Changes in sun-related attitudes and behaviours, and reduced sunburn prevalence in a population at high risk of melanoma

Daily UVB exposure levels in high-school students measured with digital dosimeters

UV radiation exposure increases skin cancer risk. A substantial portion of a person's UV exposure occurs before the age of 18 years. We sought to determine UVB radiation exposure levels in high-school students during normal daily activity. Digital dosimeters were worn by 4 high-school students during 11 school days. Students were subjected to daily erythemal and suberythemal doses of UVB radiation. Programs to educate high-school students in sun-protective practices even during regular school activities are needed.

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.

Barriers to sun safety in a Canadian outpatient population

BACKGROUND

It has long been recognized that compliance with recommended sun safety practices is suboptimal, yet few investigations have explored the barriers that people face in practicing good sun safety. In this context, barriers can exist at the following three levels: knowledge of sun safety, acquisition of sun safety information, and implementation of specific sun protective measures.

OBJECTIVE

The investigation reported herein sought to elucidate barriers to sun safety that individuals face. Ultimately, this study aimed to qualify the possible barriers that lead to a misalignment of current recommendations and sun safety practices.

METHODS

The study design was observational, and the instrument used for data collection was a self-administered questionnaire. Thirty-four outpatients of the RK Schachter Dermatology Centre of Sunnybrook and Women's College Health Sciences Centre (SWCHSC), Toronto, Ontario, as well as 27 outpatients of the Sport Care facility of SWCHSC were enrolled in the study. They represent the target population of those who are at greater risk of developing sun-related skin lesions. Data were analyzed using standard parametric and nonparametric techniques. Comparisons were made between the two outpatient groups and between other groups within the sample.

RESULTS

In general, level of sun safety knowledge was fairly high, though compliance to sun safety measures was suboptimal in both populations. There were no significant differences regarding level of knowledge between the 2 outpatient groups. Deficiencies in knowledge centered around risk factors for skin cancer. Frequently cited barriers to sun safety include inconvenience (34% of respondents), forgetting to use sun safety measures (49%), a desire to be tanned (33%), and protective clothing being too hot to wear (56%). High compliers were notable for their great likelihood of being counseled by a physician about sun safety ( P < 0.025) and their slightly higher mean knowledge scores.

CONCLUSIONS

These data support that knowledge alone does not predict compliance and that sun awareness campaigns should be evaluated based on their ability to affect behavior.

Sustaining dietary changes for preventing obesity and diabetes: lessons learned from the successes of other epidemic control programs

A degree of success has been achieved in controlling several epidemics of infectious and non-infectious causes of death in countries, such as, Australia and New Zealand. Using the epidemiological triad (host, vector, environment) as a model, the key components of the control of these epidemics have been identified and compared to the current status of interventions to prevent obesity and its main disease consequence, type 2 diabetes. Reductions in mortality from tobacco, cardiovascular diseases, road crashes, cervical cancer and sudden infant death syndrome have been achieved by addressing all corners of the triad. Similarly, prevention programs have minimized the mortality from HIV AIDS and melanoma mortality rates are no longer rising. The main lessons learned from these prevention programs that could be applied to the obesity/diabetes epidemic are: taking a more comprehensive approach by increasing the environmental (mainly policy-based) initiatives; increasing the 'dose' of interventions through greater investment in programs; exploring opportunities to further influence the energy density of manufactured foods (one of the main vectors for increased energy intake); developing and communicating specific, action messages; and developing a stronger advocacy voice so that there is greater professional, public and political support for action. Successes in the other epidemics have been achieved in the face of substantial barriers within individuals, society, the private sector and government. The barriers for preventing obesity/diabetes are no less formidable, but the strategies for surmounting them have been well tested in other epidemics.

Sunburn reduction through parental role modeling and sunscreen vigilance

OBJECTIVES

To identify characteristics associated with child sunburn experience and sun protection practices, including parent and child demographics, phenotype, and sun-related knowledge, attitudes, and behaviors.

STUDY DESIGN

A nationally representative telephone survey conducted in 1999 with 651 parents of children 5 to 12 years of age to collect data relating to the sun-related knowledge, attitudes, and behaviors of the parent and child.

