1. health and fitness
2. disease
3. cancer

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Primary Prevention of
Skin Cancer in Australia
Report of the Sun Protection
Programs Working Party
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Primary Prevention of
Skin Cancer in
Australia
Acute pain management:
information for consumers
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Report of the Sun Protection Programs Working Party
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December 1996
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National Health and Medical Research Council
NH MRC
Primary prevention of skin cancer in Australia
ii
© Commonwealth of Australia 1996
ISBN 0 642 27247 6
This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the
inclusion of an acknowledgement of the source and no commercial usage or sale. Reproduction for purposes
other than those indicated above, requires the written permission of the Australian Government Publishing
Service, GPO Box 84, Canberra ACT 2601.
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The strategic intent of the NHMRC is to work with others for the health of all Australians, by promoting
informed debate on ethics and policy, providing knowledge based advice, fostering a high quality and
internationally recognised research base, and applying research rigour to health issues.
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This document is sold through the Australian Government Publishing Service at a price which covers the cost
of printing and distribution only.
National Health and Medical Research Council documents are prepared by panels of experts drawn from
appropriate Australian academic, professional, community and government organisations. NHMRC is grateful
to these people for the excellent work they do on its behalf. This work is usually performed on an honorary
basis and in addition to their usual work commitments.
Publications and Design (Public Affairs, Parliamentary and Access Branch)
Commonwealth Department of Health and Family Services
Publication No. 2120
Primary prevention of skin cancer in Australia
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Contents
Terms of reference
viii
Executive Summary
ix
Section One
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1
Introduction
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1.1 Conceptual
Framework
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1.2 Trends in Melanoma
1.3 Economic Burden
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2
2
Section Two
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2
Section Three
3
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The Epidemiology of the Adverse Effects of Sunlight
2.1 Introduction
2.1.1 Sunlight
2.1.2 Ultraviolet radiation
2.2 Skin Cancer
2.2.1 Malignant melanoma
2.2.2 Non-melanocytic skin cancer
2.3 Non-malignant Skin Conditions
2.4 Ocular Disease
2.4.1 Cornea
2.4.2 Lens
2.4.3 Retina
2.5 Effects on the Immune System
2.6 Conclusion
2.7 Implications for Prevention
2.8 Recommendations 1, 2
Measuring Sun Exposure and Sun Behaviour
3.1 What Measures Do We Need?
3.1.1 Applications
3.2 Sun Exposure Measures
3.2.1 Conceptualising measurement of sun exposure
3.2.2 Measuring sun exposure in different subgroups
3.2.3 Ambient ultraviolet radiation level
3.2.4 Personal UV radiation exposure
3.3 Behavioural Influences on Sun Exposure
3.3.1 Measures of sun protection behaviour
3.4 The Physical and Regulatory Environment
3.4.1 Time spent outdoors
Primary prevention of skin cancer in Australia
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3
3
4
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5
7
8
9
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3.5
3.6
3.7
3.8
3.9
UV Radiation on the Skin
Personal Sensitivity
Implications for Prevention
A Broader Outcomes Framework for Primary Prevention Programs
Recommendations 3,4,5,6,7,8
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18
18
18
19
Section Four
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21
21
21
23
24
24
24
25
Section Five
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4 Primary Prevention Behaviours
4.1 Introduction
4.2 Sun Protective Behaviours
4.2.1 Sunscreens
4.2.2 Clothing
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4.2.3 Other
forms
of personal protection
4.2.4 Shade
4.3 Primary Prevention Surveys
4.4 Recommendations 9,10,11
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Evaluated Intervention Programs
5.1 Australia
5.1.1 Scope of Australian programs
5.2 Case Study 1: Slip! Slop!, Slap! And SunSmart:
the ACCV Skin Cancer Control Program
5.2.1 Outline of the SunSmart Campaign
5.2.2 Key achievements by SunSmart
5.2.3 Implications for prevention
5.3 Case Study 2: ME NO FRY Campaign
5.3.1 Background
5.3.2 Aims and objectives of MNF
5.3.3 Campaign strategies
5.3.4 Evaluation of the MNF campaign
5.3.5 Implications for prevention
5.4 Case Study 3: Evaluation of Interventions to Improve Solar Protection
in Primary Schools
5.4.1 Implications for prevention
5.5 Projects Recently Completed: Skin Cancer and Teenagers (SCAT) Project
5.5.1 Introduction
5.5.2 Methods
5.5.3 Results (to date)
5.6 Projects in Progress: Cancer Action in Rural Towns (CART) Project
5.7 International
5.7.1 Overview
5.8 Recommendations 12,13,14,15,16,17,18,19,20,21
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Section Six
6
Conclusions
6.1 Introduction
57
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Primary prevention of skin cancer in Australia
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6.2
6.3
6.4
6.5
6.6
6.7
Directions for Preventive Action
Indicators of Program Performance
Evidenced-based Practice for Facilitating Behavioural Change
Administrative and Legislative Options
Workforce Development
Recommendations 22,23,24,25,26
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Section Seven
7
Bibliography—Primary Prevention of Skin Cancer
61
Appendix A
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A Strategic
Plan
for the Prevention of Skin Cancer
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management:
information
consumers
(Extract
fromforSkin
Cancer Control in NSW)
75
Appendix B
Evaluated Primary Prevention Programs in Australia
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Appendix C
Submissions Received During Public Consultation
List of Figures
Lists of Tables
Table 5.6:
Table 5.7:
Table 5.8:
Primary prevention of skin cancer in Australia
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Table 5.4:
Table 5.5:
Factors affecting UVB radiation at the surface of the earth
Children—Australia
Children—Overseas
Adolescents—Australia
Adolescents—Overseas
Adults—Australia
Adults—Overseas
Preference for a tan by year of survey
Agreement with beliefs about tanning by year of survey (by %)
Sun protection measures between 11am and 3pm on the previous Sunday
(by %)
Preference for a suntan by school students in 1990 and 1993 (by %)
Adjusted percentage sunburnt of previous weekend
(any reddening of the skin) (%)
Percentage of the sample who were exposed to any advertising
related to sun protection and who identified it as MNF in
1991/92, 1992/93, 1993/94 and 1994/95
Percentage of adolescents with exposure periods who used a high level
of protection in 1991/92, 1992/93, 1993/94 and 1994/95 i.e. score of 12/16
International Intervention Studies
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Table 2.1:
Table 4.1:
Table 4.2:
Table 4.3:
Table 4.4:
Table 4.5:
Table 4.6:
Table 5.1:
Table 5.2:
Table 5.3:
IN
Figure 2.1: Electromagnetic spectrum with enlargement of ultraviolet radiation region
Figure 3.1: UV exposure and its effects
95
103
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13
4
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vi
A REPORT OF THE
SUN PROTECTION PROGRAMS WORKING PARTY
OF THE HEALTH ADVANCEMENT STANDING COMMITTEE
Ms Sophie Dwyer (Chair)
Assoc. Prof. John Lowe
Public Health Services
Centre for Health Promotion and
Queensland Health
Cancer Prevention Research
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Dr Ron Borland
University of Queensland
Acute pain management:
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Centre for Behavioural Research in Cancer
Prof. Robin Marks
Anti-Cancer Council of Victoria
Department of Medicine
Consumer Representative
Dr Dallas English
Department of Public Health
University of Western Australia
Dr Afaf Girgis
Health Information Centre
Queensland Health
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Cancer Education Research Program (CERP)
New South Wales Cancer Council
Dr Ian Ring
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Ms Penelope Edwards
University of Melbourne
PREPARED BY
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The Centre for Health Promotion and Cancer Prevention Research
University of Queensland Medical School
EDITED BY
Dr Warren Stanton
Primary prevention of skin cancer in Australia
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CONTRIBUTORS
Principal authors of the sections of this report (in alphabetical order) were as follows:
Peter Anderson
Peter Baade
Kevin Balanda
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Ron Borland
Acute pain management:
Helen Dixon
information for consumers
Sophie Dwyer
Dallas English
Amaya Gillespie
SC
Afaf Girgis
John Lowe
Robin Marks
Ian Ring
Warren Stanton
IN
ACKNOWLEDGEMENTS
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The editing and typing was produced by Natalie Paul. Many others contributed substantially to the preparation
of this report, including Sandra Chippindall, Alexandra Clavarino, Paula McDonald, Michelle Sheldrake and
Michelle Willis. Also, thanks to Cheryl Bray for her comments. Much of the information for this report was
collected by NHMRC through the efforts of Felice Delgado and Christine Benger.
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DISCLAIMER
The programs listed in this report were selected on the basis of information made available at the time. It is
acknowledged that this may not be a complete list of programs conducted throughout Australia or overseas.
Primary prevention of skin cancer in Australia
viii
Sun Protection Programs Working Party
Terms of reference:
The terms of reference for the Sun Protection Programs Working Party were to identify, review and assess
Australian and international population-based sun protection interventions focusing on children and teenagers,
having regard to their effectiveness, cost, cost effectiveness, aggregate and distributive impacts, feasibility
of implementation, and precision of evaluation, for the purposes of:
reviewing and reporting on the state of scientific knowledge;
•
identifying gaps in knowledge, research needs and preventive action;
•
identifying the special needs of high risk population groups, as well as the needs ofthe general population;
•
review and determination of measurable and qualitative indicators of program performance.
•
recommending guidelines for evidence-based best practice;
•
advising on the administrative and legislative options to implement recommendations; and
•
assessing the implications of recommendations for workforce development.
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•
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Primary prevention of skin cancer in Australia
ix
Executive Summary
Section One:
Introduction
RE
Australia has the highest incidence of skin cancer of any country in the world. Melanoma is now the third
most common potentially fatal cancer, after cancer of the prostate and lung in men, and cancer of the breast
and colon in women (Jelfs et al., 1996). The principal goal of preventive efforts is to reduce exposure to
sunlight through behavioural and environmental changes. The specific behavioural objectives currently
promoted include wearing of appropriate clothing, application of sunscreen, use of sunglasses, seeking shade
or remaining indoors during the middle of the day. The terms of reference focus on the identification, review
and critique of Australian and international population-based sun protection interventions primarily involving
children and adolescents. Specifically, this report will: review and report on the state of scientific knowledge;
identify gaps in knowledge, research needs and preventable action; identify special needs of both the high
Acute pain management:
risk and general population; review and determine measurable and qualitative indicators of program
information for consumers
performance; recommend guidelines for evidence-based best practice; advise on the administrative and
legislative options to implement recommendations, and assess the implications of recommendations for public
health workforce development.
The Epidemiology of the Adverse Effects of Sunlight
SC
Section Two:
There are three types of skin cancer related to sun exposure: malignant melanoma, basal cell carcinoma
(BCC) and squamous cell carcinoma (SCC). Malignant melanoma is the most serious, but occurs less frequently
than the other two types of skin cancer. BCC is the most common cancer in Australia, followed by SCC.
IN
Most skin cancer in Australia is caused by sun exposure. Childhood sun exposure is particularly important in
determining melanoma risk. In adult life, recreational (intermittent) sun exposure appears to be the strongest
determinant of melanoma risk followed by total sun exposure and occupational exposure. There is evidence to
suggest that sunlight sensitivity modifies the relationship between melanoma and sun exposure.
DE
The epidemiology of BCC appears similar to that of melanoma, with evidence suggesting that childhood
exposure and recreational exposure are strongly related to BCC. However, the epidemiology of SCC is
different. Cumulative sun exposure, latitude and occupational sun exposure are associated with SCC. The
relative contributions of the theories of intermittent exposure and lifetime exposure are part of the current
debate.
A number of non-malignant skin conditions, and premature aging are also related to sun exposure. In addition,
there is some evidence that sun exposure causes several forms of eye disease.
It is recommended that:
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One of the major implications of the epidemiological data in relation to prevention programs is that strategies
to reduce sun exposure among children are more likely to have greater impact on the incidence of skin
cancer than are strategies to reduce exposure among adults.
1.
The NHMRC note that the epidemiological evidence demonstrates the need to continue to focus on the
prevention of UV exposure in childhood.
2.
Further investigation is required of the natural history and dose response relationship between actual
sun exposure and indicators, for example skin features like naevi, which are possible indicators of sun
exposure, especially during childhood.
Section Three:
Measuring Sun Exposure and Sun Behaviour
Sun exposure measurements have a wide range of applications, including studies of skin cancer risk, descriptive
studies of prevalence of sun-related behaviours, and as dependent variables in predictive models of sunrelated behaviours. Types of sun exposure measures dealing with UV exposure include the ambient UV
level, time spent outdoors, sun protective behaviours, UV radiation (UVR) of the skin, and personal
susceptibility.
Primary prevention of skin cancer in Australia
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Ambient UV level is influenced by a number of factors, including season, time of day, and weather conditions.
Measurement of time spent outdoors should include both deliberate sun exposure such as at the beach, or
gardening and incidental exposure that arises from ordinary daily activities. The time of day and type of
activity are important components of time spent outdoors. Sun protective behaviour not only includes a
number of components such as shade, sunscreen and hats, but also measurements of the quality and quantity
of each component.
These sun protection behaviours may be classified in terms of active and incidental behaviours. Behaviour
may be measured by observation of individual behaviour, diaries, cued recall and uncued retrospective reports
of specific instances of behaviour. Such behaviours are promoted or mitigated by the physical and regulatory
environment.
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The UV dose received on the skin can be estimated by a combination of the ambient UV levels and time
spent outdoors, adjusted for the protective benefit attributable to the sun protective behaviours. To do this
would require tables similar
to the food composition tables used in nutritional epidemiology. There is some
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evidence that the UV information
effect depends
on a number of personal characteristics, including genotype, tanability
for consumers
of skin, skin type, and number of freckles and moles.
A broader outcomes framework is required for program evaluation, including measures at different levels
based on a program logic approach.
SC
It is recommended that:
Further research be undertaken to develop more effective population measures of sun exposure,
particularly with respect to monitoring sun exposure of children, including infants.
4.
Australian cancer prevention research teams initiate a project to establish consensus on the viability
of uniform indicators of success in intervention studies, including the development of a comprehensive,
sensitive index of behaviour change that accounts for the different recommended primary prevention
behaviours. If a consensus on its viability is agreed, work should proceed.
5.
Researchers estimate the average exposure to UVR in Australians across various geographic strata
and estimate how this relates to probable exposure patterns for people at higher latitudes in other
countries where skin cancer is less of a problem (except perhaps among those frequently holidaying
in high UV destinations).
6.
Further research be undertaken into the relationship between self-report measures of exposure and
other more objective measures, for example video recording of behaviours or polysulphone badges
attached to body parts.
7.
Australian Institute of Health and Welfare (AIHW), in conjunction with groups already active in the
field, instigate a national program to monitor both behavioural and structural sun protective
measures, building on work already done.
8.
Evaluation of sun protection programs be multiphasic, addressing the shorter-term direct effects such
as knowledge, attitudes and behaviours; the less direct effects such as a change in naevi and skin
damage; and eventually, the long-term effects such as reduction in the incidence of melanoma.
Section Four:
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3.
Primary Prevention Behaviours
Sun protection behaviours emphasise natural protection such as clothing, hats and staying in the shade.
Sunscreens are an adjunct to natural protection and are recommended when these forms of protection are less
practical.
Youth has been suggested to be the greatest demographic risk factor for sunburn. Although children have
high levels of knowledge about skin cancer and skin protection, children generally have low levels of skin
protection when outside in the sun. Similarly, adolescents display low levels of skin protection. Adolescent’s
use of skin protective measures appears related to fashion trends and peer pressure.
Primary prevention of skin cancer in Australia
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Generally, males and young people are more exposed to the sun. Males and older people are more likely to
wear hats outside, while females and young people are more likely to wear sunscreen. Protective clothing is
not appealing to adolescents, but is viewed as more appropriate by older people.
The strength of the relationship between knowledge and skin protective behaviour varies across countries. In
general, results in Australia suggest little or no relationship, overseas results have shown some association.
This difference may be attributed to the currently higher levels of knowledge in Australia.
It is recommended that:
Sun protection programs continue to emphasise that sunscreens are an important adjunct, but not a
substitute for, other forms of protection such as staying out of the sun in the middle of the day, use of
shade and wearing protective clothing.
