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

Skin cancer prevention: a time for action

Skin cancer is the most common malignancy in the United States accounting for more than 840,000 cases and 9,400 deaths annually. It is estimated that 90% of non-melanoma skin cancers and much of melanoma incidence can be attributed to sun exposure. The evidence suggests that regular use of sunscreen (Sun Protective Factor (SPF) of 15 or higher), wearing protective, tightly woven clothing and wide brimmed hats, and avoiding sun exposure when the ultraviolet rays are strongest (between 11:00 a.m. and 3:00 p.m.) can dramatically reduce the risk of skin cancer. Interventions to promote sun-protection behaviors that target children and adults are necessary to reduce the growing incidence rate of skin cancer in the United States.

Sunburn and sun protection among young children

OBJECTIVE

To examine the extent of sun exposure, sun protection and experience of sunburn among young New Zealand children on summer weekends.

METHODS

In a telephone survey of 1243 respondents, those with children in the household were asked about sun exposure and protection for the youngest child in the family. Information was obtained for 285 children aged from infancy to 10 years.

RESULTS

Over 90% of the children were reported to be outside on the preceding Saturday and/or Sunday; 7% of those outside experienced some degree of sunburn. The worst burning was on the face, head, neck or ears. On either day about half the children were wearing sunscreen and 60% were wearing a hat. Parental use of sun protection was the strongest predictor of sun protection among the children.

CONCLUSIONS

While reports of sun protection among young children were encouraging, many children in the community are still at high risk of sunburn. Efforts to promote sun protection as a family responsibility may reduce the experience of burning among the young.

Sun behaviour and perceptions of risk for melanoma among 21-year-old New Zealanders

This study investigated perceived risk of melanoma, sunscreen use and frequency of sunburn in a large sample of young New Zealanders. A self-report questionnaire was administered to a sample of 909 21-year-olds to survey their perception of how sun behaviours affect their risk of getting melanoma, how often they get sunburn, how often they use sunscreen and what factors would get them to use sunscreen more often. Knowledge of melanoma was high, but myths concerning 'safe tanning' persisted. Many young adults believed that sunbathing regularly using a sunscreen and obtaining a good base tan from gradual sun exposure decreased their risk of getting melanoma. They were unsure about the use of artificial sun beds and if their use would increase or decrease their risk. Males and females differed significantly on many aspects of their sun behaviour. Most used sunscreen only 'sometimes' and its use was linked to knowledge of melanoma and perceptions of risk. The best way to modify the sun behaviour of young adults is to target both their knowledge of melanoma risk factors and their perceptions of risk.

Skin type and optimistic bias in relation to the sun protection and suntanning behaviors of young adults

The study examined the roles of general and personal beliefs and skin type in relation to suntanning and sun protection, by assessing various perceptions of risk of skin cancer both for the self and for the average person. A sample of 355 people aged 16 to 25 years was selected randomly from the telephone directory of a coastal provincial city. Highly structured interviews were conducted over the telephone. The findings were presented in relation to three research questions. First, skin type, classified as burn only, burn then tan, or tan without burning, influenced both general and personal beliefs. Compared to the tan-only group, the burn-only group perceived earlier age at onset, greater number of years of life lost, and greater severity of skin cancer, for both the average person and the self, and greater susceptibility to skin cancer for the average person. Second, differences were found between personally relevant and population-relevant beliefs on susceptibility to skin cancer, time of onset, and years of life lost due to skin cancer but not for perceptions of severity and curability. Finally, skin cancer beliefs were poor correlates of tanning and protecting behaviors. The factor explaining the greatest proportion of variance in both behaviors was skin type.

Predictors of sun exposure in adolescents in a southeastern U.S. population

PURPOSE

With the increase in melanoma incidence, the sun exposure and protective behaviors of adolescents are of great concern. Limited data are available on the prevalence and predictors of risk behavior in adolescents in the southeastern United States. This study examined the levels of sun exposure and variables predictive of sun exposure among adolescents in two Alabama middle schools.

METHODS

A total of 509 sixth-graders completed a self-administered survey assessing: (a) their knowledge, attitudes, and beliefs about malignant melanoma; and (b) their sun exposure and sunburns for a specific weekend and for the summer.

RESULTS

Levels of sun exposure and frequency of sunburn were high. Regression models determined the predictors of weekend and summer sun exposure, and weekend sunburn. Significant predictors varied by outcome and included gender, perceived importance of a suntan, parent and peer modeling, and sunscreen use.

CONCLUSION

Reducing the risk of melanoma will require a three-pronged intervention strategy with efforts directed at adolescents, their parents, and the broader community.