RESULTS

Nearly half of parents (49%) and children (44%) were sunburnt during the previous summer. Parents who reported that they had been sunburnt were more likely to have children who had been sunburnt (OR = 2.9, 95% CI = 2.0, 4.2). Conversely, parents with a high level of sun protection behavior were less likely to report being sunburnt (OR = 0.6, 95% CI = 0.4, 0.9), and their children were more likely to have a high level of sun protection behavior (OR = 3.0, 95% CI = 2.0, 4.6) and sunscreen vigilance (OR = 2.7, 95% CI = 1.7, 4.5). High sunscreen vigilance was associated with a 60% reduction in child sunburning.

CONCLUSIONS

The sunburn experience and sun protection practices of children (5-12 years of age) are closely linked to a number of modifiable attitudes and behaviors of their parents. Therefore the inclusion of parents and care givers in interventions targeting children may increase program efficacy.

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.

Lifestyle behaviours of young adult survivors of childhood cancer

This cross-sectional study collected baseline data on the health behaviours of a large population of survivors of childhood cancer in the UK, aged 18-30 years, compared with those of sex- and age-matched controls. Data from 178 young adult survivors of childhood cancer, diagnosed and treated at Bristol Children's Hospital, 184 peers from the survivors' GP practices and 67 siblings were collected by postal questionnaire. Conditional logistic regression analysis showed that, for matched sets of survivors and controls, survivors of a variety of childhood cancers reported lower levels of alcohol consumption (P=0.005), lower levels of cigarette smoking (P=0.027) and lower levels of recreational drug use (P=0.001) than controls. Analysis of matched sets of survivors and siblings showed similar trends but no significant differences. A health behaviour index for each participant was constructed from the data collected on five key health behaviours which influence future health status. Comparison of the means for each case group showed that survivors of childhood cancer were leading healthier lives than controls or siblings. This finding was expressed most clearly as the difference in the means of the health behaviour index for each case group, derived from five health behaviours (one-way ANOVA, P<0.001).

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.

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.

Sun protection among parents and children at freshwater beaches

OBJECTIVES

This paper describes the sun-related behaviour of parents and their children, ages 5-12 years.

METHODS

In-person interviews were conducted with parents and observations of parents and their children to ascertain: 1) parents' self-reported use of sunscreen, 2) parent-proxy reports of children's sunscreen use, and 3) observations of parents' and children's use of shade, hats and protective clothing. Data collection took place at freshwater beaches in BC's Southern Interior, between 12 pm and 5 pm, over a seven-day period during August 1999.

RESULTS

94 parents were interviewed and observed. Parent-proxy reports and observational data were collected on 161 children. Half (53%) of parents reported they were wearing sunscreen at the time of the on-beach interview. Most (65%) of parents reported that their children were wearing sunscreen at the time of the on-beach interview. Children's first application of sunscreen took place on average 1.5 hours prior to interview. Most parents (86%) reported that their children's sunscreen had not been reapplied at the time of interview. Few parents (13%) or children (5%) used shade as provided by nearby trees or umbrellas.

CONCLUSION

Public education should emphasize sunscreen re-application. Actions should be taken to enhance the convenient use of shade structures at public beaches.

Sunbathing intentions in Irish people travelling to Mediterranean summer holiday destinations

As exposure to UV light is thought to be the most significant environmental and behavioural risk factor for avoiding skin cancer, we have analysed the sunbathing intentions and attitudes of Irish people travelling to Mediterranean and Iberian holiday destinations. Ninety per cent of respondents planned to get a suntan on their vacation with 44% likely to burn their skin in the process. Although all intended to apply sun cream on holiday only 40% would apply >SPF 15. Sixty-four per cent planned to sunbathe between 11.00 am and 3.00 pm, with 25% intending to spend <5 hours in the sun. One-third of those intending to sunbathe for >6 hours per day were aged between 16 and 24 years. Approximately eight out of 10 people thought suntans made them feel healthier or attractive. Fifty-six per cent regularly checked their moles but men were less likely to check their skin for pigment changes. The results provide baseline information on sunbathing attitudes of Irish people. They show that while most people feel they adopt a careful approach to sunbathing, the experiences and intentions, especially in younger people, are influenced by the desirability of a suntan, and reflect a behaviour that increases their risk of skin cancer.

Developing areas in cancer in New Zealand

New Zealand has a cancer profile similar to those of Western developed countries, with a high rate of melanoma, similar to Australia. Statistics separating the Maori from the non-Maori population, although open to difficulties in interpretation, show higher rates in Maori of liver, stomach, lung and cervix uterine cancer and lower rates of colorectal cancer and of melanoma. Screening and prevention programmes are limited by resource constraints; there is population screening for cervical cancer and breast cancer screening is being developed. Screening for hepatitis B and liver cancer is proposed, despite conflicting scientific opinions, while screening for colorectal cancer is not planned, despite randomized trial evidence of benefit. There is no clear national cancer control programme at present. Investigation of stomach cancer in Maori families had identified a new gene.