10.
Sun protection programs should include consumer education campaigns on how to correctly use
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sunscreens.
11.
Sun protection programs continue to focus on increasing availability and accessibility of protective
measures, reducing barriers to sunscreen use, making sunsafe clothing more acceptable and reducing
outdoor activity during hours of high radiation.
RE
9.
information for consumers
Evaluated Intervention Programs
SC
Section Five:
IN
Very few pre-post evaluated intervention programs have been conducted in Australia. The available case
studies provide data on the impact of multi-strategic sun protective programs. The most noted is the ‘SunSmart’
program in Victoria, launched in 1988. The long-term aim of this program is to reduce the morbidity and
mortality from skin cancer in Victoria, with short-term aims based on changing attitudes, beliefs and behaviours
affecting skin cancer risk, and encouraging early detection of skin cancers. Target settings were schools,
media, sporting events, government authorities, general practitioners, community health centres and industry.
Over a period of seven years, the SunSmart program has had success in changing attitudes and sun safe
behaviours. Recent assessments have not shown continued decreases in reported sunburn.
DE
Other programs include the ‘Me No Fry’ campaign, run since 1990/91 in New South Wales, and since 1994/
95 in Western Australia. This campaign is directed specifically at adolescents, and deliberately attempts to
fit into the preferred fashions and assumptions of the Australian youth culture. The campaign aimed to increase
adolescents’ knowledge, desirability of sun protection, and sun protection behaviours. In NSW, the program
has resulted in increased knowledge, favourable sun safe attitudes and behaviours. As in other States and
Territories, the amount of change has been observed to level off in the last two years.
D
An evaluation of interventions aimed at improving sun protection in primary schools was conducted in NSW
in 1992–93. An intensive intervention, the ‘SKIN SAFE’ program, aimed to increase knowledge levels, and
to develop the attitudes and skills to reduce their risk of skin cancer. Minimal intervention did not result in
behaviour change but the intensive intervention resulted in an increase in solar protection.
A number of overseas programs were also reviewed. Results of these programs show similar trends to those found in
Australia, but with less success in achieving behaviour change in relation to primary prevention of skin cancer.
It is recommended that:
12.
Australian schools (secondary and primary) and child care services that have not already done so,
should implement policies which facilitate a comprehensive approach to sun protection, including
teaching sun protection in the class room, reducing exposure during outdoor activity, involving
teachers, parents and the community in sun protection and environmental changes (ie in a manner
consistent with the notion of health promoting schools).
13.
State governments support the monitoring and publishing of information on the adoption and
implementation of sun protection policies and programs by schools, childcare services, community
organisations and local services (eg sporting clubs).
Primary prevention of skin cancer in Australia
xii
Studies be funded to further test the benefits of multifaceted comprehensive strategies such as policy
development and implementation, intersectoral collaboration, educational strategies, media strategies,
and economic incentives in availability of protective products and aids, and further inform the
development of best-practice principles. This will involve more extensive evaluation and research on
innovative programs as well as more traditional intervention studies. Single approaches, like one
classroom lesson, or a pamphlet or even one advertisement in the absence of other strategies are not
recommended.
15.
Sun protection programs focus on the development of strategies to ensure that changes are sustained
in the longer-term, particularly for those subgroups within the population (such as adolescents) who
are placing themselves at risk.
16.
Research projects be funded to investigate the long-term impact of intervention programs shown to
be effective in the short term.
17.
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Studies be undertaken
to ascertain the feasibility of disseminating information from successful sun
information for consumers
protection interventions,
and of adapting comprehensive programs to new settings.
18.
Research in the field of skin cancer be undertaken to address the effect of policies regarding exposure
to the sun. This needs to be documented to provide information about the impact of sun safe policies
on sun exposure by the individual, group or community.
19.
All Government departments (Commonwealth and State) review their programs to determine their
contribution to sun safety in their workforce and the community.
20.
Sun protection programs continue their intersectoral effort to generate those environmental and
structural changes, eg shade creation and rescheduling sporting events, that facilitate protective
behaviours.
21.
Sun protection program managers place greater priority on program evaluation (at a level relevant to the
size of the program), including pre- and post- intervention monitoring (see Recommendation 8).
Conclusions
IN
Section Six:
SC
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14.
DE
Prevention of exposure in the early stages of life is likely to have a greater impact on the incidence of skin
cancer than strategies to reduce exposures in adulthood, though programs targeting adults are also important.
Care must be taken in sun protection programs to remind the community of the risk associated with high and
intermittent exposure. In terms of health promotion, the occurrence of sunburn provides immediate feedback
to the individual about their harmful exposure. On a longer time frame, naevi may provide early biological
markers of subsequent risk of melanoma.
Most States and Territories have programs that include broad community education, and local educational
and structural change activity.
D
On the one hand, Australia is among the world leaders in efforts to prevent skin cancer. There have been a
number of innovative research studies and comprehensive programs, which set a benchmark for communitywide activity. On the other hand, much more needs to be done. In Australia to date, there has been no national
approach to primary prevention for skin cancer. While specific activities or programs in some communities or
States and Territories have been well planned and implemented, across the country as a whole the application
of programs has been ad hoc and limited in scale. The ‘Slip, Slop, Slap’ programs have focused on the protection
of children, either directly or through their parents. Similarly, a number of programs have targeted teenagers
and adults. Given the epidemiological evidence of the impact of exposure in childhood, there is a need to
continue to focus on preventing exposure to solar radiation in this age group. The Working Party also noted that
there are differences across the country in the targets chosen, and the comprehensiveness of effort. Evaluated
Australian programs have demonstrated some changes in sun safe attitudes and behaviours. Such campaigns
have built upon existing community-based efforts and indicate the need for sustained commitment of effort and
investment to achieve the desired community-wide change.
Primary prevention of skin cancer in Australia
xiii
It is recommended that:
Health promotion funding bodies ensure that funding of sun protection programs is at a level to ensure
meaningful changes in the community, beyond a higher profile for the issue. Further, funding needs
to be provided for a sufficient number of years to maintain and improve on the adoption of sun
protective strategies in the community. Dedicated funding to enhance program evaluation needs to be
considered by funding agencies. The evaluation and research budgets should be supplemented (by
governments if necessary) to ensure that achievements and processes are well documented.
23.
Australian efforts on skin cancer prevention be coordinated through an intersectoral National Sun
Protection Strategy that links Cancer Organisations, State, Territory and Commonwealth health
departments and other relevant sectors.
24.
Assessment of the feasibility of undertaking an economic evaluation should occur based on our
current knowledge of the effectiveness of primary prevention programs. The work must provide
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insight into
models for economic evaluation that can be applied to current and new programs. As this
information for consumers
is outside
the scope of this report, an economist should be commissioned to conduct this assessment.
25.
Commonwealth and State Governments liaise with tertiary institutions and professional organisations,
such as medical faculties and colleges, Divisions of General Practice, the Institute of Environmental
Health, Schools of Education, Architecture,Town Planning, Nursing and Public Health to incorporate
information on sun exposure, sun protective programs, intervention studies and relevant research
into vocational education, training and continuing education.
26.
The NHMRC update triennially the available information provided in this report, and its
recommendations.
D
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IN
SC
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22.
Primary prevention of skin cancer in Australia
1
Section One
Introduction
RE
Australia has the highest incidence of skin cancer of any country in the world. Melanoma is now the third most
common potentially fatal cancer, after cancer of the prostate and lung in men and cancer of the breast and colon in
women (Jelfs et al., 1996). The rate has been increasing by about 5 per cent per year. Recent evidence has indicated
that melanoma mortality rates have now plateaued at 5.0 per 100 000 person years for males and 2.4 for females
and may be declining in recent aged cohorts (Giles et al., 1996). The incidence of melanoma, which rose considerably
Acute pain management:
in the 1980’s, may have plateaued in about 1988 (Jelfs et al., 1996), this being most clear in those aged under 65.
information for consumers
Epidemiological evidence suggests that exposure to sunlight is the primary risk factor for melanoma and other
skin cancer. Exposure to the sun in childhood and teenage years has been suggested to account for a large proportion
of skin cancer risk.
SC
The principal goal of preventive efforts is to reduce exposure to sunlight through behavioural and environmental
changes. The specific behavioural objectives currently promoted include wearing of hats, wearing of appropriate
clothing, application of sunscreen, use of sunglasses, seeking shade or remaining indoors during the middle of the day.
IN
This review of sun protection programs has been undertaken as part of the NHMRC National Health Advisory
Committee’s program, being managed by its Health Advancement Standing Committee (HASC). HASC established
a series of working parties to examine community-based interventions. Such interventions involve health promotion,
behavioural modification, community development and prevention programs. The focus of the reviews was largely
on the effectiveness, cost, overall impact, impacts within specific subgroups of the population, feasibility of
implementation, and the provision of advice on the policy and research implications. These reviews of communitybased health promotion interventions are expected to contribute significantly to the establishment of evidencebased guidelines for best practice.
DE
The terms of reference for the Sun Protection Programs Working Party focused on the identification, review and
critique of Australian and international population-based sun protection interventions primarily involving children
and teenagers. The evaluations of these interventions were measured with regards to their effectiveness in changing
behaviour, cost effectiveness, feasibility of implementation and precision of evaluation.
The Centre for Health Promotion and Cancer Prevention Research, University of Queensland Medical School was
commissioned to write the report with consultation from the Sun Protection Programs Working Party. An outline
for the contents of the report was determined by the Sun Protection Programs Working Party.
D
1.1 Conceptual Framework
Reducing over exposure to ultraviolet radiation by avoiding excessive sun exposure can reduce the risk of a
number of diseases including skin cancer. Sun exposure is affected by a wide range of individual sun protection
behaviours as well as by societal and natural structures.
Sun protection is one of many public health priorities which in turn is one of a number of society-wide activities
for fostering the well-being of the community. Priorities for sun protection need to be developed and pursued in
relation to other priorities. In some cases, there is a possibility of conflict eg with outdoor recreation and physical
fitness encouraging people outdoors, or with fashion encouraging suntans and non-protective attire.
Some of the activity that affects sun exposure can be brought under the coordination of an organised program,
which if it conducts activities in its own right, can be thought of as a comprehensive sun protection program.
Programs can serve to disseminate education material, enact structural change that is within their control, and/or
advocate change in areas beyond their control.
Primary prevention of skin cancer in Australia
2
Sun protection programs should operate within a set of overarching principles that inform theoretical and practical
development of all public health initiatives. They should work to ensure:
•
equity, access and participation—ensuring the program reaches everyone to whom it is relevant;
•
sustainability—ensuring that the program is embedded in the community and is structural and enduring;
•
reflection—ensuring that the program is founded on, guided by, and re-evaluated with accurate and
comprehensive information; and
•
accountability—ensuring that the program meets (or makes progress towards) its goals in a manner that is
acceptable to the community and is maximally effective and efficient.
RE
1.2 Trends in Melanoma
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It is too early to provide
definitive data on whether trends in melanoma incidence and mortality have declined, but
information for consumers
rising trends of the 1980’s have certainly slowed. The evidence for declines in melanoma is strongest in younger
people, where effects of prevention programs are likely to be first felt.
SC
Giles et al. (1996) cautiously noted that the results they reported on trends in melanoma mortality provided
indirect evidence that ‘provide encouragement to public health programs designed to decrease exposure to the
sun...’ (p.1224). The long lag times between preventive programs producing behavioural change and skin cancer
outcomes, means that it is likely to be at least another ten years before we will be able to have any confidence
about whether the emerging trends have consolidated and are likely to be attributable, at least in part, to the
benefits of the prevention campaigns.
1.3 Economic Burden
IN
DE
Limited information is available on the economic burden of skin cancer in Australia. Unpublished Australian
Institute of Health & Welfare (AIHW) data estimates that the direct costs of melanoma and other skin cancer are
approximately $175 million per year, with the breakdown being $19 million for melanoma, $96 million for nonmelanoma and $60 million for benign skin neoplasms (Armstrong, unpublished data, 1996). Information is not
available on the indirect costs including, for example, sick leave and foregone earnings.
In its review of the effectiveness of primary prevention programs, this report will consider the effectiveness of
strategies that have been and can be implemented by both government, non-government and the community. It is
not feasible to extend this report to include an accurate cost-effectiveness analysis, as a precise costing of existing
initiatives is not available, and costs for prevention are not limited to health promotion programs, but are borne
across the community.
D
Further, the Working Party has not costed all the recommendations, though in considering the implementation
options, the calculation of costs of initiatives is a necessary future step.
Primary prevention of skin cancer in Australia
3
Section Two
The Epidemiology of the Adverse
Effects of Sunlight
RE
Acute pain management:
2.1 Introduction
information for consumers
2.1.1 Sunlight
SC
In this section we review the evidence linking exposure to sunlight with a number of adverse health effects. The
International Agency for Cancer Research (1992) concluded that there was sufficient evidence that solar radiation
causes skin cancer. Sunlight probably causes certain diseases of the eye and there is also some evidence that it
affects the immune system. Attention is focused upon activities and patterns of exposure that are known to increase
risk of one or more sun-related conditions and that are amenable to change. This section begins with a brief
review of sunlight and its component parts, including ultraviolet (UV) radiation.
IN
The sun emits energy in the form of electromagnetic radiation (Figure 2.1). The highest energy radiation, cosmic
rays, gamma rays and X-rays, have wavelengths of less than 100 nm. The ultraviolet part of the spectrum extends
from wavelengths of 250 nm to 400 nm and visible light from 400 nm to 700 nm. Infrared radiation and radio
waves have longer wavelengths and less energy. Radiation at wavelengths less than about 290 nm is blocked by
the ozone layer of the stratosphere and does not reach the earth’s surface.
D
DE
Figure 2.1: Electromagnetic spectrum with enlargement of ultraviolet
radiation region
Source: International Agency for Cancer Research (1992)
Primary prevention of skin cancer in Australia
4
2.1.2 Ultraviolet radiation
The ultraviolet portion of sunlight is divided into three parts, ultraviolet C (UVC) at wavelengths from 100 to
280 nm, ultraviolet B (UVB) from 280 to 315 nm and ultraviolet A (UVA) from 315 to 400 nm. As was noted
above, no radiation in the UVC spectrum reaches the earth’s surface. Even with severe depletion of stratospheric
ozone, no UVC will reach the earth (Gies, Australian Radiation Laboratory, personal communication, 1996).
RE
The relative effectiveness of ultraviolet radiation (UVR) of different wavelengths in causing health effects is
called the action spectrum. The action spectra for erythema (sunburn) in humans and cancer in experimental mice
are
similar
(de Gruijl, 1995), suggesting that the action spectrum for cancer in humans is likely to be similar. UVB is much
more effective at producing erythema or cancer in animals than is UVA—wavelengths of about 340 nm are less
than 1/1000 times as likely to produce an effect as wavelengths of about 295 nm (de Gruijl, 1995). Thus, although
UVB comprises only about 5 per cent of total solar UVR that reaches the earth (Sliney & Wolbarsht, 1980), it is
largely responsible forAcute
the adverse
health effects of sunlight.
pain management:
information for consumers
The amount of UVB reaching
the earth is affected by a number of factors (Table 2.1).
Table 2.1:
Factors affecting UVB radiation at the surface of the earth
Time of day
Season
Surface reflection
Stratospheric ozone
D
Source: International Agency for Cancer Research, 1992.
DE
Altitude
Air pollution
IN
Clouds
UVB radiation decreases with increasing distance from the equator.
It varies more with latitude than does UVA.
UVB radiation is highest in the middle of the day. It varies more during
the day than does UVA.
UVB radiation levels are higher in the summer than in the winter. Seasonal
variation in UVB is greater in southern Australia than in northern
Australia.
Clouds reduce UV ground irradiance. Light clouds scattered over a blue sky
have little effect, but complete light cloud cover prevents about 50 per cent of
UVB from reaching the earth’s surface (Diffey, 1990).
A person’s UVR exposure will be greater on a reflective surface.
Sand reflects about 10–15 per cent of UVB; the sea near the coast is also highly
reflective. Grass does not reflect much UVB (Sliney, 1986).
UVB radiation levels increase with altitude.
