such use, but not to media advertizing. Assessment of adolescent knowledge is important in the formulation of health promotion strategies designed to prevent excessive UV exposure at this young age.

Factors associated with skin cancer prevention practices in a multiethnic population

A better understanding of factors influencing sun protection practices can improve the design and evaluation of skin cancer prevention programs. These data are from a cross-sectional survey of 756 parents with children in Grades 1 through 3, and 176 recreation program staff members in a multiethnic population in Hawaii. Questionnaires asked about skin cancer prevention practices (sunscreen use, covering up, shade seeking), knowledge, benefits and barriers, policies, and staff norms for prevention. The most important correlates of children's prevention practices were their parents' sun protection habits. Multiple regression models--which included knowledge, beliefs, program policies, and covariates related to sun protection--explained a total of between 38% and 41% of the variance in children's sun safety habits, 22% to 25% of parents' habits, and 24% of recreation staff members' sun safety habits. The models were less successful at predicting the use of hats, shirts, and shade seeking and a composite sun protection habits index. Parents and caregivers' knowledge, beliefs, and behaviors, as well as recreation program policies, are strong predictors of sun protection practices among children in Grades 1 to 3 in a multiethnic sample.

Promoting sun protection in children: rationale and challenges

This article outlines the epidemiological and educational arguments for promoting sun protection during childhood and highlights factors that may facilitate or hinder achievement of this behavioral outcome. A model describing behavioral factors in the causation of skin cancer is presented. Summary results from previous behavioral studies and interventions relating to primary prevention of skin cancer are described, and recent data on the cost-effectiveness of sun protection in Australia and its implications for health insurers are discussed. This article also includes a commentary on the demonstration projects promoting skin cancer prevention among children and their caregivers featured in this special issue of Health Education and Behavior.

The Falmouth Safe Skin Project: evaluation of a community program to promote sun protection in youth

A multidimensional community-based skin cancer prevention program was conducted in Falmouth, Massachusetts, combining community activism with publicity campaigns and behavioral interventions to improve sun protection knowledge; attitudes; and practices in parents, caregivers, and children. The program was associated with improvements in target outcomes, based on two telephone surveys of random samples of parents (n = 401, 404). After program implementation, fewer parents reported sunburning of their children, particularly among children 6 years old or younger (18.6% in 1994 vs. 3.2% in 1997), and more parents reported children using sunscreen, particularly continuous use at the beach (from 47.4% to 69.9% in younger children). Hat and shirt use did not increase. Improvements also were seen in parent role modeling of sun protection practices, parents' self-efficacy in protecting children from the sun, and sun protection knowledge. While these findings must be interpreted cautiously, they do suggest that this project was effective in promoting sun protection.

Humour and alarmism in melanoma prevention: a randomized controlled study of three types of information leaflet

Effectiveness of melanoma prevention depends on how it is accepted by the population. Humour and alarmism are often used in campaigns, but no information is available about how much they may improve or limit the impact of a campaign. Three different leaflets containing the same information about sun exposure and skin cancers were developed using three different tones of presentation: humoristic (H-leaflet), alarmist (A-leaflet) or neutral information (N-leaflet). In this randomized controlled study, each type of leaflet was mailed to a sample of 300 subjects representative of the sociodemographic population of the South of France. A fourth sample to whom no leaflet was sent was used as a control. Fifteen days after the mailing, the 1200 individuals were interviewed by phone. Four hundred and forty-four of the 900 who received the mail read the leaflet. The percentage of individuals with a good awareness of melanoma was higher in leaflet groups than in controls. The percentage of individuals who read a leaflet was lower in the A-leaflet group and the percentage of individuals knowing what a melanoma is tended to be lower in the H-leaflet group. There was no significant difference between groups with regard to ability for self-assessment of skin sun sensitivity, risk factors and sun exposure. The tone of presentation seems to have a limited impact on the effect of a campaign, but alarmism tends to reduce the number of people reached by the message whereas humour tends to decrease the impact of the message.

Predictors of sun protective behaviors among school students

A random sample of students (N = 3,655) in Grades 7, 9, and 11 from 55 schools in Queensland (Australia) were surveyed about their sun protection knowledge, attitudes, and behaviors. An aggregate sun protection behavior index (SPBI) was developed from self-reported behaviors on a school day and a weekend day. Repeated measures regression analyses revealed that negative views of sun protection measures were associated with low scores on the SPBI, an association that was strongest among older students and in larger schools. Low perceived parental sun protective behaviors were associated with low SPBI ratings, and this association was greatest in small schools and on Saturdays. Older students had lower SPBI ratings, but their scores increased on Saturdays. Gender did not appear to be independently related to the SPBI after adjustment for the other variables. These findings reinforce the need for adolescent sun protection programs to address the complex interactions among psychological, social, and environmental factors that influence different subgroups of the student population.

Sun protection and sunburn in primary school children: the influence of age, gender, and coloring

BACKGROUND

Childhood is a high-risk period for skin damage due to excessive sun exposure. This damage may lead to skin cancer later in life.

METHODS

The present study measured children's knowledge and attitudes, and reported usual behavior relevant to sun protection and parents' encouragement of their children's sun protection among a sample of 735 primary school students and their parents, in Victoria, Australia. The incidence of sunburn among the children over late spring and early summer was monitored weekly for 8 weeks.