Mass media interventions: effects on health services utilisation

BACKGROUND

The mass media frequently cover health related topics, are the leading source of information about important health issues, and are targeted by those who aim to influence the behaviour of health professionals and patients.

OBJECTIVES

To assess the effects of mass media on the utilisation of health services.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (1996 to 1999), MEDLINE, EMBASE, Eric, PsycLit (to 1999), and reference lists of articles. We hand searched the journals Communication Research (February 1987 to August 1996), European Journal of Communication (1986 to 1994), Journal of Communication (winter 1986 to summer 1996), Communication Theory (February 1991 to August 1996), Critical Studies in Mass Communication (March 1984 to March 1995) and Journalism Quarterly (1986 to summer 1996).

SELECTION CRITERIA

Randomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of mass media interventions. The participants were health care professionals, patients and the general public.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twenty studies were included. All used interrupted time series designs. Fifteen evaluated the impact of formal mass media campaigns, and five of media coverage of health-related issues. The overall methodological quality was variable. Six studies did not perform any statistical analysis, and nine used inappropriate statistical tests (ie not taking into account the effect of time trend). All of the studies apart from one concluded that mass media was effective. These positive findings were confirmed by our re-analysis in seven studies. The direction of effect was consistent across studies towards the expected change.

REVIEWER'S CONCLUSIONS

Despite the limited information about key aspects of mass media interventions and the poor quality of the available primary research there is evidence that these channels of communication may have an important role in influencing the use of health care interventions. Although the findings of this review may be affected by publication bias, those engaged in promoting better uptake of research information in clinical practice should consider mass media as one of the tools that may encourage the use of effective services and discourage those of unproven effectiveness.

Tanning habits and sunburn in a Swedish population age 13-50 years

As part of a skin cancer control programme, we studied the occurrence of self-reported outdoor tanning, sunbed use and ultraviolet (UV)-induced erythema in an urban area. A cross-sectional questionnaire study of 6000 adolescents aged 13-19 years, and 4000 adults aged 20-50 years was applied. Non-response was analysed for outdoor tanning and sunbed use. Results, in general, did not differ between responders and non-responders. Females aged 17-29 years tanned outdoors most frequently. Sunbed use and related erythema was twice as common in young females. In males, outdoor tanning was not age-related. In the past 12 months, 55% reported sunburn and/or burn from sunbed use, one-third were burned in Sweden, one-quarter on sunny resorts abroad. Sunburn occurs frequently. Compliance with recommendations for sunbed use is poor, especially among adolescents and young adults. To reduce the occurrence of erythema, the influence of risk settings upon behaviours is a critical issue for exploration.

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.

Population based intervention to change back pain beliefs and disability: three part evaluation

OBJECTIVE

To evaluate the effectiveness of a population based, state-wide public health intervention designed to alter beliefs about back pain, influence medical management, and reduce disability and costs of compensation.

DESIGN

Quasi-experimental, non-randomised, non-equivalent, before and after telephone surveys of the general population and postal surveys of general practitioners with an adjacent state as control group and descriptive analysis of claims database.

SETTING

Two states in Australia.

PARTICIPANTS

4730 members of general population before and two and two and a half years after campaign started, in a ratio of 2:1:1; 2556 general practitioners before and two years after campaign onset.

MAIN OUTCOME MEASURES

Back beliefs questionnaire, knowledge and attitude statements about back pain, incidence of workers' financial compensation claims for back problems, rate of days compensated, and medical payments for claims related to back pain and other claims.

RESULTS

In the intervention state beliefs about back pain became more positive between successive surveys (mean improvement in questionnaire score 1.9 (95% confidence interval 1.3 to 2.5), P<0.001 and 3.2 (2.6 to 3.9), P<0.001, between baseline and the second and third survey, respectively). Beliefs about back pain also improved among doctors. There was a clear decline in number of claims for back pain, rates of days compensated, and medical payments for claims for back pain over the duration of the campaign.

CONCLUSIONS

A population based strategy of provision of positive messages about back pain improves population and general practitioner beliefs about back pain and seems to influence medical management and reduce disability and workers' compensation costs related to back pain.