Ozone and other pollutants in the atmosphere can reduce UVB radiation at
the earth’s surface.
Variations in stratospheric ozone by season and latitude can affect UVB radiation. Long-term decreases in stratospheric ozone are expected to increase UVB
radiation.
SC
Geographic latitude
2.2 Skin Cancer
There are three types of skin cancer which are caused by sunlight. Malignant melanoma is a cancer of melanocytes,
the cells in the epidermis that produce pigment. It is the least common type, but is more serious than the other two
types. About 800 Australians die each year from it. The other two types of skin cancer are basal cell carcinoma
(BCC) and squamous cell carcinoma (SCC). Together, they are often referred to as non-melanocytic skin cancer.
BCC is the most common cancer in Australia by far, and SCC is the second most common cancer. It has been
estimated that about 150 000 non-melanocytic skin cancers are diagnosed each year in Australia (Giles et al.,
1988). Although non-melanocytic skin cancers grow slowly and are easily treated, about 200 Australians die each
year from them, and they account for the highest health care costs of any neoplasm in Australia (AIHW, personal
communication, 1996).
Primary prevention of skin cancer in Australia
5
Wherever possible, evidence from Australian studies will be used to illustrate the relationship between sun exposure
and skin cancer. Two major case-control studies of melanoma have been conducted in Australia, one in Queensland
by Green and colleagues, and another in Western Australia by Holman and colleagues. Population-based studies
of non-melanocytic skin cancer have been conducted in Nambour (Queensland), Geraldton (Western Australia)
and Maryborough (Victoria) and two national surveys of the incidence have also been conducted. In writing this
section, we have drawn extensively on two recent reviews (Armstrong & English, 1996; Kricker et al., 1994). In
many studies, strong associations have been observed with measures of ambient sunlight (ie the amount of sunlight
occurring at places where people live or work), but much weaker associations have been observed with measures
of actual exposure to individuals.
2.2.1 Malignant melanoma
SC
RE
Melanoma is sometimes divided into the histological subtypes of superficial spreading melanoma, lentigo maligna
melanoma, acral
lentiginous melanoma and nodular melanoma. Superficial spreading melanoma is the most
Acute pain management:
common, accounting
for more than 50 per cent of cases (Armstrong & English, 1996). Lentigo maligna melanoma
information for consumers
(sometimes called Hutchinson’s melanotic freckle melanoma) occurs predominantly on the head and neck, whereas
superficial spreading melanoma and nodular melanoma are more common on the trunk and the limbs. There is
some dispute about the validity of the histological classification. Reviewing the epidemiology of melanoma is
complicated because some investigators have excluded lentigo maligna melanomas while others include them.
Regardless of whether the histological classification is meaningful, the exclusion of these melanomas could change
the overall anatomic site distribution. Because the relationship between sun exposure and risk of melanoma may
be related to anatomic site, differences among studies may be confounded by differences in site distributions.
IN
Observations on the incidence and mortality of melanoma in relation to geographic latitude, migration to sunny
climates, anatomic site distribution and ethnic origin, provide persuasive evidence that sun exposure causes
melanoma. In Australia and the USA, melanoma incidence increases with increasing proximity to the equator
(Scotto & Fears, 1987; Jones et al., 1992). Indeed, observations by Lancaster (1956) regarding the relationship
between mortality from melanoma and latitude were among the first indications that melanoma was related to sun
exposure. In a similar vein, Holman & Armstrong (1984) found that the subjects who had lived in places with a
high annual number of hours of bright sunshine had the highest rates of melanoma.
DE
Migrants who move from areas of low incidence to areas of high incidence with sunny climates such as Australia,
Israel and New Zealand, generally have lower rates of melanoma than native-born residents of the host countries
(Katz et al., 1982; Cooke & Fraser, 1985; Khlat et al., 1992). British immigrants to Australia and New Zealand,
have mortality rates about half those of the Australian-born residents (Cooke & Fraser, 1985; Khlat et al., 1992);
similar differences have been observed in incidence rates in Western Australia (Holman et al., 1980). People who
migrated to Australia in the first decade of life had risks about equal to people born in Australia but those who
arrived later in life had much lower risks (Holman & Armstrong, 1984). These results suggest that early childhood
exposure to the sun is an important aetiological factor for melanoma.
D
When proper adjustment is made for body surface area, it is apparent that melanomas occur most frequently on
body sites that receive the most sun exposure (Green et al., 1993).
Armstrong & Kricker (1993) used data on the anatomic site distribution of melanoma, variation by ethnic origin,
latitude of residence and migration from the United Kingdom to Australia to estimate that between 68 per cent
and 98 per cent of melanoma was due to sun exposure.
A number of observations, however, are apparently inconsistent with a simple relationship between sun exposure
and melanoma. In many populations, melanoma occurs as commonly in women as in men, although men are
more likely to work outdoors. It shows a relative peak in incidence in middle life, which is not the pattern to be
expected from lifelong exposure to an environmental agent, and it occurs frequently on the back in men and lower
limbs in women, sites which are not maximally exposed. Of more significance, perhaps, is the relationship between
incidence of melanoma and occupation and socioeconomic status—melanomas are more common in indoor than
Primary prevention of skin cancer in Australia
6
outdoor workers and are also more common in people of high socioeconomic status (Holman et al., 1980; Cooke
et al., 1984).
These observations led to the postulation of the ‘intermittent exposure hypothesis’ for the relationship of sunlight
to melanoma (Fears et al., 1977; Holman et al., 1980). Briefly, this hypothesis states that:
1.
Incidence of melanoma is determined as much (or more) by the pattern of sun exposure as by the total
accumulated ‘dose’ of sun exposure.
2.
Infrequent (intermittent) exposure of untanned skin to intense sunlight is particularly effective in increasing
the risk of melanoma. Thus, there is an initial rise in incidence as frequency of exposure increases, but a fall
in incidence as exposure becomes more continuous.
RE
A number of case-control studies and cohort studies have obtained information on individual amounts and patterns
of sun exposure. These are discussed below.
SC
Acute pain management:
There have been inconsistent
results relating to ‘total lifetime’ exposure to the sun; some studies have found
information
for consumersof melanoma while others have found negative associations (Armstrong
positive associations with
the incidence
& English, 1996). The associations have been quite strong for biological markers of sun exposure. For example, in
the Western Australian study, a strong positive association was seen with increasing evidence of solar damage to
the skin (Holman & Armstrong, 1984) and in the Queensland study, the risk was highest among people with sunrelated tumours on the face (Green & O’Rourke, 1985). However, these markers do not provide any information
about the patterns of exposure; it may be, for example, that in Australia extensive solar damage to the skin can
occur from an intermittent pattern of exposure.
IN
Consistent with descriptive findings relating to indoor and outdoor work, Holman & Armstrong (1984) found that
people who spent the most time outdoors in summer had the lowest risk of melanoma. Fifteen studies have considered
occupational exposure to the sun, classified simply as ‘outdoor’ occupation in some studies and according to
actual hours outdoors in other studies; their results have been inconsistent, with about half showing lower risks
among outdoor workers (Armstrong & English, 1996). Some of the inconsistency probably relates to the failure to
account for body site; none of the studies compared risks for sites likely (or unlikely) to be exposed at work.
D
DE
Intermittent exposure to the sun has usually been equated with recreational exposure. Most studies show convincing
trends towards increasing risk of melanoma with increasing recreational exposure to the sun (Armstrong & English,
1996). However, the Queensland study found no consistent association with total time spent at the beach (Green
et al., 1985b). The Western Australian study found increased risks for boating and fishing in summer, but only
weak associations with sunbathing and the proportion of time outside during the summer that was recreational
(Holman et al., 1986). It did find a strong association between risk of melanoma on the back in women and type of
bathing suit worn at ages 15–24. Compared with women who wore a one piece suit with a high backline, those
who wore a one-piece suit with a low backline had an odds ratio of 4.0 (95 per cent confidence interval 0.6–25)
and the relative risk for wearing a two piece bathing suit, or none at all, was 13.0 (2.0–8.4). This finding was not
confirmed, however, by Weinstock et al., (1991) who found an odds ratio of 1.8 (95 per cent confidence interval
0.9–3.5) for predominant wearing of a bikini.
Sunburn is perhaps one of the most easily recalled and, therefore, least misclassified measures of intermittent sun
exposure. It may also have the advantage of indicating dose received at the level of the basal layer of skin, taking
account of both intensity of exposure to the sun and degree of natural protection.
Sunburn has been consistently associated with melanoma (Armstrong & English, 1996). In 16 of 20 relevant
studies, a moderate to strong positive relationship between sunburn and melanoma was observed. In one of the
studies that did not follow this pattern consistently (Holman et al., 1986), there was quite strong evidence for a
relationship between number of blistering sunburns and incidence of melanoma. In another study which did not
show an effect, questions were asked about sunburns in recent years (Grob et al., 1990), whereas most of the other
studies assessed sunburn in childhood and adolescence.
There is some evidence that the relationship between sun exposure and melanoma is modified by a person’s
sensitivity to sunlight. Weinstock et al. (1991) found that risk of melanoma was negatively associated with frequency
of exposure in women who tanned readily, but positively associated in women who tanned poorly. Similarly,
Nelemans et al. (1993) found much higher relative risks associated with sunbathing, water sports, vacations to
sunny places and history of sunburn in those who tanned poorly. White et al. (1994) also found modification of the
effect of estimated total sun exposure in adolescence and childhood by cutaneous sensitivity to the sun. However,
Primary prevention of skin cancer in Australia
7
the fact that the risk of melanoma did not increase with increasing estimated exposure to the sun even in those
who tanned poorly is hard to explain.
There are sources of ultraviolet radiation other than the sun to which people are exposed. These include sunlamps
and sunbeds, ultraviolet lamps used for treating various skin conditions, and occupational sources
(eg welding arcs). Several recent case-control studies have shown that people who use sunlamps or sunbeds are at
increased risk of melanoma (Swerdlow et al., 1988; Walter et al., 1990; Westerdahl et al., 1995; Autier et al.,
1995), although some studies have not shown such associations (Elwood et al., 1986; Gallagher et al., 1986;
Holly et al., 1995). In those studies which have found positive associations, the relative risks have generally been
around 2.0–3.0. The relative risk was almost nine among people who had experienced a skin burning due to
sunlamps in one case-control study (Autier et al., 1995).
2.2.1.1
RE
Early model sunlamps emitted significant amounts of UVB radiation. The radiation emitted by modern sunlamps and
sunbeds is almost all UVA radiation, but a small amount of UVB radiation is also emitted (IARC, 1992). It is not
possible to determine
whether the increased risk associated with sunlamps and sunbeds is due to the predominant UVA
Acute pain management:
radiation, the small
amount
of UVB radiation or to both. In view of the present uncertainty regarding the carcinogenic
information for consumers
effect of UVA radiation, it is prudent to assume that UVA exposure from sunlamps and sunbeds is harmful.
Comment
SC
The migrant studies show that sun exposure early in childhood is particularly important in determining risk of
melanoma. Whether this is partly due to increased susceptibility of young children is unknown, although there is
some evidence from studies of naevi (which are strongly related to risk of melanoma) that the number per unit
area of skin does not increase much in children after about ten years of age (English & Armstrong, 1994).
IN
In adult life, recreational sun exposure appears to be a stronger determinant of melanoma risk than either total
exposure or occupational exposure. However, the associations (even for recreational exposure) are fairly weak,
apart from sunburn. Error in the measurement of exposure is known to weaken associations, and in case-control
studies that require subjects to recall their exposure from many years previously, error in measurement is likely to
be substantial. Thus, the true associations are likely to be substantially stronger than has been observed. Whether
sunburn is indeed a specific risk factor or simply a proxy for intermittent exposure or confounded with sun
sensitivity is unknown. Furthermore, its strong relationship with melanoma may be due, in part, to recall bias
whereby people with melanoma are more likely to recall past episodes of burning.
DE
The observations, if correct, have profound implications for the design of programs to reduce sun exposure. If the
pattern of exposure changes to a more intermittent one, the risk of melanoma may increase even though amount
of exposure has been reduced.
Evidence from very recent studies suggests that the relationship between risk of melanoma and sun exposure is
modified by constitutional sensitivity to sunlight. Those who tan poorly appear to have an increased risk of
melanoma with increasing levels of exposure, compared to those who tan well. There is less evidence of increasing
risk with increasing exposure, and in some studies the risk decreases with increasing exposure.
D
2.2.2 Non-melanocytic skin cancer
The incidence of non-melanocytic skin cancer, like melanoma, increases with increasing proximity to the equator.
In Australia, the incidence rate north of 29° S is some four times higher for BCC and almost ten times greater for
squamous cell carcinoma SCC compared with south of 37° S (Marks et al., 1993). Migrants to Australia from the
United Kingdom have incidence rates about half those of native-born Australians (Marks et al., 1993). The risk of
BCC in those who migrate to Australia before the age of 10 years is about the same as in people born in Australia
but substantially lower for people migrating later in life (Kricker et al., 1991). Measures of ambient sun exposure,
such as hours of bright sunshine and total global radiance at places of residence are related to risk of BCC
(Kricker et al., 1995a) and SCC (Kricker, 1992).
SCC favours anatomic sites that are usually exposed to the sun. Over a five-year period of observation in Geraldton,
41 per cent of SCC that occurred in males and 27per cent in females were on the head and neck (unpublished
observations). BCC also favours usually exposed sites, but a greater proportion of (BCCs) and SCCs occur on the
trunk (Kricker et al., 1990). High quality data on individual’s habits of sun exposure from case-control studies of
non-melanocytic skin cancer are limited. Total sun exposure accumulated over a lifetime and exposure accumulated
on working days showed little association with risk of BCC in the case-control study from Geraldton (Kricker et
Primary prevention of skin cancer in Australia
8
al., 1995a). When total lifetime exposure to the site of the BCC was considered, the risk initially increased with
increasing exposure, but thereafter fell with increasing exposure. The trunk was the only site for which people
with the greatest hours of exposure had the highest risks of BCC. Results from the Geraldton study regarding SCC
are less conclusive because of small numbers, but again showed no evidence of association between total exposure
or exposure on working days and risk of SCC (Kricker, 1992). In their study from Maryborough, Marks et al.
(1989) found that outdoor workers had a relative risk of 1.6 for BCC (p=0.03) and a relative risk of 1.7 (p=0.11)
for SCC. In the Nambour study, Green & Battistutta (1990) found that the risk of BCC was 1.3 (95 per cent
confidence interval 0.6–2.8) times higher in people who worked ‘mainly outdoors’ than in people who worked
‘mainly indoors’, whereas the risk of SCC was 5.5 times higher in outdoor workers.
RE
Among traditional fishermen (watermen) in Maryland, total lifetime exposure to the sun was not associated with BCC
but it was with SCC (Vitasa et al., 1990). Gallagher et al. (1995a,b) found no association between occupational exposure
or total exposure to the sun and BCC in Alberta, but a strong association between SCC and occupational exposure in the
past ten years. However, they did not find an association between total cumulative sun exposure and SCC.
Acute pain management:
SC
Recreational sun exposure
was associated with increased risk of both BCC and SCC in the Geraldton study
information for consumers
(Kricker et al., 1995b; Kricker, 1992). The risk of BCC was also high among people who had received almost all
their weekly exposure at the weekend between ages 15 to 19 years (Kricker et al., 1995b). Green & Battistutta
(1995) found no association between recreational activity (defined as mainly indoors, indoors and outdoors, or
mainly outdoors) and BCC, but increased risks for SCC, for those whose leisure time was spent mainly outdoors.
Gallagher et al. (1995a,b) found increased risks for BCC associated with high levels of recreational exposure
before age 20, but little association with mean exposure per year over the whole of life and no consistent evidence
of any association between recreational exposure and risk of SCC.
A weak association between number of painful sunburns to the anatomic site and BCC was seen in the Geraldton
study (Kricker et al., 1995b). No association was found in the Nambour study (Green & Battistutta, 1990). A
strong association with SCC was observed in the Geraldton study and there was also an association with SCC in
the Nambour study. Quite strong associations have been seen in some overseas studies (Kricker et al., 1994).