Predictors of sunbathing and sunscreen use in college undergraduates

Sunbathing and sunscreen use, as well as related intentions, attitudes, beliefs, and knowledge, were assessed in 90 Southern Appalachian undergraduates. A large majority (75%) reported sunbathing, with more than half reporting sun lamp use. A slight majority (56.7%) reported some use of sunscreen. Subjects reporting an intention to tan spent more time sunbathing, both outside and under a sun lamp. Individuals reporting a sun protection intention had lighter tans and spent less time sunbathing. Sunbathing was predicted by perceptions of sunbathing as relaxing, while sun lamp use was predicted by more positive views of suntans. Sunscreen use was predicted by more positive sun protection attitudes and less negative sunscreen attitudes.

Public education projects in skin cancer. Experience of the Canadian Dermatology Association

The mandate of the Canadian Dermatology Association's Sun Awareness Program is to increase awareness of the dangers of the sun's ultraviolet (UV) rays and to provide information on prevention and early detection of skin cancer. Major projects include an annual national press campaign, which reaches an increasing number of Canadians each year, and the production and distribution of educational materials. Each year during Sun Awareness Week, screening stations have been established across the country, staffed by volunteer dermatologists and members of the Canadian Cancer Society. In Vancouver between 1991 and 1993, 1767 people were screened for skin cancer. Results indicate that these events can attract people at risk for skin cancer, even though people older than age 65 are probably underrepresented as a group. Although popular with the public, these screenings are difficult to organize and are limited by human resources. These events continue in limited numbers, because they provide an excellent venue for the dissemination of educational material. Cooperation with federal agencies has been a major focus of the program. For the past 2 years, educational material on protecting newborns and children from the sun has been made available free to every new mother in Canada, while Environment Canada's Ultraviolet index program provides daily information on UV intensity along with public health messages. With the realization that health promotion requires a sustained change in behavior of an individual, we are now embarking on a national program to evaluate the knowledge, attitudes, and behavior of Canadians concerning UV radiation. With this information, we hope to adapt our educational materials so that people will adopt and maintain healthy behavior choices while out in the sun.

Suntanning and sun protection: a review of the psychological literature

Excessive sun exposure has been linked to skin cancer and to premature aging, drying and wrinkling of the skin, predominantly among Caucasians. This review examines the psychological literature on suntanning and sun protection behaviours among Caucasians. The research is examined in relation to: methods of study; attitude and normative beliefs towards suntanning and sun protection; differences in suntanning and sun protection knowledge and behaviour as a function of age and sun protection; differences to change sun related behaviours. A consistent finding across studies is that many people show a high level of knowledge of the dangers of excessive sun exposure and the need for sun protection, however, this knowledge often does not transfer into behaviour, with many people, particularly adolescents, still desiring and actively seeking a suntan. The implications of these findings for intervention studies are discussed.

Skin cancer prevention: a link between primary prevention and early detection?

The aim of this paper was to determine if there is any link between primary prevention and early detection for skin cancer. Results from a study of a large random sample of Gold Coast residents (N = 995) identified an association (P < 0.01) between individual primary prevention and early detection activities. People were also more likely to use both prevention methods if they had personal experience with skin cancer (P = 0.01) or if they were male (P = 0.05). Future primary prevention and early detection skin cancer programs might be most effective if they are combined.

Investigating changes in awareness about cutaneous malignant melanoma in Britain using the Omnibus Survey

Awareness about cutaneous malignant melanoma and sun protection was investigated in a national sample of 3961 adults. Awareness about malignant melanoma seems to have increased in England since the mid-1980s but it is lower in men, the under 25s, the elderly, those without a partner and the poorer socioeconomic groups. As mortality rates for melanoma are higher in elderly men than other age-sex groups, the possibility for improved awareness and prevention needs to be explored further within this group. Most people in the survey knew about sun protection. Further primary prevention initiatives should be monitored, using markers for behaviour such as the incidence of sunburn, as the potential benefits of a reduced incidence of skin cancer might not be seen for up to 20 years.

Melanoma: prevention and early diagnosis

Over the past two decades there has been a rapid rise in the numbers of people developing and dying from malignant melanoma. Sunlight is the main aetiological factor linked with melanoma. Exposure to the sun is a risk factor that can be modified provided that people are aware of the dangers. Health promotion campaigns can play a part in producing such change. General practitioners and practice nurses have an important part to play in providing those most at risk with information and advice about sensible sun exposure and sun protection measures. Campaigns to reduce delay in diagnosis by a combination of professional and public education have been reported from several centres around the world. The effects of these campaigns in reducing the depth distribution of cutaneous malignant melanoma have sometimes been encouraging, but in other instances have shown little effect. Until there is clear evidence that early detection reduces mortality from melanoma, the opportunistic promotion of early detection may not be cost effective and will fail to reach all sections of the community at risk. At the present time, therefore, the emphasis should be on the primary prevention of skin cancer.