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 the incidence of cutaneous malignant melanoma in New South Wales, 1983-1996

The incidence of cutaneous malignant melanoma (CMM) has been rising in fair-skinned populations throughout the world for decades. The upward trend may, however, finally be slowing in some of these populations. Recent (1983-1996) CMM incidence trends for a high incidence area (New South Wales, Australia) have been examined according to gender, age group, body site and tumour thickness. Despite continuing upward trends in older age groups, particularly among men (e.g., 7.20% increase per year in men aged 75+), incidence for younger ages is stabilizing (in men) or declining (in women): average annual percentage changes of -3.03 and -0.88 were observed for women aged 15-34 and 35-54, respectively. Patterns suggest a birth-cohort effect, with those born since 1945 or 1950 having lower (females) or similar (males) rates to those born earlier. For each gender, all-ages incidence rose by a similar amount for each of the main body sites except the leg in women, where incidence fell by 0.49% per year. In men, the incidence of both thin (</=75 mm) and thick (>75 mm) melanomas increased (significantly, by 2.63% per year and non-significantly, by 0.93% per year, respectively) between 1989 and 1996. In women, incidence remained stable for both thickness subgroups. These data are consistent with a stabilization or reduction in either total sun exposure or intermittency of exposure among New South Wales cohorts born since about 1950. Because incidence rates are still much higher than they were a few decades ago, however, efforts to reduce sun exposure, particularly in children and youth, must continue.

Sun protection practices in preadolescents and adolescents: a school-based survey of almost 25,000 Connecticut schoolchildren

Sun protection practices in children and adolescents fall well below national recommendations. We present the results of a survey of sun protection use and other health-related behaviors in a sample of Connecticut Caucasian students aged 9 through 18 years (N = 24,645). Our objectives were to estimate the prevalence of sun protection use and to evaluate the relationship between sun protection use and health-risk behaviors and attitudes about appearance. We present data from 1988 through 1995 from the Connecticut Health Check, a health risk appraisal survey sponsored by the Connecticut Department of Public Health. Students enrolled in public and private elementary junior as well as senior high schools took the self-administered anonymous survey, which included multiple-choice questions about use of sun protection, cigarettes, and alcohol and about body image and self-esteem. We report prevalence proportions for use of sun protection by demographic features. We compared the proportion of students in 3 categories of outcome (always, sometimes, and never use sun protection) who reported various health-risk behaviors. Twenty percent of the sample reported always using sun protection; this is well below national goals set forth in the Healthy People 2000 recommendations. Sun protection use was inversely related to age and was higher among girls than boys at all ages. At all ages, students who did not use sun protection were more likely than those who did to report other health risk behaviors, such as use of cigarettes and alcohol. The data suggested that use of sun protection is associated with positive attitudes about appearance and self-image. Use of sun protection may be one component of an overall mode of health awareness and behavior. Programs promoting safe sun practices should target boys and be integrated into an overall campaign aimed at other risk-taking behaviors.

Assessing “Sun Know How”: comparing outdoor and indoor workers

The aim of this study was to compare knowledge of the “Sun Know How” campaign’s primary sun safety messages (i.e. covering up, seeking shade and applying sunscreen) between adults who work predominantly outdoors and adults who work predominantly indoors. A questionnaire survey was conducted amongst a purposive sample of local authority and National Health Service employees across four boroughs in the Northern and Yorkshire region (N = 273). While findings support the value of concentrating efforts and resources on outdoor workers, they also highlight the necessity for interventions which reflect and account for distinct needs, practical circumstances, and the developing evidence base.

Effects of a sun protection program targeting elementary school children and their parents

BACKGROUND

Excessive sun exposure in childhood is considered a risk factor for later development of skin cancer, so sun awareness programs targeting children have been developed.

OBJECTIVE

To assess the benefits of involving parents at home in the sun protection program received by their children at school.

METHOD

The existing "Sun and the Skin" program was enhanced in two ways. Parents were educated both about their child's program and with supplemental information. Also, sunscreen was distributed to each child.

RESULTS

Certain methods of sun protection, particularly the use of sunscreen, are being practiced by the majority of children, while others, such as protective clothing, have not been readily adopted. The enhanced group of students showed improvement over control and standard groups in their attitude toward tanning. There is a need for teachers to remind their students to practice protective measures.