IN
2.2.2.1 Comment
DE
It was long considered that non-melanocytic skin cancer was caused by cumulative exposure to the sun. The
evidence reviewed above indicates that for BCC at least, such a belief may be ill-founded. The epidemiology of
BCC appears to be similar to that of melanoma.
It shows little or no association with total lifetime exposure to the sun, or with occupational exposure, but appears
to be related, albeit inconsistently, to recreational exposure. The Canadian study and the Geraldton study provide
evidence that recreational exposure before age 20 is an important determinant of BCC risk. These data are consistent
with the observations of migrants, which show that exposure early in life is strongly associated with BCC.
D
The picture for SCC is somewhat different. Its anatomic site distribution indicates that cumulative sun exposure
plays a stronger role than for BCC. The latitude gradient is also stronger than for BCC, indicating that the exposureresponse relationship is stronger than for BCC. There have been few large, high quality epidemiological studies of
SCC, so there are only limited data on the association with measures of individual exposure. What little evidence
is available, while inconsistent, does provide some support for the hypothesis that SCC is associated with
occupational exposure.
2.3 Non-malignant Skin Conditions
A number of non-malignant skin conditions are also linked to sunlight. These include solar keratoses, lentigines
and naevi. Loss of elasticity of the skin, sometimes referred to as premature aging or photoaging, is also related to
sunlight (Cockerell et al., 1961; Marshall, 1965). Comparison of photoaging for people with different complexions
(Kligman, 1974; Mitchell, 1968; Marshall, 1965) and for body sites with different levels of sun exposure (Gilchrest
1983, 1979; Mera et al., 1987), confirmed this association. In some animal studies, UVA radiation has been shown
to cause premature aging (Bissett et al., 1989; Kligman & Sayre, 1991). If true, these observations suggest that
while skin cancer might be prevented by avoiding UVB exposure, avoidance of UVA exposure is necessary to
prevent premature aging.
Primary prevention of skin cancer in Australia
9
Melanocytic naevi (moles) are strongly related to the risk of melanoma. Whether naevi are precursors to melanoma,
or simply markers of risk is contentious. However, the relationship is so strong that naevi are likely to be useful
intermediate, biological markers of the risk of melanoma. In terms of evaluating sun protection measures, their
usefulness depends on whether they are caused by sun exposure.
In children, sun exposure appears to increase the prevalence of naevi. In Australia, the mean number of naevi on
children aged 6 to 15 years increased with falling latitude (Kelly et al., 1994). More directly, number of naevi has
been shown to be related to measures of sun exposure in individual children in several studies (Coombs et al.,
1992; Harrison et al., 1994; Gallagher et al., 1990; Pope et al., 1992). Markers of intense, intermittent exposure,
such as sunburn and holidays in sunny places have shown the strongest relationships.
SC
RE
Sun exposure is also related to the prevalence of naevi in adults, but in an apparently more complex manner.
Migrants to Australia and New Zealand have fewer naevi than do the native-born (Cooke et al., 1985; Armstrong
et al., 1986). Positive associations between numbers of naevi and measures of sun exposure were found in Western
Australia (Armstrong
et al., 1986) and presence of more than 50 naevi was associated with the number of sunburns
Acute pain management:
before 20 yearsinformation
of age inforaconsumers
European study (Garbe et al., 1994). However, the number of naevi has been found to
be negatively associated with total sun exposure (Kopf et al., 1978), and the density of naevi has been found to be
higher on intermittently exposed skin and least on chronically exposed skin (Augustsson et al., 1994). Thus, naevi
may be less appropriate as endpoints to evaluate sun protection programs in adults.
2.4 Ocular Disease
A number of diseases of the eye have been associated with sunlight. These include pterygium (a growth of the
conjunctiva that extends onto the cornea), cataracts, macular degeneration of the retina and ocular melanoma.
However, for most conditions, the evidence is weaker than for skin cancer. Assessment of the relationship with
sun exposure has often been based upon ambient exposure.
IN
2.4.1 Cornea
2.4.2 Lens
DE
Pterygium is widely believed to be caused by sun exposure, but there are few epidemiological studies in which
individual measurements of exposure have been made. In the Watermen study referred to earlier (Vitasa et al.,
1990) lifetime estimates of UVB radiation to the eye were calculated from time spent outdoors and use of hats and
glasses (Taylor et al., 1989). A positive dose-response relationship was observed. In Australia, Moran and Hollows
(1984) demonstrated a latitude gradient similar to that seen for skin cancer and MacKenzie et al. (1992) found
that people who worked outdoors on reflective surfaces were at high risk, as were people who had lived the early
part of their lives at low latitudes. Pterygia are common in Aborigines (Moran & Hollows, 1984).
D
Cataracts have long been thought to be caused by sun exposure, but the epidemiological evidence is weak and at
least one reviewer has questioned the validity of the hypothesis (Harding, 1994). This subject has been reviewed
extensively (Dolin, 1994; Taylor, 1994-95; Eaton, 1994-95; Wolff, 1994).
In the United States, surgery rates for cataract are inversely related to latitude (Javitt & Taylor, 1994–95). Positive
associations were found in the Watermen study (Taylor et al., 1988) for cortical cataracts but not for nuclear
cataracts. A weak association between an index of UVB exposure and cortical lens opacities was seen in men but
not women in the Beaver Dam Eye Study (Cruickshanks et al., 1992). There was no association with nuclear
sclerosis or posterior subcapsular opacities. A positive association was seen between a sunlight exposure index
and cortical cataracts in a third study (Rosmini et al., 1994).
2.4.3 Retina
The lens absorbs almost all UVB radiation (Taylor, 1989), so only a small amount strikes the retina. Less UVA
radiation is absorbed by the lens, particularly in early childhood.
There is limited evidence that macular degeneration is associated with sun exposure. In the Watermen study,
macular degeneration was associated with increased levels of exposure to visible light, but not with increased
exposure to UVA or UVB (Taylor et al., 1992). Several measures of sun exposure were positively associated with
Primary prevention of skin cancer in Australia
10
prevalence of macular degeneration in the Beaver Dam Eye Study (Cruickshanks et al., 1993), including total
time spent outdoors and amount of leisure time outdoors.
There is no latitude gradient among white populations of the incidence of ocular neoplasms, about 80 per cent of
which are likely to be melanomas. Four case-control studies of ocular melanoma have been conducted (Gallagher
et al., 1985; Tucker et al., 1985; Holly et al., 1990; Seddon et al., 1990). The first included all ocular melanomas
while the last three were restricted to uveal melanomas. Although positive associations were present with some
outdoor activities in one or more of the studies, the results are inconsistent and difficult to interpret.
2.4.3.1
Comment
RE
Although there are few high quality studies of sun exposure and eye disease, there is limited evidence that sun
exposure does cause several forms of ocular disease. Although no study to date has considered the pattern of
exposure, there is no reason to believe that pattern of exposure is likely to be of the same importance for the eye
Acutetanning
pain management:
as it is for the skin where
and skin thickening are protective mechanisms.
information for consumers
2.5 Effects on the Immune System
2.6 Conclusion
SC
Animal experiments show that UVR can alter immune function (see Kripke, 1990), but there are few epidemiological
data for humans. Recurrent infections due to lesions resulting from Herpes simplex viruses 1 and 2 can be induced
by UVB radiation (Wheeler, 1975) and can be prevented by sunscreens (Rooney et al., 1991).
DE
IN
Most skin cancer in Australia is caused by sun exposure. When considering the effects of sunlight in Australia it
is worth recalling that the majority of Australians are descended from migrants who originated in places far from
the equator where the energy from sunlight is much lower than in most parts of Australia. London, for example, is
at 51° north latitude, whereas the most southerly Australian mainland capital, Melbourne, is at 37° latitude and
Brisbane is at 28°. Hobart is at a similar latitude to Rome in the northern hemisphere and Perth is at about the
same latitude as Cairo.
The epidemiological evidence indicates that early childhood exposure is particularly important for skin cancer.
An intermittent pattern of exposure is important for melanoma and possibly also for BCC, while for SCC total
accumulated exposure may be the main determinant. Certain eye diseases are also probably related to cumulative
sun exposure. In designing strategies to prevent skin cancer, in particular, the complexities of these relationships
need to be taken into account.
•
D
2.7 Implications for Prevention
The epidemiological evidence implicates childhood exposure as an important cause of skin cancer. Exposure
in adult life appears to be less important; few epidemiological studies have found strong associations between
skin cancer and exposure. However, randomised trials in adults have shown that the use of sunscreens has an
immediate effect on solar keratoses, which are strongly related to non-melanocytic skin cancer.
Thus, the epidemiological evidence suggests that strategies to reduce sun exposure in children are likely to
have greater impacts on the incidence of skin cancer than are strategies to reduce exposure in adults.
Accordingly, children should be the principal target of prevention programs. However, where possible,
programs should also be directed at adults, partly because there is some evidence of late effects of sun
exposure, but also because whole-community approaches are likely to be more effective.
•
The epidemiological evidence suggests that exposure in the first decade of life is important in determining
the lifelong risk of skin cancer. However, the data on the relative importance of childhood and adolescent
exposure are derived largely from studies of migrants and cannot be taken to be definitive. However, exposure
during childhood or adulthood should both be considered important.
Primary prevention of skin cancer in Australia
11
For many cancers, there is often a long time between exposure to a causative agent and their diagnosis.
Smoking-related cancers, for example, occur most frequently in the elderly although most smokers commence
smoking in adolescence and early adult life. Sun exposure and skin cancer follows this pattern.
•
Because naevi are strongly related to risk of melanoma, and because they develop during childhood and
adolescence, they may be useful as early biological markers of subsequent risk. Evidence that they are related
to sun exposure is accumulating. If they are, they may be used to monitor future population risks of melanoma
and to evaluate specific interventions directed at children. However, more evidence in the relationship
between sun exposure and naevi is required before we rely heavily on them to evaluate prevention programs.
•
The incidence of melanoma in males and females in Australia is similar. Thus, equal effort should be expended
on prevention of melanoma in males and females. Males have a much higher mortality from melanoma than
do females. These data indicate that early detection of melanoma in males needs to be targeted.
•
The available evidence suggests, paradoxically, that use of sunscreens is associated with an increased risk of
Acute
pain management:
melanoma.
However,
these data are subject to substantial bias. At present, little can be concluded about the
information forto
consumers
value of sunscreen
prevent cancer. However, randomised trials of sunscreen have shown that they can
reduce the number of solar keratoses. Furthermore, they are also effective in preventing sunburn. Although
sunscreens have a role in photoprotection, it is clear that this role is a secondary one to other forms of natural
protection.
•
Most skin cancer is due to sun exposure. Thus, we can confidently predict that keeping people out of the sun
will prevent skin cancer. However, because of the complexity of relationship between sun exposure and
melanoma in particular, focus should be on activities likely to give rise to intense, intermittent exposure to
the sun.
SC
RE
•
2.8 Recommendations
IN
It is recommended that:
1. The NHMRC note that the epidemiological evidence demonstrates the need to continue to focus
on the prevention of UV exposure in childhood.
D
DE
2. Further investigation is required of the natural history and dose response relationship between
actual sun exposure and indicators, for example skin features like naevi, which are possible
indicators of sun exposure, especially during childhood.
Primary prevention of skin cancer in Australia
12
RE
Acute pain management:
information for consumers
D
DE
IN
SC
Primary prevention of skin cancer in Australia
13
Section Three
Measuring Sun Exposure and
Sun Behaviour
SC
RE
Along with measures of the occurrence of disease, measures of exposure to the sun and sun protection behaviours
are the key outcomes for the evaluation of any primary prevention program. There are no universally accepted
Acute pain management:
measures of these outcomes, or any of their components, nor is there any agreement on how to interpret measures
information for consumers
made in different settings and locations. For example, a given absolute sun protection may be of more benefit to
those living in a less harsh or lower risk environment. It is not currently known how much behaviour change is
required before the majority of skin cancers are likely to have been prevented. This may mean that different levels
of sun protection are accepted in different risk contexts. For example, it is likely to be the case that people living
closer to the equator need to take more precautions on the whole. The evidence presented in this reports suggests
that, at least for hat wearing, they do take more precautions. The purpose of this section is to outline some of the
issues involved, and to give a preliminary framework for the development of these measures.
The path of ultraviolet radiation (UVR) leaving the sun and striking a person’s body is influenced by a number of
factors both physical and behavioural (see Table 3.1). Furthermore, the health effects of exposure are mediated
both by the nature of the exposure and by a range of biological factors.
IN
In principle, exposure can be changed through changing personal behaviours that affect exposure (including
choices of protective aids). Structural changes can also affect UVR exposure directly (eg by reducing the depletion
of ozone in the upper atmosphere) or indirectly (eg through provision of shade structures which will only be
effective if people actually use them).
Figure 3. 1: UV exposure and its effects
DE
➛
Ambient UV level
➛
Modulated by time spent outdoors and sun protective behaviours
D
➛
Determine UV exposure (dose to the skin)
Mediates biological effects of exposure (including skin cancer)
3.1 What Measures Do We Need?
In considering ‘measurement’, it is important to distinguish between measures of the radiation related to the
environment, namely: measures of sun protection, that is, behavioural or other efforts to reduce sun exposure;
measures of UVR exposure, that is, of the dose radiation received; and measures of biological effects, eg sunburn.
All four kinds of measures are needed to assess the effectiveness of sun protection behaviour in reducing sun
exposure.
Primary prevention of skin cancer in Australia
14
3.1.1 Applications
There are three key tasks:
To document the distribution of sun protection practices, exposure levels, and/or biological effects throughout the
population. Here, equivalent validity across the various sociodemographic groups of interest is critical.
2.
To document changes over time in populations. This requires repeated sampling of populations with the same
measures, and for the measures not to be subject to context effects.
3.
To demonstrate causal links between interventions and change (or relative change) in UVR related outcomes.
Ideally, this is done with the use of randomised controlled trials (RCTs) using measures that are robust to context
effects. This is rarely possible. As a result, consideration should be given to the balance of evidence from all
available sources, weighted according to quality and consistency. This includes demonstration of change, or rate
of change associated with an intervention; demonstration of the causal power of component parts of the communitywide campaign; documentation
of change in cognitive determinants targeted by the campaign, and attributions of
Acute pain management:
influence to the campaign
by
the
target population.
information for consumers
RE
1.
SC
In behavioural, epidemiological or evaluative studies, the focus will usually be on the time spent outdoors and on
sun protective behaviours. Sometimes these will involve component behaviours such as sunscreen use, at other
times an aggregate behavioural index will be required. In assessing exposure, sun-related behaviours (eg sunscreen
use) might also be required. However, in this case, it may be more important to know where and how well it was
applied. Clearly, the characteristics that we require of a measure will depend on the particular application.
3.2 Sun Exposure Measures
3.2.1 Conceptualising measurement of sun exposure
IN
In measuring sun exposure we need to consider four, conceptually different aspects of exposure:
the total amount of exposure—also sometimes called total accumulative exposure, cumulative exposure,
lifetime exposure, etc.;
•
the period over which this exposure accumulated—it may be ‘lifetime’ or the period may be restricted to one
which is considered more relevant to the purpose of the measurement, eg childhood;
•
the pattern of exposure over time—the way in which the amount of exposure is distributed in the period over which
it is being measured. For example, it may be intermittent (large amounts of exposure accumulating over short
periods of time infrequently) or continuous (continuous accumulation with relatively little day-to-day variation in
increments of exposure). The intermittent pattern may, for example, show variation on a weekly cycle (eg high
exposure on weekends, low exposure during the working week) or a yearly cycle (eg high exposure during an annual
summer holiday, little exposure at other times of the year); and
•
the pattern of exposure by body site (eg the face and back of hands typically have the highest exposures).
D
DE
•
For each of these fundamental measurement concepts there will be proxy measures that reflect the fundamental
measurement with greater or lesser degrees of fidelity. For example, sunburn is often taken as a proxy for an
intermittent pattern of exposure. Clearly, however, it also includes elements of total amount of exposure and also
sensitivity of a person’s skin to UVR. A person’s current or usual frequency of sun exposure may be used as a
proxy for total lifetime exposure or exposure over some recent period of time. Its accuracy as a measure of
exposure over any period in the past will depend on the stability of the person’s exposure behaviour.