RESULTS

The results indicate that children's knowledge of sun protection is moderately high and that positive sun protection attitudes, reported frequency of parents encouraging protection, and children carrying out sun protection are generally high. Trends for age indicate that while knowledge of sun protection increases with age, attitudes and behaviors supportive of sun protection decline. Sunburn rates increase with age. There was some evidence to suggest that children with fairer coloring receive greater encouragement from parents to protect themselves and are marginally better protected than children with darker coloring. However, this highly susceptible group still suffers more burns. There was little variation based on children's gender.

CONCLUSIONS

The mid-primary school years may be a critical time for interventions promoting sun protection.

Public health interventions for melanoma. Prevention, early detection, and education

Worldwide melanoma control programs that include some combination of primary prevention, education, and screening activities have only recently begun to undergo an evaluation process. More studies with rigorous design and evaluation are needed. Until then, the proper public health policy guidelines for melanoma control, especially screening, are open to debate. Future studies must determine how screening, early detection, case finding, and education can best be used to reduce mortality and achieve optimal melanoma control.

Successful behavioral interventions to prevent cancer: the example of skin cancer

Important behavioral sources of risk for cancer have been identified and programs to reduce this risk have been initiated. The most heavily studied behavioral risk is tobacco use, but considerable attention has also gone to prevention of skin cancer by modifying sun exposure. Research has shown a strong link between sun exposure and skin cancer, and opportunities to prevent this cancer by changing behavior should be effective. Unlike unmodifiable sources of risk, sun exposure should be modifiable through behavioral intervention. This review considers research in this expanding area, concentrating on predictors of sun protective behaviors, modification of sun exposure, and surveillance for early signs of cancer. The elements of behavior change programs that contribute to successful intervention as well as barriers to successful behavior change and future directions for this effort are considered.

Skin cancer prevention for children, parents, and caregivers: a field test of Hawaii's SunSmart program

BACKGROUND

Children are at particular risk for sun exposure, a major cause of skin cancer. Parents and caregivers can help protect children by educating them about practicing safe sun habits, serving as role models, and providing supportive environments.

OBJECTIVE

We evaluated SunSmart, a cancer prevention program for 6- to 8-year-old children, their parents, and outdoor recreation staff.

METHODS

The intervention included staff training, on-site activities for children, interactive take-home booklets, behavior-monitoring scoreboards, incentives, providing sunscreen, and encouraging sun safe environments and policies. The program was evaluated by baseline and follow-up surveys of parents and recreation staff, monitoring forms, and on-site observations.

RESULTS

There were positive changes in all major outcomes, including knowledge; sun protection habits of parents, children, and staff; readiness to change; sun protection policies; and sun protection norms. The changes ranged from improvements of 3% to more than 20%, and several changes were statistically significant.

CONCLUSION

The results demonstrated the feasibility and short-term impact of Hawaii's SunSmart program and suggested areas for refinement and expansion.

Application of Azjen's theory of planned behavior to predict sunbathing, tanning salon use, and sunscreen use intentions and behaviors

Ajzen's (1988) theory of planned behavior (TOPB) was used to examine psychological determinants of high-risk UV radiation exposure-related behaviors (sunbathing, tanning salon use, and sunscreen use). Undergraduates at a midsized southeastern university were assessed on their psychological and behavioral tendencies toward high-risk UV radiation exposure-related behaviors. The results generally supported the utility of the TOPB as an explanatory model for high-risk behavior. Attitudes were strongly associated with high-risk intentions (e.g., not utilize sunscreen, use salons), whereas subjective norms were less so. Perceived behavioral control was found to moderate the relationship among attitudes, norms, and intentions to sunbathe and tan at a salon. Implications for intervention strategies and future model building in this area are discussed.

Trends in sun exposure knowledge, attitudes, and behaviors: 1986 to 1996

BACKGROUND

The American Academy of Dermatology's national program Melanoma/Skin Cancer Detection and Prevention, developed in response to the rising incidence of invasive melanoma in the United States, has annually during the past decade produced extensive print, radio, and television coverage about the dangers of sun exposure and benefits of sun protection.

OBJECTIVE

We measured the progress achieved in increasing the awareness and knowledge of skin cancer and changing the attitudes, beliefs, and behaviors that affect skin cancer risk. We also describe current sun-related behavior including sunburning, assess the likelihood of practicing sun protection strategies, and provide a baseline against which future changes in sun protection behavior may be evaluated.

METHODS

A 1996 telephone survey repeated questions used in 1986 to evaluate change and used classifying questions to better define attitudes and behaviors.

RESULTS

From 1986 to 1996, the knowledge of the perceived harmful effects of the sun significantly broadened, but the UV exposure behavior as measured by sunburning (30% to 39%) and regular use of a tanning booth (2% to 6%) also increased. There was a decline in the attitude that having a tan was healthy; however, in 1996 having a tan was still considered to enhance appearance, particularly by men. Sunscreen use increased (35% to 53%). Women, younger persons, persons residing in areas with fewer sunny days, and whites were more likely to tan intentionally, but men who lived in the South were more likely to sunburn.

CONCLUSION

During the past decade, the early process of change involving cognitive and emotional activities began. With this study, high-risk population subsets performing specific adverse behavior were identified. In the future, they can be targeted with messages that promote attitudinal and behavioral change.