CONCLUSIONS

While a sun-awareness curriculum has been shown to be beneficial for elementary school children, the adjunct of parental and school involvement in this process can improve the results and ultimately decrease the risk of skin cancer in the children.

An international evaluation of the cancer-preventive potential of sunscreens

The IARC convened a working group of experts in Lyon, France, on 10-18 April, 2000, to evaluate the cancer-preventive activity of sunscreens and to compile the fifth volume of the IARC Handbooks of Cancer Prevention. The working group concluded that the topical use of sunscreens reduces the risk of sunburn in humans and that sunscreens probably prevent squamous-cell carcinoma of the skin when used mainly during unintentional sun exposure. No conclusion can be drawn about the cancer-preventive activity of topical use of sunscreens against basal-cell carcinoma and cutaneous melanoma. Use of sunscreens can extend the duration of intentional sun exposure, such as sunbathing. Such an extension may increase the risk for cutaneous melanoma. The working group warned against relying solely on sunscreens for protection from UV radiation.

Evaluation of primary prevention initiatives for skin cancer: a review from a UK perspective

To ensure effective primary prevention of skin cancer, aimed at changing behaviour in the sun, and ultimately at reducing the incidence and mortality rates from skin cancer, sufficient information needs to be known about the relationship between sun exposure and skin cancer, the effectiveness of sun protection measures, and the acceptability and uptake of protective measures by the general public. This review specifically addresses the quality and outcome of studies designed to evaluate the impact of primary prevention initiatives in the U.K. Four main areas of concern are highlighted: (i) teenage behaviour in the sun is difficult to change; (ii) fashion, in part, dictates adult and adolescent behaviour in the sun; (iii) there are practical problems related to response rates, follow-up and interpretation of self-reported behaviour; and (iv) a strategy for primary prevention in the U.K. may be falsely based on the experience and results of Australian and American programmes. Standardized methods for monitoring general population behaviour are needed in the U.K. Evaluation of interventions targeting specific groups, especially parents and young children, and the relative costs of different strategies should be reported. Primary prevention messages and strategies should be adapted to the type of ultraviolet radiation exposure experienced, and the overall low risk of melanoma, while addressing controversies on the health effects of sun exposure and sun screens.

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.

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.

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.

Sun avoidance practices among non-Hispanic white Californians

This study measures self-reported sun avoidance practices, use of protective clothing, and use of sunscreen among 4,749 non-Hispanic white adults living in households in California. Data are from the California Behavioral Risk Factor Survey, a population-based telephone survey of health behaviors and attitudes. The average respondent spent at least 15 minutes in the sun on 21.4 days out of the last 30 days. Regular use of protective clothing was reported by 30.7%, regular use of sunscreen by 22.2%, and regular sun avoidance by 17.1% of the respondents. Results varied by month, gender, skin tone, age, education, and presence of children in the household. Health strategies should target younger adults (especially men), households with children and adults with less than a high school education. Because of relatively low rates of sun avoidance behaviors overall, a general population campaign also is warranted.

Do people who apply sunscreens, re-apply them?

Little is known about Australians' practices regarding sunscreen re-application, yet it is routinely advised and has recently been shown to increase the protective efficacy of sunscreens. A baseline survey of sunscreen application and re-application behaviour was therefore conducted in a Queensland community using a standard self-administered questionnaire. Other sun protection methods were also assessed. Of a total of 669 adult respondents, 76% reported using sunscreen and of those, 61% reported re-applying sunscreen. Significantly more women (66%) than men (55%) reported re-applying sunscreen and re-application was inversely related to age (79% of those aged less than 45, 57% of those 45-59 years old and 46% of those over 60 years). Increased rates of re-application were reported during times of increased sun exposure, as well as by those with greater knowledge of the benefits of sunscreen re-application. A recent personal history of non-melanoma skin cancer did not lead to improved rates of sunscreen application, sunscreen re-application, or most forms of physical 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.

Recent declines in worldwide mortality from cutaneous melanoma in youth and middle age

Trends in age-standardised death-certification rates for skin cancer [mainly cutaneous malignant melanoma (CMM)] over the period 1955-1995 were considered for 22 developed countries (18 from Europe, Canada, the United States, Australia and New Zealand) on the basis of the World Health Organization database. Between 1955 and 1984, mortality from CMM has been rising in both young adults (20 to 44 years) and middle aged population (45 to 64 years) in most European countries, North America and Australia. Between 1985 and 1995, CMM mortality rates were still rising in several countries for middle-aged males, though, to a lesser extent, they were more favourable in middle-aged women and declined in young adults in most countries, particularly in northern Europe.