Other important factors that will have to be taken into account when considering the biological effects of sun
exposure are those which determine how much UVR reaches the target tissue in a given period of time outdoors
and the degree of natural protection that the tissue has against the effects of UV. These include:
•
ambient UVR levels;
•
the availability and use of shade in the local environment;
•
external protection of the target tissue (clothing, sunscreens, etc.); and
•
sensitivity to the sun of the individual’s skin or other target tissue.
Primary prevention of skin cancer in Australia
15
3.2.2 Measuring sun exposure in different subgroups
It is unclear if instruments developed for a particular population subgroup can be used in a different subgroup. An
obvious example is the extent to which a complex diary or even self-report might be used for younger children.
Other subgroups of interest include urban and rural groups, and coastal and inland residents. Instruments developed
for assessing recreational exposure may be quite inappropriate for assessing occupational exposure.
3.2.3 Ambient UVR level
This represents the severity of the hazard to which the person is potentially exposed. A number of factors influence
the actual ambient UVR level, including:
altitude and latitude (ozone depletion and air pollution);
•
temporal factors, such as season and time of day;
•
current weather
conditions, such as cloud cover; and
information for consumers
•
proximal environment, such as reflection and natural shade.
RE
•
Acute pain management:
Further details are given in Section 2 of this report (see Table 2.1).
SC
A network of fixed UVR monitors exists in Australia (Gies et al.,1994). These monitors provide an accurate
measure of UVR reaching the ground where they are located. However, because UV levels are affected by factors
like cloud cover and the reflective nature of the proximal environment, actual UVR levels may vary considerably
even in locations that are close together. Hill et al. (1992) have found a relationship between UVR levels as
measured at one site in Melbourne, and sunburn levels reported across the entire metropolitan area. This suggests
that such monitoring sites have measurement utility for estimating exposure at a population level, especially when
combined with behavioural data.
IN
3.2.4 Personal UVR exposure
DE
UVR exposure to the body varies by site in interaction with activity, orientation, sun protection measures, and the
nature of the ambient UVR. There is now good evidence that exposure levels to different parts of the body vary
greatly, independent of any sun protection measures (Holman et al., 1983). This variation is influenced by patterns
of body orientation, for example orientation to the sun and function of activity engaged in (Herlihy et al., 1994).
Exposure to unprotected skin is essentially a compound function of the direction and amount of UVR and the
orientation of parts of the body to that UVR. This natural variation in exposure risk is made greater by usual
patterns of protective behaviours eg clothing use.
D
There are two kinds of personal UV monitors: polysulphone badges, and electronic monitors which can be linked
to data loggers (Diffey, 1989; Diffey & Saunders, 1995). The use of multiple polysulphone badges on individuals
has shown that the potential UVR dose available at different sites of the body varies considerably. Studies using
continuous monitors have also indicated that the potential exposure on a given site can vary on a moment-tomoment basis as an individual moves freely within outdoor environments. These methods can be used to measure
potential exposure at meter sites and to compute activity-related exposure algorithms for body parts. Together,
these can be used to estimate exposure patterns once ambient UVR levels, activity patterns and sun protection
measures (eg sunscreen and clothing use) are known.
For estimation of long-term exposure, indirect measures are needed as direct observation and precise estimation
are not possible. The indirect measures used include latitude and altitude, the outdoor-indoor profile of the person’s
occupation, estimates of tendency to spend recreational activity outdoors and reported history of sunbathing or of
sunburn.
Primary prevention of skin cancer in Australia
16
3.3 Behavioural Influences on Sun Exposure
When we talk about sun protection behaviour, we are talking about a complexity of different types of behaviour.
These include:
•
active behaviours such as applying sunscreens, changing attire, moving into the shade, wearing sunglasses; and
•
incidental behaviours, such as wearing clothes, having sunscreen on (these are background components of
ongoing behaviour).
Behaviours that affect sun exposure vary in purpose ranging from those where exposure regulation is the prime
purpose (eg application of sunscreens for sunbathing), through to those where it is an acknowledged part
(eg wearing a hat on a picnic), to those where it is entirely incidental (eg clothing use for modesty).
SC
RE
A range of environmental factors influence individual sun protection behaviour, in some cases independent of
intention to reduce UVAcute
exposure.
For example, on mild sunny summer days in southern Australia, the air temperature
pain management:
may be such that it feels
cold
in
the
shade and much more pleasant in the sun, leading to greater sun exposure. By
information for consumers
contrast, on a hot day comfort in the sun will be less and comfort in the shade greater, leading to greater sun
protection. The finding of a curvilinear relationship between ambient temperature and risk of sunburn (Hill et al.,
1992) could thus be due to factors that are independent of attempts to regulate UVR exposure. Motive (or reason
for action) will affect the relationship between the availability and avoidability of sun protection possibilities and
their use. For example, if UVR exposure is not an issue, then putting shade in a person’s path will result in them
using it, but the person will not go out of their way to seek it.
There can be complex variations within specific active behaviours, including:
the choice of materials in clothing as well as its design;
•
the size of the brim of a hat;
•
the sun protection factor of the sunscreen used and its regular re-application; and
•
distribution and quality of shade which is influenced by such factors as reflection, the amount of diffuse
sunlight and the blocking factor of the cover.
IN
•
3.3.1 Measures of sun protection behaviour
DE
Major types of measures are briefly described. More detailed discussion of these kinds of measures is available in
Hill & Borland (1996).
Observation of individual behaviour: The observation can be via use of trained human observers (Diffey &
Saunders, 1995) or be mediated by video camera or photographs (Borland & Theobald, 1990). It is only
possible in some public situations, but is an objective and potentially very accurate form of measurement. To
the extent that the observation is unobtrusive, it could be assumed to have no impact on the behaviour being
observed, but where it is not unobtrusive, there is potential for reactive effects. Generally, it is likely to be
difficult to collect more than small samples of data from any given individual.
2.
Diaries and cued recall: These methods involve getting the person to record or report on their sun protection
behaviour in various contexts. Such methods have been used successfully in descriptive and intervention studies
(Cockburn et al., 1992; Girgis et al., 1993; Girgis et al., 1994). In principle, these reports are likely to be most
accurate when they are made during or immediately after a period of behaviour. However, it is often difficult
to guarantee that this happens. These methods are subject to reactive effects; for example, in intervention studies
where the intervention groups are likely to know what they are supposed to be doing.
3.
Uncued retrospective reports of specific instances of behaviour: These methods include interviewing people
about their activities, over relatively short periods of time (eg outdoor activity in the day or two previously), and
getting recall of behaviours undertaken and protection strategies that are used (Hill et al., 1992, 1993). The major
problem with these methods is that they are subject to memory loss and recall biases because some sun protection
behaviours are not highly salient. Comparison of observation data with percentages of reports of more salient
observable sun protection practices, albeit within different studies, suggest that the reporting of behaviours is
probably reasonably accurate, at least for observable behaviour.
D
1.
Primary prevention of skin cancer in Australia
17
4.
Reports of usual behaviour: Sun protection behaviours are very much situation specific and often contingent
on other protective strategies that are available. At least with younger people, reports of usual behaviour tend
to overestimate observed behaviour (Bennetts, Borland & Swerissen, 1991) and such measures are probably
best thought of as indices of behavioural tendency of what people think they do. For sun protection these are
probably the weakest of all indices of behaviour.
3.4 The Physical and Regulatory Environment
RE
Sun protection is affected by aspects of the physical environment. The availability of useable shade in parks,
along footpaths and in other places where people congregate, influences shade use. The availability of indoor
venues and indoor alternatives to outdoor activities influences the likelihood of spending time outside. It is important
to better understand when and how people use structures and how this impacts on sun protection behaviour. Some
steps have beenAcute
taken
quantify sun protective aspects of outdoor environments (Scholfield et al., 1991), but
painto
management:
much more work
is
needed.
information for consumers
SC
Rules and regulation can also affect sun protection. These can range from: ‘no hat, no play’ rules at schools;
governmental regulation governing the sale of sunscreens; policy governing the sale of sunscreens; to policy
decision to resource shade provision. Encouraging appropriate regulation is an important tool of health promotion,
but for sun protection at least, the effects of such activities have not often been systematically studied. Systematic
attempts to document these policies or to document their impact on practices also has not occurred. A start has
been made in some areas with attempts to document practices and policies in schools (Schofield et al., 1991;
Clarke, 1994) and in local government (Montague, Borland & Whitty, 1995a).
3.4.1 Time spent outdoors
3.5 UVR on the Skin
DE
IN
The most important behavioural influence on UVR exposure is time spent outdoors, so measuring of this is of
critical importance. People go outside for different reasons: to spend extended time outdoors; to move between
indoor settings; and to do tasks, for example, hanging washing on the line. It is likely that people’s awareness of
the importance of sun protection will vary as a function of their reasons for being outside and the anticipated
length of that period of exposure. For example, if people are going to spend a day at a sporting venue, they may be
more likely to take protective actions than if they think they are only going out for two or three minutes. Being
outside is observable in some (public) contexts, but it is often not possible to observe those people who are not
outside.
D
Ambient UV levels can be combined with an estimate of time spent outdoors, adjusted for the protective benefit
attributable to the exhibited sun protective behaviours, to estimate the UV dose received by the skin. To do this it
will be necessary to develop what might be called ‘Sun Protective Tables’ analogous to the food composition
tables in nutritional epidemiology. These tables would provide adjustments/factors indicating the protective effects
of the various protective measures such as the sun protection factor of sunscreens and various clothing materials,
hats, etc. Some of this radiophysical research is currently underway.
3.6 Personal Sensitivity
Here the aim is to take into account the variation in the effect of a given dose of UV to the skin. For example, there
is some epidemiologic evidence that the effect of a given dose of UV depends on a number of personal characteristics
such as a person’s ability to tan, propensity to sunburn, skin, hair and eye colour, past exposure and existing skin
damage, number of acquired naevi (moles) and level of tan.
Primary prevention of skin cancer in Australia
18
3.7 Implications for Prevention
A comprehensive program of sun exposure reduction would be one which looked towards and coordinated
changes on all fronts, but in a manner that assessed the relative costs and benefits of change in relation to
risk reduction. It would also choose strategies known to be effective (where possible) and evaluate the
effectiveness of the methods used.
RE
The lack of measures in some areas: A systematic approach to the problem of exposure reduction requires
extensive monitoring of determinants over time. In Australia at present there is very little national monitoring.
There is a national grid of fixed UVR monitors but they are small in number. A range of measures have been
developed which have potential to act as monitoring tools for sun protection or sun exposure, but most are not
used for regular surveys. There is no national monitoring of sun protection behaviours, although in some States
and Territories the sun survey protocol developed by Hill et al., (Girgis et al., 1993; Hill et al., 1993) has been
applied with some regularity for those aged 14 years and above. The national secondary schools survey has a
Acute pain management:
component which monitors reported usual sun behaviours, but there is no national data available on primary or
information for consumers
pre-school children. Collecting
data to demonstrate whether children and adolescents are still overexposed to
UVR is a high priority. There is a need for a program of national monitoring and work to ensure the validity of the
measures used.
Such a program should include the following:
SC
a review of all existing instruments in terms of their target group, validity and reliability, and the feasibility
of their use;
•
discussion of relevant issues for the development of suitable measures;
•
an assessment of the adequacy of existing measurements and identification of gaps;
•
systematic development of a suite of standard measures of established validity and reliability for relevant
population subgroups and activities; and
•
identification of the possible implications of using imperfect standard measures.
IN
•
This research program will require input from epidemiologists, radiophysicists, behavioural and social scientists,
and the range of professionals involved in the built and natural environments. The focus should be on:
methods for collecting the required data;
•
methods for the construction of aggregate indices where required;
•
techniques for validating and verifying the reliability of measures;
•
assessment of comparability with existing data; and
•
mechanisms to promote the use of standard measurements.
D
DE
•
3.8 A Broader Outcomes Framework for Primary Prevention
Programs
Sun protection needs to be conceived from a broad outcomes framework. This broader framework includes other
structural or environmental measures, such as sun safe policies in schools and the workplace, and the organisation
of outdoor activities. However, it should be noted that this broader framework does not occur without cost. These
opportunity costs include, but are not limited to, those incurred by the person, society or environment. These costs
to society need to be monitored and analysed to determine overall benefit.
Such a broader framework includes measures at different levels based on a program logic approach, for example,
in the New South Wales Health Promotion Strategic Plan (1995) ‘Skin Cancer Control in New South Wales’, an
extract of which is provided in Appendix A. The New South Wales document was developed in relation to a
strategic planning process and it forms the basis for a broader structure of outcome measures for primary prevention
which could be used to extend beyond the research program proposed in this section. Other examples are to be
found in Section 5.
Primary prevention of skin cancer in Australia
19
3.9 Recommendations
It is recommended that:
3. Further research be undertaken to develop more effective population measures of sun
exposure, particularly with respect to monitoring sun exposure of children, including infants.
RE
4. Australian cancer prevention research teams initiate a project to establish consensus on the
viability of uniform indicators of success in intervention studies, including the development of
a comprehensive, sensitive index of behaviour change that accounts for the different
recommended primary prevention behaviours. If a consensus on its viability is agreed, work
should proceed.
5. Researchers
estimate the average exposure to UVR in Australians across various geographic
Acute pain management:
strata
and
estimate
how this relates to probable exposure patterns for people at higher latitudes
information for consumers
in other countries where skin cancer is less of a problem (except perhaps among those
frequently holidaying in high UV destinations).
SC
6. Further research be undertaken into the relationship between self-report measures of exposure
and other more objective measures, for example video recording of behaviours or polysulphone
badges attached to body parts.
7. Australian Institute of Health and Welfare (AIHW), in conjunction with groups already active
in the field, instigate a national program to monitor both behavioural and structural sun
protective measures, building on work already done.
D
DE
IN
8. Evaluation of sun protection programs be multiphasic, addressing the shorter term direct
effects such as knowledge, attitudes and behaviours; the less direct effects such as a change in
naevi and skin damage; and eventually, the long-term effects such as reduction in the incidence
of melanoma.
Primary prevention of skin cancer in Australia
21
Section Four
Primary Prevention Behaviours
4.1 Introduction
RE
‘While an inherited pale skin renders some people more susceptible to skin cancer, the development of skin cancer
Acute pain
management: (Stern et al., 1986, p538)
is largely behaviour
determined.’
information for consumers
SC
Primary prevention is concerned with the identification of risk factors and reducing or removing them so that the
disease does not develop. The epidemiological literature emphasises the considerable influence of ultraviolet
radiation on the incidence and mortality of melanoma in Australia. Therefore, the priority for primary prevention
in Australia should be to focus on reducing the risk associated with those factors, most notably sun exposure.
Primary prevention of skin cancer is the attempt to reduce a person’s exposure to the known risk factors of skin
cancer through environmental changes, social changes and behavioural modification to increase personal protection,
such as wearing hats, using sunscreen and staying in the shade.
4.2 Sun Protective Behaviours
4.2.1 Sunscreens
DE
IN
In recognition of the high rates of skin cancer, the National Health Goals and Targets for Australia (Commonwealth
Department of Human Services and Health, 1994) recommends a reduction in exposure to sunlight for all, especially
those people at high risk of skin cancer. Included in this group are those people whose skin burns and never tans,
those who have a large number of acquired melanocytic naevi and freckles, those who have dysplastic naevi, and
those who have solar keratoses (see Section 2). Those who have more than one of these characteristics are at even
greater risk.
The Australian Cancer Society (1993) recommends that ‘natural’ protection is the best form of protection. This
includes creating shade by planting trees or constructing other canopies and rescheduling work practices and
sporting times and other similar activities. They suggest that sunscreens should be an adjunct to natural protection,
and not a substitute for it.
D
Sunscreens do offer an alternative means of protection for situations where clothing may not be desirable or
appropriate. Sunscreens are given a Sun Protection Factor (SPF) to indicate the degree to which they protect
against sunburn. The SPF relates specifically to the increase in the dose of UVR necessary to induce sunburn
when skin is protected by sunscreen compared with the dose necessary for unprotected skin. Sunscreens absorb
UVR and in some cases also physically reflect radiation. Stenberg and Larko (1985) examined the effectiveness
of sunscreen as a method of primary prevention for skin cancer. They found that when subjects applied sunscreen
to themselves, there was considerable variation in the thickness and therefore the effectiveness of the sunscreen.