Knowledge of sunlight effects on the eyes and protective behaviors in the general community

The knowledge of sunlight effects on the eyes and protective behaviors was assessed in the general community of Brisbane, Australia. Five hundred people were systematically sampled and surveyed via a telephone questionnaire. Of the participants, 279 (56%) were female and 258 (52%) were aged 40 years or less. Levels of knowledge were found to be lower in the older subjects, those with dark complexions and outdoor workers. Most were unaware of specific ultraviolet light related eye diseases such as cataract, pterygium and eye cancer. Three hundred and ninety (78%) wore sunglasses > 10% of the time while outdoors during the day; the most common reasons for wearing included protection from glare in 254 (65%) and driving in 60 (15%). Ninety-six (19%) never wore sunglasses, the most common reasons being inconvenience in 16 (17%), thought unnecessary in 16 (17%) and uncomfortable in 13 (14%). Promotion of sun protection to prevent ultraviolet light related diseases should include information on the eye. This information is important for establishing preventative behaviors and the selection of optimal eye protective measures.

Melanoma prevention: is it possible to change a population's behavior in the sun?

With the highest incidence and mortality rates of melanoma in the world, Australia has been running carefully designed primary prevention programs for more than 10 years. These have included public education programs aimed at all ages but concentrating particularly on young people. The programs have also included structural changes such as provision of shade in open space, rescheduling work and sport activities, removal of sales tax from approved sunscreens, and provision of cheap sunscreens. There have been substantial changes in knowledge, attitudes, and beliefs about melanoma, sunlight, and suntans. There have been significant increases in sun protective behavior reflected in the reduced proportions of people sunburnt at the weekend in summer in recent years. The incidence rate of melanoma continues to rise, as expected. Although there has been considerable success so far, we still have a long way to go.

A survey of sunscreen use and sun-protection practices in Darwin

A study was conducted to determine the prevalence and determinants of sun-protection practices in a sample of the non-Aboriginal population at the outdoor weekend markets in subequatorial Darwin, Northern Territory, at a time of intense sun exposure, between 11 a.m. and 1 p.m. from August to October 1992. All non-Aboriginal market-attenders who were seated within defined areas adjacent to food stalls were eligible to participate. Of 106 eligible market attenders, 105 (99 per cent) agreed to participate. Overall, fewer than 20 per cent of persons in this setting of extreme sun exposure were wearing sunscreen and less than one-third were wearing a hat. Only 44 per cent of people with a past history of skin cancer sitting in the midday sun had applied sunscreen and 61 per cent were wearing a hat; however, this was significantly more than those not reporting skin cancer (P < 0.002). The longer people had lived in the Northern Territory (compared with visitors and short-term residents) the less likely they were to have applied sunscreen in preparation for the midday sun (trend chi 2 = 3.99, P = 0.046). No association was demonstrated between the use of sunscreen and age or sex of the respondent. These results suggest that the sun-protection practices of visitors to the Northern Territory are less than optimal, and that among the longer-term residents of the Northern Territory who are at greatest risk of developing skin cancer, precautions against sun exposure could be greatly improved.

Trends in non-melanocytic skin cancer treated in Australia: the second national survey

An Australia-wide survey in 1985 recorded the highest rates of medically treated non-melanocytic skin cancer (NMSC) ever reported. We report the findings of a repeat survey conducted in 1990. This second survey confirmed the differences, by age, sex, body site, latitude, country of birth and skin reaction to strong sunlight, that were observed in 1985. Over the 5-year period certain changes were noted: the incidence of NMSCs increased by 19%, of basal-cell carcinomas (BCC) by 11% and of squamous-cell carcinomas (SCC) by 51%. With advancing age, men and women differed in their incidence, and this difference was greater for SCC than for BCC. Log-linear modelling, however, failed to detect either a cohort or a survey effect between the 2 surveys. The proportional distribution of BCCs and SCCs by body site indicated an increase in BCCs on the trunk in both men and women, and half the proportion of SCCs on the head and neck in women as compared with men. The latitudinal gradients observed in 1985 were even stronger in 1990; the population living north of 37 degrees S experienced a 30% increase in the incidence of treated NMSC between 1985 and 1990, while the population living south of 37 degrees S had a 25% decrease. The implications of these findings for cancer-control initiatives are discussed.