Two decades of the public health approach to skin cancer control in Australia: why, how and where are we now?

Incidence and mortality rates due to skin cancer are rising in most Western countries. Early detection of these tumours at a stage when they can be easily cured is the primary approach taken by many people wishing to deal with the problem. A primary prevention approach, that is, reduction in sunlight exposure, is being considered by an increasing number of organizations. The public health approach to primary prevention of skin cancer, including melanoma, requires an understanding of the role of sunlight in the production of these tumours. Despite a clear understanding of exactly how sunlight does this, there is enough epidemiological and laboratory evidence to suggest a broad approach to the problem. This includes reduction of sunlight exposure, particularly in childhood and adolescence. It also suggests the need to recommend avoidance of suntanning and particularly the excessive exposures that lead to sunburn. Widespread primary prevention public health programmes have been running in Australia for almost 20 years. The data measuring the effect of these programmes indicate a very large shift in knowledge attitudes and beliefs about sunlight exposure and suntans, and major shifts in behaviour. Suntans are no longer as popular as they were and people are reducing their sunlight exposure by a variety of methods encapsulated in Slip! Slop! Slap! Cohort analysis of the incidence rates for melanoma and non-melanoma skin cancer show that the incidence of these tumours is levelling out in young people and is dropping in some instances. These are the people who were able to be influenced by the public health programmes in recent decades. Finally, following initial dramatic changes in all the behavioural variables related to the programme, a period of consolidation with continuing effort and more specific targeting will be required in the coming decades to maintain the improvement.

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.

Trends in the incidence of non-melanocytic skin cancer (NMSC) treated in Australia 1985-1995: are primary prevention programs starting to have an effect?

Non-melanocytic skin cancer (NMSC) is the most common cancer in Australia, but data on its incidence are not routinely collected by cancer registries. National surveys were conducted in 1985, 1990 and 1995 to estimate NMSC incidence. Trends in incidence between 1985 and 1995 have been examined to determine the impact of primary prevention campaigns aimed at controlling skin cancer in Australia. National random household surveys of Australians aged over 13 years were used to estimate NMSC incidence in 1985, 1990 and 1995. Age- and sex-specific rates by survey year were modelled using Poisson regression. Basal cell carcinoma (BCC) rates in 1995 were 788 per 100,000, an increase of 19% since 1985. Squamous cell carcinoma (SCC) rates rose by 93% over the same period, from 166 to 321 per 100,000. The ratio of BCC:SCC changed from 4:1 in 1985 to 2.5:1 in 1995. BCC rates in latitudes <29 degrees S remained at about 3 times those in latitudes >37 degrees S over the decade. The ratio of SCC incidence between these latitudes changed from around 7:1 to 3:1 over the same period. Although NMSC incidence rates continue to rise, there have been reductions in BCC observed in younger age groups. Incidence rates of NMSC continue to rise in Australia, but there is evidence of a reduction in BCC incidence in younger cohorts. This is evidence that public health campaigns to reduce sun exposure may be having a beneficial effect on skin cancer rates.

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.

Issues in the epidemiology of melanoma

Malignant melanoma imposes a considerable public health burden. Both incidence and mortality have increased many fold over the past several decades, although current trends suggest possible change in the prior patterns. Etiologic factors have been established, of which the most important is intense sun exposure. Primary prevention and early detection are both potentially critical in reducing the burden of melanoma. Much remains to be clarified in our management of this disorder on a population basis, and methodologic difficulties are plentiful. The potential for substantial reductions in melanoma mortality requires that we address the difficulties so that maximally effective public health initiatives may be undertaken.

Solar protection behaviors among outdoor workers

Due to the lack of information regarding how US workers protect themselves from ultraviolet radiation, this study explored solar protection behaviors among three groups of outdoor workers. This cross-sectional research involved two separate studies. Study 1 consisted of observations of 312 outdoor workers, and Study 2 was a paper and pencil survey (n = 240). For each data set, occupational groups were compared on ultraviolet radiation protection. Observational data indicated that 50.4% of the workers had adequate protection. Across occupational groups, the ranking from highest to lowest levels of protection was consistent for both data sets. Face and lower arms were consistently the least protected sites. The pattern of findings suggests the importance of assessing protection of individual body sites, as well as composite protection.