On average, the sunscreen provided only about half the protection as indicated by the SPF on the container.
Stenberg and Larko suggested that cost may be a barrier to sunscreen use and contributes to reducing the effectiveness
of sunscreen as a protective measure against skin cancer. They found that subjects used twice as much sunscreen
when it was provided free of charge, compared to reported usage rates of purchased sunscreen. Additionally, thin
application of sunscreen or minimisation of the areas of application may also be used as a strategy to minimise
cost and will increase the risk of sunburn in a context where the person may not be aware that they are inadequately
protected.
Stenberg and Larko (1985) recommended that skin protective clothing should be the first choice of protection and
that sunscreen should be applied only to those areas not covered by clothing.
Primary prevention of skin cancer in Australia
22
4.2.1.1
Epidemiological reasons
The current very high incidence and mortality rates of skin cancer in Australia have been attributed to population
exposure to sunshine in general. They have not occurred as a result of exposure to only specific subgroups of the
solar spectrum.
Laboratory based research has centred on which specific wavelengths within the solar spectrum might be responsible
for the induction of tumours. For SCC, this has been shown in experimental animals in the laboratory to be within
the UVB spectrum. For BCC and melanoma, it is not entirely clear, as there are no satisfactory laboratory animal
models.
RE
In humans, the UV ray spectrum has been implicated as the major component of the solar spectrum responsible for each
of the three common types of skin cancer. UVB has been suggested as the major problem, with some possible contribution
from UVA. Nevertheless, the exact contribution of each of the wavelengths and whether or not the remaining solar
spectrum is important in either initiating or promoting the effects of the UV spectrum in humans is not entirely clear.
Acute pain management:
SC
Although sunscreens information
are testedfor for
protection against burning, they are usually not tested for their capacity to
consumers
prevent UVR carcinogenesis. Gallagher (1988) tested two sunscreens and found that neither protected totally
against UVR. He concluded that there was a need for more rigorous testing of sunscreens to answer such questions
as how much protection they provided against skin cancer, the possible effect of the sunscreen ingredients on the
skin, and changes that might occur to sunscreen over periods of time (shelf-life) and whether this would change
their protective benefits or cause any problems.
In a number of epidemiological studies, use of sunscreens, particularly recent use, has been associated with
increased risks of melanoma (eg Autier et al., 1995) and non-melanocytic skin cancer (Kricker et al., 1995b;
Hunter et al., 1990). However, in the Geraldton study, the risk of BCC was also increased in people who wore hats
in the 10 years before diagnosis, suggesting that the association is an artefact resulting from people at high risk
taking action to protect themselves from the sun.
IN
This type of confounding is extremely difficult to overcome in case-control and cohort studies, and it is unlikely
that such studies will be able to estimate the effectiveness of protective devices and behaviours. For that, randomised
trials are necessary. While no randomised trials of skin cancer prevention by use of sunscreens have been reported
yet, two trials have shown that sunscreens can prevent solar keratoses (Naylor et al., 1995; Thompson et al.,
1993), which are strongly associated with risk of non-melanocytic skin cancer.
DE
For these reasons, the public health approach to skin cancer control has always been to reduce exposure to the
total spectrum until we know in more detail which specific components are the offenders. Sunscreens block out
only a proportion of this spectrum, particularly within the UV range. The extent to which they do so varies across
the wavelengths even within the UV range.
D
Therefore, natural protection including avoidance of the sun around the middle of the day, the use of clothing,
hats and seeking shade from a variety of shade producing structures are recommended. They filter out the whole
of sunlight because these are physical barriers to sunlight. Natural protection therefore has been recommended as
the first approach to primary prevention of skin cancer.
Sunscreens block out only a proportion of the wavelengths within the UV spectrum and have been recommended as an
adjunct to natural protection. They are to be used only when there is difficulty in providing physical barriers to sunlight.
4.2.1.2
Behavioural reasons
With physical barriers, such as clothing, it is easy to determine whether the physical barrier is in place and
whether or not it remains there after time. That is because they are visible barriers. This ability to see the product
in place does not exist with most sunscreens.
SPF numbers are a laboratory grading worked out on a specific amount of the product being applied to a specific area of
skin. This is very rarely, if ever, replicated in practical use in the community. There are now data showing that frequently
in practice the amount applied by the public is not the same as that which is used in the laboratory. It has also been shown
that the products are not applied evenly over all areas requiring protection. It is not uncommon for areas of skin to be
completely missed during the initial application. This does not become apparent until 12 to 24 hours later when sunburn
appears in the area missed. The fact that sunscreen is not covering an area satisfactorily is not apparent, as there is no
measure of how much or what area is covered when these products are applied. They cannot be seen on the skin.
Primary prevention of skin cancer in Australia
23
Perspiration, frequently touching the skin, rubbing of hats or clothing can also remove sunscreen which initially had
been applied satisfactorily. There is no way that an individual can determine whether or not the sunscreen that might
have been initially applied adequately is still present and has not been removed to any extent two hours later.
For all these reasons, sunscreens are not seen as a primary resource for photoprotection.
Cost may be a barrier to sunscreen use, particularly given the recommended two hourly re-application of sunscreen
when out in the sun. As sunscreens do not attract sales tax, opportunities by government to reduce the cost of
sunscreen are not available to consumers.
4.2.1.3
Medical reasons
RE
The long-term application of sunscreen does have some theoretical concerns. These products contain a wide
variety of both organic and inorganic chemicals. The long-term safety data related to application of these products
are not available in many instances. Many of them have only been developed within the last 20 years.
Acute pain management:
Recent data have
shownforthat
at least 15 per cent of people who used a commonly dispensed sunscreen in Australia
information
consumers
developed an inflammatory reaction within one or two months of applying it regularly. This is an acute and shortterm response which would be sufficient to prevent its use. For this reason and the fact that we don’t have longterm safety data, the logical approach is to use these products in conjunction with other methods of photoprotection
such as the use of hats, clothing and shade apparatus and avoiding the sun in the middle of the day.
SC
4.2.2 Clothing
In considering clothing as a form of natural protection, it has been demonstrated that the protective effect of
textiles can vary, depending on a range of factors including fabric construction, fibre type, colour, presence of
additives and whether or not the clothing is wet (Pailthorpe, 1994; Gies, Roy, Elliot and Wang., 1994).
DE
IN
The tighter the weave of the fabric, the less UVR is transmitted to the skin (Welsh & Diffey, 1981). Fabric protection will
vary depending on fibre types, eg bleached cotton and viscose provide less protection than do fibres such as lycra. However,
more UVR transmission occurs when a fabric is stretched (Australian Radiation Laboratory, 1994a). Fabric dyes also
influence a fabric’s protective ability, specifically, the darker the colour, the more protective it is. UV absorbing additives
can increase protection afforded by a fabric, so long as it is ‘fast’ to washing and sunlight (Pailthorpe, 1994). Jetvic (1990)
demonstrated in vivo that the protective effect of fabrics is significantly reduced when wet.
Given the variability in protection offered by different fabrics, the Ultraviolet Protection Factor (UPF) rating
scheme has been developed by the Australian Radiation Laboratory to describe the relative amount of protection.
Fabrics are rated in a similar manner to sunscreens, however, the range extends from 10 to 50+ for fabrics compared
to 2–15+ for sunscreens. A UPF 15+ shirt provides the same protection as a SPF 15+ sunscreen properly applied
(Australian Radiation Laboratory, 1994b). As a consequence, a label informing consumers of the sun protection
capability of a particular garment can now be attached to clothing.
D
4.2.3 Other forms of personal protection
The efficacy of other forms of personal protection varies according to their design. According to the Australian
Radiation Laboratory (1994b), wearing a hat with a brim of about 8 cm reduces the solar radiation dose to the face
by one-third. Baseball style caps provide less protection. Legionnaire caps provide good protection to the face,
ears and neck. Sunglasses sold in Australia must comply with Australian Standard AS 1067 ensuring the lens is
protective. Sideshields on sunglasses reduce the amount of UVR entering the eyes from the side. It has been
demonstrated that wearing sunglasses reduces the amount of UVR to the eyes by 80 per cent and if a widebrimmed hat is also worn, the UVR to the face is reduced by 65per cent (Gies, Roy & Elliot., 1992).
4.2.4 Shade
Shade structures and trees can reduce the level of direct exposure to UVR. Various shade and roofing materials have
differing protective properties. Shade cloth, for example, acts as a physical barrier and its UPF factor varies from 2 to
as high as 20 (that is, more than 95 per cent UVR is absorbed). Most awning materials, transparent and opaque plastic
sheeting and umbrella materials have UPF ratings of 50+. The protection afforded by window glass varies depending
on tinting and glass type. For example, car side windows have a UPF rating of 12, while car windscreens (laminated)
have a UPF rating of 50+ (Australian Radiation Laboratory, 1994b).
Primary prevention of skin cancer in Australia
24
The total level of protection is also strongly influenced by the level of indirect exposure/reflection from the surrounding
surfaces in the environment (Gies, Roy & Elliot., 1992). For example, grass has a mean reflectance of 1.1 per cent, while
concrete and beach sand have a reflectance of 6.6 per cent and 9.4 per cent respectively (Department of Architecture,
1995).
4.3 Primary Prevention Surveys
A large number of studies have investigated the primary prevention activities of population groups and specific
target groups in Australia and overseas. A summary of these studies can be found in the tables attached.
RE
Children in both Australia and overseas, whilst spending considerable time in the sun, have been found to use
inadequate levels of sun protection. Parental sun protection behaviour was found to be one of the main influences
on young children’s behaviour.
Acute pain management:
Adolescents tended to information
spend more
time in the sun and were influenced more than other age groups. Although their
for consumers
knowledge of sun protection issues was high, their use of sun protection methods was low. The type of sun
protection favoured by adolescents depended on their perceptions of acceptability and fashion. Males were less
likely than females to protect themselves from the sun.
SC
Although the use of sun protection measures by adults is relatively low, there is evidence to suggest that their
behaviour and attitudes are improving. As with adolescents, adult females’ use of sun protection methods is greater
than that of males’, although males are more likely to wear hats and females more likely to wear sunscreen.
While information from surveys on protection behaviours is available for adults, secondary school children and
primary school children, little data is available on the sun protection behaviours of young children and their
parents and caretakers.
It is recommended that:
D
4.4 Recommendations
DE
IN
The majority of the studies described in this section rely on self-reported behaviour. Self-report is commonly
acknowledged as a limitation of many attempts to evaluate primary prevention (Hill et al., 1992; Bennetts et al.,
1991; Borland et al., 1990). However, Hill et al. (1990) found that self-report is correlated with actual behaviour.
Similarly, Girgis et al. (1993) indicated that self-report by primary school students was generally a valid measure
of solar protective behaviour, a finding replicated by Girgis et al. (1994) in a study of outdoor workers. Furthermore,
intentions have been correlated with usual behaviour, and this relationship has also been used to legitimise the use
of self-reports versus objective measures of exposure, by arguing that increased levels of reported usual behaviour
are likely to translate into some actual behavioural change (Borland, 1990). However, it has been suggested that
self-report may overestimate actual protective behaviour (Bennetts et al., 1991). In a study of beachgoers, Bennetts
et al. (1991) also found consistencies between self-reported and observed behaviour for those using skin protection,
but inconsistencies for those not using skin protection.
9. Sun protection programs continue to emphasise that sunscreens are an important adjunct, but
not a substitute, for other forms of protection such as staying out of the sun in the middle of the
day, use of shade and wearing protective clothing.
10. Sun protection programs should include consumer education campaigns on how to correctly
use sunscreens.
11. Sun protection programs continue to focus on increasing availability and accessibility of
protective measures, reducing barriers to sunscreen use, making sun-safe clothing more
acceptable and modifying outdoor activity during hours of high radiation.
Primary prevention of skin cancer in Australia
Explore the prevalence and
predictors of solar protection
behaviour.
Foot et al.,
(1993)
Investigate solar protection
issues for schools.
D
Primary prevention of skin cancer in Australia
Schofield et al.,
(1991)
To measure sun protection
behaviour at the beach
during summer.
Objective
Bennetts et al.,
(1991)
Authors (Year)
50 children and 68
parents in Victoria.
Participants
Principals (n=40)
and direct
observation of
students in primary
schools (n=20) in
NSW.
670 people (children
and adults) at
beaches in Newcastle
district, NSW.
Findings
information for consumers
DE
• Most parents and children inadequately
covered.
• Children’s cover influenced by parents’
level of cover and child’s tan level.
• Children better protected than their parents.
• Minimal level of solar protection in
schools.
• Considerable levels of time spent out in
the sun.
• Significantly greater proportion of 0–9
year olds were better protected than 11–14
year olds.
• No gender difference in the use of sun
protection measures by children under 15
years old.
IN
SC
Children—Australia
Acute pain management:
RE
Table 4.1:
• Structural and
environmental change is
needed to maximise
opportunities for solar
protection in schools.
• Need for interventions
to target potentially high
risk groups, including
school aged children.
• Self-report may
over estimate actual
behaviour.
Implications
25
Study sunbathing habits in
children (and adolescents).
Look at practices of mothers
in protecting children from
sun, and the incidence of
sunburn among these
children.
Jarrett et al.,
(1993)
Objective
D
150 children (3 year
olds) in Marseilles,
France.
Participants
200 mothers
attending Sunderland
Hospital, England.
Information on 416
children obtained.
DE
Grob et al.,
(1993)
Authors (Year)
Findings
information for consumers
IN
• 68% of children aged less than 10 were
exposed to the sun at least once over past
year without a shirt.
• 55% of children aged less than 10 used
sunscreen at least once in last year.
• 65% of children aged less than 10 wore a
hat in past year.
• Adequate sun protection measures used
by 63 per cent of children.
• One-third of children were highly
overexposed.
• Good sun protection habits of parents were
predictors of acceptable sun exposure in
children.
SC
Children—Overseas
Acute pain management:
RE
Table 4.2:
• Need for more public
education about the
dangers of sunlight,
particularly children.
• Primary target of
campaigns should be
parents, since they not
only control children,
but serve as examples.
Implications
26
Primary prevention of skin cancer in Australia
Participants
191 secondary school
students in Year 9,
Victoria.
5 004 students from
72 secondary schools
in Victoria.
Objective
Explore the relationship
between level of suntan
and perceptions of
healthiness and attractiveness.
Measure knowledge, beliefs
and attitudes of self-reported
usual behaviour about suntanning and sun protection.
Determine the prevalence
of the use of sun protection
measures in adolescents.
Broadstock
et al., (1992a)
Broadstock
et al., (1996)
Cockburn et al.,
(1989)
Authors (Year)
Measure knowledge,
attitudes and behaviours in
relation to the sun.
Measure knowledge, attitudes
and behaviours in relation to
sun protection.
Fisher et al.,
(1996)
Gillespie et al.,
(1993)
D
Primary prevention of skin cancer in Australia
3 655 students in
Years 7 to 11
attending 55 schools
in Queensland
3 655 students in
Years 7, 9 and 11
from 55 schools in
Queensland.
3 002 students in
Years 9 and 10 from
26 secondary schools
in New South Wales.
• Student’s attitude to
suntans is a barrier to
skin cancer control
campaigns designed to
encourage reduced
exposure to the sun.
• More research required
to understand the
relationship between
knowledge and attitude
and behaviour in
adolescence.
• Perceptions of both healthiness and
attractiveness were affected by level of suntan.
• Gender affected perceptions of
attractiveness but not healthiness.
• 66% reported being sunburnt during
previous summer.
• Females scored higher knowledge than males.
• Knowledge levels increased with age.
• Reported behaviour best among 12 year olds,
declining with age to around 15.
• All students had a high knowledge of sun
protection.
• Most students perceive their risk of skin
cancer to be as high as it was.
• Little resistance to hats and sunscreen use,
more resistance to use of clothing.
• Significant associations between reported
sun protective behaviour (hat and sunscreen
use) and grade, gender, day of week and
mother’s sun protective behaviour.
• 40% of students defined as being adequately
protected.
• Male students less likely than females to use
sun protection methods.
• Interventions need to
appeal to adolescents’
interest in their
appearance and
conforming to the peer
group.
• A range of innovative
strategies will be needed
to reinforce positive sun
protective behaviour
acquired at primary
school.
• Interventions are likely
to be effective if they
are targeted at
modifying specific
beliefs, peer images and
parental influences.
Implications
Findings
information for consumers
DE
IN
SC
Adolescents—Australia
Acute pain management:
RE
Table 4.3:
27
To find predictors of
adolescents’ sun protective
behaviour.
Pratt & Borland,
(1994)
Schofield et al.,
(1991)
Study sun-related attitudes
and beliefs.
Objective
Investigate solar protection
issues for schools.
D
3 655 students in
Years 7 to 11
attending 55
representative
schools in
Queensland.
Participants
Principals (n=37) and
direct observation of
students in secondary
schools (n=20) in
NSW.
92 adolescents aged
15–20 years at the
beach (in Victoria)
during summer.
DE
Lowe et al.,
(1993)
Authors (Year)
• As found in primary schools (above), there
was minimal level of solar protection in
secondary schools.
• Considerable levels of time spent in sun.
• Most adolescents had inadequate protection
from sun.
• Dark current tan levels and intention to
sunbake were predictors of low levels of sun
protection.
• Reported behaviour best among 12 year olds,
declining with age to around 15.
• Knowledge of risk factors and role of sun
protective measures was high.
• Potential barriers included desire to be
tanned, perceived peer attitudes and
difficulties with use of particular sun
protection methods.
• Barriers more prominent among males
and older students.
Findings
information for consumers
IN
SC
Adolescents—Australia (continued)
Acute pain management:
RE
Table 4.3:
• Structural and
environmental change is
needed to maximise
opportunities for solar
protection in schools.
• Adolescents are not
adequately modifying
their behaviour to match
the degree of risk to
which they are exposing
themselves.
• Educational interventions
may need to focus on
specific health-related
issues and not on general
self-esteem or selfimprovement issues.
Implications
28
Primary prevention of skin cancer in Australia
Participants
220 paediatric
patients aged 12–19
years from Virginia,
United States.
200 adolescents from
secondary schools in
Marseilles, France.
Objective
Measure levels of sunscreen
use and beliefs about sun
protection.
Study sunbathing habits in
adolescents (and children).
Examine adolescents sun
behaviours, attitudes and use
of sun protective measures.
Banks et al.,
(1992)
Grob et al.,
(1993)
McGee &
Williams, (1992)
Authors (Year)
Assess knowledge, attitudes
and behaviours regarding
intentional sun exposure.
Explore levels and predictors of
sun protective behaviour.
Vail-Smith &
Felts, (1993)
Wichstrom,
(1994)
D
Primary prevention of skin cancer in Australia
15 169 students aged
16–18 from across
Norway.
296 Caucasian
students at a public
University in
southeastern United
States.
345 students aged
13–15 years from
20 schools in New
Zealand.
• The public’s obsession
with tanning must be
overcome.
• Parents act as role model
for adolescent sun
protective behaviour, and
hence should be targeted
by campaigns.
• Adequate sun protection measure used by
only 38% of adolescents.
• Predictive variables were sun protection
habits of the father and sunbathing only to
obtain a tan.
• Many were reasonably well-informed, but
considered the risk of sun exposure
exaggerated by the media.
• Although 90% used sunscreen, only 25%
used adequate SPF, and 50% re-applied while
bathing.
• Females sunbathed more often and longer
than males.
• Frequent sunbathers more likely to be female
and reported fewer self-perceived risk factors,
and less likely to use sunscreen.
• Concern with attractiveness appears to be a
major motivation for frequent intentional sun
exposure.
• High awareness of the danger of melanoma.
• Significant proportion with positive attitudes
towards tanning and high levels of sun
exposure without adequate sun protection.
• Exposure to information correlated with
melanoma awareness which predicted the use
of sun protection measures.
• Important that primary
prevention programs are
gender appropriate.
• Educational strategies
that stress only health
outcomes may be less
effective than those that
also stress the detrimental
cumulative effect of
suntanning.
• Continued efforts need
to be directed at
adolescents to increase
the acceptability and use
of sun protection
measures.
• The absence of sunscreen
use for those at high risk
may be symptomatic of
risk taking behaviour in
adolescents.
Implications
• Although 81% spent most weekends in the
sun, 9% always, and 33% never, used
sunscreen.
• Females more likely to use sunscreen.
Findings
information for consumers
DE
IN
SC
Adolescents—Overseas
Acute pain management:
RE
Table 4.4:
29
Measure the observed and selfreported sun protection of
parents (and children) at the
beach.
Bennetts et al.,
(1991)
Broadstock,
(1991)
Quantify aspects of sun
protection behaviour at a major
sporting event using
photographs.
Study sun protection methods
of spectators at a cricket match.
D
Borland &
Theobald, (1990)
Describe changes in skin
protection attitudes and outdoor
behaviours.
Objective
68 parents at the beach
during summer in
Victoria.
4 016 people
interviewed by
telephone in summer
during 1988/89 and
1991/92.
Participants
246 spectators at the
Melbourne Cricket
Ground, Boxing Day,
1990.
863 individuals
photographed in
sections of the crowd
at the Australian Open
Tennis Championships.
DE
Baade et al.,
(1996)
Authors (Year)
• 71% were wearing hats, 34% wearing hats
that provided maximum sun protection.
• Over half were wearing sunscreen.
• Most were wearing shirts that covered their
shoulders.
• Most spectators are
“covering up”; there is
more room for
improvement.
• Females’ sun protection
measures were more
appropriate.
• For this activity, people
were generally protecting
themselves from the sun
• Photographs can provide
a useful method to monitor
trends in sun protection.
• There is a need for parents
to increase the use of sun
protection on the beach.
• Most parents were inadequately covered
against the sun.
• Parents thought that it was important to
protect their skin against the sun.
• A high percentage of people were wearing
hats, shirts and had their legs covered.
• Most people were using at least moderate
levels of sun protection.
• The reduction of sunburn
should be a primary focus
of skin protection
campaigns.
• The generalisability of
this and similar studies
may be limited due to
environmental and climatic
differences.
Implications
• Significant improvements in some skin
protection attitudes.
• Significant improvements in time spent
outside, hat and sunscreen use, use of shade
and overall skin protection.
• Recent sunburn experience remained
unchanged.
Findings
information for consumers
IN
SC
Adults—Australia
Acute pain management:
RE
Table 4.5:
30
Primary prevention of skin cancer in Australia
Participants
3 971 photographs
from midsummer
editions of six
Australian fashion
magazines, 1982–83
to 1990–91.
312 Australian
University students.
Objective
Rate the sun protective
example provided by fashion
magazines.
Investigated knowledge,
behaviours and health beliefs
regarding skin cancers.
Authors (Year)
Chapman et al.,
(1992)
Cody & Lee,
(1990)
Explore the prevalence and
predictors of solar protection
behaviour.
Determine specific beliefs
related to intention to engage
in skin cancer precautions.
Hill et al.,
(1984)
D
150 adult volunteers
contacted through
places of employment
in Victoria.
670 beachgoers
sampled from six
beaches in Newcastle.
DE
Primary prevention of skin cancer in Australia
Foot et al.,
(1993)
Findings
information for consumers
IN
• Important sex differences, as well as
similarities, were discovered in the beliefs
related to the precautionary intentions.
• Certain beliefs appear to be targets for factual
based approaches, others require a more
indirect approach.
• Nearly half of the sample were using a high
level of solar protection.
• Sunscreen was applied to at least one part of
the body by 69% of the sample.
• Marital status and skin self-examination over
the last 12 months were predictors of overall
level of solar protection.
• Skin type, previous experience with skin
cancer, and perceived barriers, were significant
predictors of knowledge, intention and
behaviour.
• Skin protection intentions increased
significantly after viewing one of two videos.
• An increase in the proportion of light tans.
• Increase in proportion of models wearing
hats.
• Three quarters of outdoor photos were taken
in unshaded settings.
• Female models more likely to wear hats in
unshaded settings.
SC
Adults—Australia (continued)
Acute pain management:
RE
Table 4.5:
• Guidelines for a
segmented health strategy
are suggested.
• More indirect strategies
could be tried to increase
the use of skin protective
behaviour.
• Need for information on
appropriate or most
effective modes of sun
protection.
• There is a need for
interventions to target
potentially high-risk
groups.
• Video presentations had a
positive impact on
knowledge and intentions
relating to skin cancer
prevention.
• There is an indication that
suntans are now being
perceived as less
fashionable
Implications
31
Determine trends in exposure
to sunlight.
Hill et al.,
(1993)
Whiteman et al.,
(1994)
Assess the prevalence of
sunscreens in an environment
of high UV exposure.
Determine the prevalence and
determinants of sun protection
practices.
D
Pincus et al.,
(1991)
Determine the independent
contribution of behavioural
factors to the occurrence of
sunburn.
Objective
Hill et al.,
(1992)
Authors (Year)
4 428 adult residents
in Melbourne,
Victoria during the
three summers of
1987/88–1989/90.
1 655 adults in
Melbourne, Victoria
surveyed during
summer, 1987/88.
Participants
105 non-Aboriginal
people attending a
weekend market in
Darwin, Northern
Territory.
243 individuals on
beaches in southeast
Queensland during
March, 1989.
• UV radiation, temperature, sensitive skin,
type youth and being male were
independently associated with sunburn.
• After controlling for all other predictors, body
exposure index made a strong independent
contribution to the explanation of sunburn.
Findings
information for consumers
DE
IN
• Sunscreen and hat use were low.
• Hat and sunscreen use was higher amongst
those with a history of skin cancer.
• Long-term residents of Northern Territory
were less likely to apply sunscreen.
• Nearly three quarters of the sample applied
sunscreen, half of whom used maximum SPF
sunscreen.
• Major reasons for use were to avoid skin
cancer and to avoid sunburn.
• Reduction in reported sunburn.
• Substantial attitudinal shifts.
• Hats and sunscreen use increased.
SC
Adults—Australia (continued)
Acute pain management:
RE
Table 4.5:
• Sun protection practices
of visitors to Northern
Territory are less than
optimal.
• Precautions against sun
exposure amongst residents
of Northern Territory could
be greatly improved.
• More subtle aspects of
efficacious sunscreen use
in education campaigns
may be required.
• Sun exposure of
populations can change
fairly rapidly, and that well
conducted health
promotion campaigns can
contribute to such change.
• Behavioural change
strategies to prevent
malignant melanoma of
the skin are warranted.
Implications
32
Primary prevention of skin cancer in Australia
Participants
214 individuals who
attended a skin cancer
screening clinic in
Connecticut, 1988.
3 843 adults aged
35–64 years in
Alberta, Canada.
Objective
Examine the associations
among attitudes, knowledge
and behaviour of skin cancer
screenees.
Measure sun-related knowledge,
beliefs, occupational and
recreational exposure and
protective behaviours.
Berwick et al.,
(1992)
Campbell &
Birdsell, (1994)
Authors (Year)
Empirically examine
psychosocial factors in
sunbathing and sunscreen use.
Evaluate sun exposure habits
and beliefs, and the use of
sunscreen.
Johnson &
Lockingbill, (1984)
D
489 medical clinic
outpatients in
Pennsylvania, during
1982.
120 beachgoers in
California.
DE
Primary prevention of skin cancer in Australia
Keesling &
Friedman, (1987)
Findings
information for consumers
IN
• Men, and those aged over 30, had the greatest
level of sun exposure.
• Those with sensitive skin spent less time in
the sun, and were more likely to use sunscreen.
• Knowledge levels improved after a brief
educational campaign.
• These is still a need for
educational efforts, those in
the pre-contemplative and
contemplative phases of
behaviour can be recruited
to take action.
• Beliefs, attitudes and
norms of high risk groups
regarding sunscreen use
should be investigated to
design interventions to
decrease skin cancer
incidence.
• Clear need for
modification of public’s
belief and sun protection
behaviours.
• Less than half were likely to routinely use
sun avoidance, protective clothing, hats or
sunscreen.
• Men and women differed in type of
protection preferred.
• Sunbathing related to risk taking, knowledge
of skin cancer, relaxed mood, peers and
attempts to maintain positive physical
appearance.
• Sunscreen use related to gender, knowledge
of skin cancer, knowing people with skin
cancer and high anxiety levels.
• More targeted education
in the domain of
knowledge would benefit
males and those over the
age of 59.
Implications
• Attitudes towards tanning were not correlated
with knowledge or behaviour.
• Sunscreen use was correlated with knowledge,
and associated with younger age group,
females, higher education and perceived high
risk of melanoma.
SC
Adults—Overseas
Acute pain management:
RE
Table 4.6:
33
35
Section Five
Evaluated Intervention Programs
5.1 Australia
RE
Australian States and Territories have implemented a range of skin cancer prevention programs focusing on different
Acute pain management:
sectors of the community,
and the aim of a substantial proportion of these programs has been to improve sun protective
information
for consumers
behaviours amongst
young
children and teenagers. In this section, the scope of programs implemented in Australia in
recent years is reviewed. A number of those programs which had established a comprehensive evaluation strategy
were selected as case studies. The Australian case studies, and a selection of interventions conducted overseas were
used to provide information on the impact and effect of skin cancer prevention intervention programs.
SC
The Working Party sought information from all State governments and State-based cancer societies to establish
both the scope and impact of these programs on the community. A list of the primary prevention programs conducted
in each State, based on the information provided by these sources, can be found in Appendix B. As this list
demonstrates, not all programs have been evaluated, and even fewer have published their results in peer review
journals. Therefore, the Working Party found it necessary to use a case study approach in order to gain insight into
the impact and effect of these programs.
IN
5.1.1 Scope of Australian programs
Most States and Territories have implemented media-based sun protection campaigns focusing on the general
community, specifically adults and young people. While such campaigns may have reached parents, few campaigns
have been directed specifically toward advising parents about the protection of young children. State campaigns
have been supplemented with local activity to varying degrees.
DE
The NHMRC (1997) has identified that school health programs need to focus on curriculum, school environment,
health services, and partnerships between schools, community, parents and private or government organisations.
These factors need to be integrated with supportive school policy structures.
D
With respect to sun protection, all States (except Northern Territory, for which information was not provided)
have worked with schools to develop sun protection policies. Schofield et al. (1991) reported that such policies
are better established in primary, rather than secondary schools. Further, despite policies being established in 64
per cent of primary schools, one of the most important features of such a policy—the ‘no hat, no play’ policy—
was observed in only 13 per cent of schools surveyed. Development of curriculum, and promoting the construction
of shade structures are some of the strategies pursued in local programs.
It is recognised that effective health promotion in schools should be comprehensive in concept and content, and
not focused only on single issues (Effective School Health Promotion: Towards health promoting schools, NHMRC,
1996). On that basis, sun protection programs in schools should be linked with other school health initiatives.
The issue of sun protection has been included in the national child care accreditation guidelines (National Child
Care Accreditation Council, 1993) in New South Wales and Queensland. Programs exist in a number of States
and Territories, for example, New South Wales and Queensland, which work with child care centres in promoting
a comprehensive response to prevention of UV exposure of children in this setting. Through sponsorships and the
development of guidelines, sports clubs have been included in some campaigns. Some States and Territories have
also pursued the prevention of exposure to solar radiation at work (Borland et al., 1991; Girgis et al., 1994).
However, these programs are not reviewed in this report as they operate within the context of occupational health
and safety legislation, and do not target children or young people.
Primary prevention of skin cancer in Australia
36
Several States and Territories have presented a comprehensive strategic approach to their sun protection programs.
For example, New South Wales Health and the Cancer Council of New South Wales (1995) have developed a
strategic plan for ‘Skin Cancer Control in New South Wales’ which provides a model for planning of communitybased interventions at the State level, including a comprehensive monitoring and evaluation scheme. Queensland
is currently pursuing a whole-of-government policy approach, through a consultative process built around the
‘Discussion Paper Towards a Policy on the Prevention and Early Detection of Skin Cancer’ (Queensland Health,
1995b).
5.2 Case Study 1: Slip! Slop! Slap! and SunSmart: the Anti Cancer
Council of Victoria’s Skin Cancer Control Program
RE
Some of the material inAcute
this section
is adapted from the SunSmart Program’s 1996–1999 application to the Victorian
pain management:
Health Promotion Foundation;
Montague
and Sinclair, 1995.
information for consumers
The Anti-Cancer Council of Victoria (ACCV) has run a skin cancer control program since 1980. It began with the
Slip! Slop! Slap! Campaign, and was followed by the SunSmart Campaign which was launched in 1988 with
substantial funding from the Victorian Health Promotion Foundation.
SC
The long-term aim of the SunSmart Campaign is a reduction in the incidence of morbidity and mortality from skin
cancer in Victoria. The short-term objectives are based on changing attitudes, beliefs and behaviours which affect
individual skin cancer risk, modifying the environment to facilitate skin protection, and encouraging early detection
of skin cancers. (This last objective is not reviewed here).
DE
IN
SunSmart is a multifaceted public education campaign. It works to impact on many routes of influence which are
amenable to change through individual and/or community action. SunSmart is also an evidence-based health
promotion program. Wherever possible, decisions about the form and content of the program are influenced by
available empirical evidence and community consultation processes. A systematic evaluation and research strategy
is in place to ensure that as much information as possible is available on process, impact and outcome measures of
the campaign’s effectiveness. Research has also been used to refine communication strategies including the major
advertisements and publications.
5.2.1 Outline of the SunSmart Campaign (Sinclair et al., 1994)
D
The SunSmart program targets the whole population and contains special strategies to target five subgroups identified
as being at greater risk for possible skin cancers: those who for genetic or biological reasons are at greater risk
particularly of melanoma, for example, fair skin, red hair, blue eyes; children; those pursuing high risk activities
which are likely to lead to over exposure such as water sports, gardening and attending sporting events; young
men; and older adults (for early detection).
SunSmart was designed to target seven key settings: schools, media, sporting events, State, Territory and Local Government
authorities, general practitioners, community health centres and industry. These were divided into four sub-programs: a
media strategy and public education program, a community support program, a schools program and a sponsorship program.
5.2.1.1
Media strategy and public education program
The media and public education sub-program involves advertising and community announcements on television
and radio and a comprehensive public relations program. It highlights high risk activities and encourages community
involvement for long-term change. The mass media messages have been designed to be maximally attractive to
young adults from lower socio-economic sector areas and often to young males. However, the messages have
been successful at reaching a broad cross-section of the population. The use of mass media is a vital part of the
ACCV’s skin cancer control strategy. SunSmart’s operating definition of mass media covers paid advertising (TV,
radio, print, outdoor) promotions, advocacy, public relations, information services and point of sale. Mass media
helps keep skin cancer control on the public agenda and defines it as an issue for everyone. The other programs are
designed to build on this by meeting additional needs of identified targets.
Primary prevention of skin cancer in Australia
37
5.2.1.2
Community support program
Community programs are built by the support and enthusiasm of local community health centres, local government
and work places. In early years, the community program was based almost entirely on resource and information
dissemination. More recently, considerable effort has gone into bringing about sustainable changes through policy
and structural development at the local level, and into training health and community workers on how to run
programs (Whitty, 1995). In 1994, over 1 500 organisations were involved in SunSmart’s Community Support
Program. The program also works with industries, that is the fashion industry that produces sun protection items
such as sunscreen, hats and clothing, to encourage production of better resources.
5.2.1.3
Schools program
5.2.1.4
RE
SunSmart provides training and curriculum resources to educators which enable them to implement SunSmart
programs in institutions from pre-schools to universities. Schools are encouraged to develop and follow a SunSmart
Acute
pain management:
policy, or at least
practice
SunSmart activities in three areas: making structural changes to reduce the sun exposure
information for
consumers skin cancer prevention lessons in the curriculum and encouraging sun protection
of the school population,
providing
behaviours for staff and students.
Sponsorship program
SC
Sponsorships, including art or sport sponsorships, are used to extend the image of SunSmart and to reinforce the
media impact of the program. For example, evidence that water-based activities place those involved at high risk
for sun exposure has led to sponsorship of the Royal Life Saving Society, the Surf Life Saving Association,
Swimming Victoria and Diving Victoria.
5.2.2 Key achievements by SunSmart
IN
5.2.2.1
Structural and environmental change
DE
5.2.2.1.1 Government policy change
The Anti-Cancer Council has worked with State Cancer Councils and other bodies with regard to such things as labelling
requirements (ie SPF limits) and standards for sunscreens and fabrics. They have also looked at the development of
standards on sun protection policy and practices for the Federal Government’s National Child care Accreditation Council.
This involves reviewing standards for quality improvement and accreditation in child care centres.
D
5.2.2.1.2 Workplace change
The Anti-Cancer Council has worked with employer and worker organisations towards the development of
guidelines on sun exposure and outdoor work. This has resulted in national guidelines produced by the ACTU and
Worksafe Victoria, and in distribution of a booklet on sun protection for workers in seven community languages
by the then Victorian Occupational Health and Safety Commission.
Skin cancer control strategies have been adopted by government and corporate bodies including Telstra, the
Victorian Police, Australia Post, the State Electricity Commission, and a significant number of local government
authorities.
5.2.2.1.3 Local government policy and practice
The work of the SunSmart program with local government is having a significant effect on the awareness, policy
development and sun protection practices. The number of local councils with a shade policy in relation to their parks
and gardens has risen from only 20 per cent in 1990 to 39 per cent in 1993. Fifty per cent of councils had a policy for sun
protection for outdoor staff in 1993, compared to only 29 per cent in 1990. Forty-seven per cent had a policy or set of
procedures which dealt with sun protection in programs for children in 1993, compared with only 22 per cent in 1990.
In 1993, 57 per cent of councils had increased their level of shade provision at council controlled facilities such as
parks, gardens, pre-schools, kindergartens, swimming and wading pools, spectator areas at sports grounds, public
seats, bus stops and footpaths (Montague, et al., 1995a).
Access to, provision of, and education about sun protection issues and items has improved at local government levels.
In particular, changes have been noted in relation to outdoor staff, children’s programs, and health education programs
Primary prevention of skin cancer in Australia
38
run by council staff and in conjunction with other agencies (Borland, et al., 1994; Montague et al., 1995a). The data on
council demand for resources and the participation by staff in educational workshops, indicate that up to early 1994
around half the local councils in Victoria had some type of active contact with the SunSmart program each year.
5.2.2.1.4 Schools and pre-schools
Seventy-seven per cent of council run children’s holiday programs now have a policy in place, compared with
64 per cent in 1990. The proportion of day care programs with a policy has risen from 59 per cent in 1990 to
72 per cent in 1993; of child care programs, from 70 per cent to 89 per cent; and of kindergartens, from 67 per cent
to 75 per cent over the years.
RE
In 1993, all the councils reported that their pre-school policy specifically included encouragement of the use of individual
sun protection items such as hats, T-shirts and SPF15+ sunscreen, compared to only 90 per cent of councils in 1990. In
1993, two-thirds of the councils claimed that their policy included the scheduling of activities to limit the time spent
outdoors between 11am and 3pm. This compares favourably with just over half the councils who reported this in 1990.
Acute pain management:
SC
In 1990, the then Department
of Education issued a memorandum (Memo 389, March 1990) recommending that
information for consumers
schools support the Anti-Cancer Council sun protection program through curriculum and school environment
changes. It also suggested that schools use Anti-Cancer Council resources. Estimated proportions of schools that
order SunSmart teaching materials have gone up from around 57 per cent in 1991, to 80 per cent in 1992 (Fletcher,
et al., 1994; Sinclair, et al., 1994b). With the development and release of three major curriculum resources targeted
at Victorian Certificate Education students, primary schools and child care centres, there has been a very large
increase in resource provision over the 1994/95 campaign period.
The 1992 survey of Victorian primary schools showed that all schools recommended hat wearing in Terms 1
and 4, and it was compulsory in 19 per cent of schools. Half the schools provided sunscreen for student use,
30 per cent had considered making timetable changes so that outdoor activities could be minimised between
11am and 3pm in Terms 1 and 4, 56 per cent had curriculum guidelines which recommended sun protection, and
17 per cent had a written school sun protection policy (Segan & Borland, 1994; Murphy, 1994).
IN
In Victorian primary schools in 1994, surveys indicated that a culture of SunSmart behaviour in primary schools had
become strong. Forty-five per cent of schools had considered making timetable changes so that outdoor activities could
be minimised between 11am and 3pm in Terms 1 and 4; 56 per cent had curriculum guidelines which recommended sun
protection, and 36 per cent of primary schools reported having a written SunSmart policy (Dixon & Borland, 1995).
DE
In 1990, teacher surveys in secondary schools showed that although only 9 per cent of secondary schools had a policy
statement on sun protection, 45 per cent of schools had a sun protection component in their health education program, and
some 72 per cent wanted support from the Anti-Cancer Council for the development of SunSmart policy and practices. Hat
wearing was rarely compulsory and the provision of shade was generally judged to be inadequate. The majority of schools
had taken steps over the previous three years to increase the amount of shade available (Clarke, 1994).
D
5.2.2.1.5 Access to sun protection items
The Anti-Cancer Council has entered the market as a retailer of affordable protective items such as sunscreen,
hats and clothing. It has promoted use of council-endorsed sunscreens and sought to improve access to other low
priced sunscreens by encouraging lifesavers to sell them on beaches. Cheaper generic brands of 15+ sunscreen
are now available through retail chains. The ACCV helped promote the introduction of Lycra body swimsuits
which have now become very popular, particularly for young children.
The market share of sunscreen with a high sun protection factor has markedly increased over the last eight years.
In 1987, only 29 per cent of the market consisted of sunscreen with an SPF of 15 or 15+; in 1992 this had risen to
65 per cent of the pharmacy sales and 76 per cent of grocery store sales. The volume of sunscreen sales has also
increased. Where volume is measured in units of 100 grams = 1000 millilitres, sales increased from 5 051 to
7 132.6 units between 1987 and 1991. In 1993, the directors of all major sunscreen manufacturers in Australia
were interviewed. The results of these interviews suggested that sunscreen manufacturers were aware that
consumers’ views were influenced by Anti-Cancer Council programs and, consequently, they promoted their
products in a manner which was consistent with the SunSmart message.
The Anti-Cancer Council has supported the sale of sunscreen through supermarkets as a way of decreasing prices
and improving consumer access. Research shows the supermarket sector has a much larger share of the sunscreen
market than does the pharmacy sector, with its 33 per cent market share in 1986/87 increasing to 50 per cent in
1990/91.
Primary prevention of skin cancer in Australia
39
Organisers of major sporting events have been encouraged to sell hats and sunscreen and to provide shaded areas,
and now do so routinely. Hat wearing is now the norm at events such as the Australian Open Tennis Championships
(Borland & Theobald, 1990).
5.2.2.1.6 Media coverage
While it is not easy to calculate the full extent of media coverage concerned with sun protection issues and
SunSmart messages, some estimates can be made. In earlier years of the SunSmart campaign, the media budget
exceeded $300 000; but since the 1992/3 campaign, the budget has declined, and more recently it has been in the
vicinity of $100 000. In the earlier years of the campaign, SunSmart messages reached most Victorians on a
number of occasions.
RE
In each campaign, the paid media budget had been supplemented by varying levels of community service
announcement support exceeding $100 000 in the best year. As well as this, mentions of the campaign through
news bulletins, interviews and other public relations activities were conducted. For example, in 1990/91 more
Acute
pain management:
than 520 relevant
articles
appeared in the print media, and more than 80 radio interviews and news items were
information
for consumers
recorded (Davidson
1995).
This level of activity has been more than sustained. In 1994/95, a total of 650 articles
appeared and a new high of 100 radio interviews was recorded. Television weather reporters have been very
supportive of the campaign, with sun protection messages and UVR reports being broadcast on a nightly basis
during daylight saving time on several TV channels.
SC
5.2.2.1.7 Activity by community organisations and professional groups
The community program area of SunSmart responds each year to between 1 500 and 2 000 requests from health
professionals for help or resources. In addition, there are more than 1 500 borrowings of relevant material each
year from the ACCV resource centre with around a third of these from new borrowers. Medical and paramedical
workers make extensive use of Anti-Cancer Council resources.
5.2.2.2
IN
Community organisations have also made great use of ACCV resources. Some policy implementation and
behavioural change, in accord with better sun protection practices, have been achieved through sponsorships. An
example of this is lifesavers wearing T-shirts, protective hats, SPF15+ sunscreen, and frequently using special
shade shelters on beaches (Sweeney, 1995).
Change in knowledge, attitudes, beliefs and behaviour
DE
One limitation of much of the research on individual sun protection behaviour is that it relies on self-report of
usual behaviour. However, Hill et al., (1990) found that reported usual behaviour and reports of specific instances
of behaviour were correlated. Also, usual behaviour is correlated with behavioural intentions (Borland et al.,
1990). These results suggest it is reasonable to assume that increased levels of reported sun protection, documented
below, are likely to represent some level of actual behaviour change.
D
5.2.2.2.1 Awareness of the Program
There has been a continuous and steady increase in awareness of the campaign. In 1989, only 46 per cent of
respondents to the annual post-campaign survey had heard of the term ‘SunSmart’, compared to 81 per cent in
1995. Young people are still more aware of the program and are more accurate in their recall of its message than
are older people. However, the gap between older and younger people’s awareness is smaller than it was seven
years ago.
5.2.2.2.2 Knowledge of the link between skin cancer and UVR
Close to 100 per cent of people are aware that skin cancer is a dangerous disease. Also, over 90per cent know that
skin cancer is linked to UVR exposure and in 1995, 80 per cent agreed with the statement that ‘I need to do more
to protect myself from the sun because of the hole in the ozone layer’ (Source: Anti-Cancer Council of Victoria
Sun Surveys).
5.2.2.2.3 Attitudes and beliefs about suntans
Research has shown that positive attitudes to tanning are inversely linked to sun protection attitudes. Behaviourchange models suggest that changes should be seen initially in beliefs and attitudes, as people prepare to change
their habits. As shown in Table 5.1, since 1988, the proportion of people who like to get a suntan has decreased by
26 per cent, and fewer people want deeper levels of tan.
Primary prevention of skin cancer in Australia
40
Table 5.1:
Preference for a tan by year of survey
1988
%
1989
%
1990
%
1992
%
1995
%
39
43
51
57
65
9
6
10
11
8
32
32
25
23
18
14
12
10
7
6
6
5
2
2
2
Do you like to get a suntan or not?
Answer—No
How deep a tan do you like to get
(% of total respondents)
Light
Moderate
Very dark
RE
Dark
Acute pain management:
information for consumers
Source: ACCV Sun Surveys 1988, 1989, 1991, 1995.
Table 5.2:
SC
Table 5.2 sets out a group of key statements of belief about suntans and gives a picture of the percentage of people
agreeing with each item for the baseline (ie pre-SunSmart) summer of 1987–88, and over the next seven years.
For each statement there has been continued change favourable to the adoption of SunSmart behaviour and
unfavourable to suntanning.
Agreement with beliefs about tanning by year of survey
1989
%
1990
%
1992
%
1995
%
Friends think suntan is a good idea
69
63
52
48
38
A suntanned person looks more healthy
66
59
53
50
49
It is easier to enjoy summer once you get a suntan
62
54
43
37
30
A suntanned person is more healthy
17
8
8
DE
Source: ACCV Sun Surveys 1988, 1989, 1990, 1992, 1995.
IN
1988
%
13
9
D
5.2.2.2.4 Use of artificial tan products
Victorian population surveys in 1993 (Purchase & Borland, 1994) and 1995 (Cappiello, Dixon & Borland., 1995)
show the use of artificial tanning procedures to be about 9 or 10 per cent with the overwhelming majority of users
being women, giving prevalence estimates for women of 19 per cent and 16 per cent in the two surveys. In 1993,
users were more likely to report sunburn, but this was not the case in 1995. In 1995, users reported higher sunscreen
use.
In 1993, a question was also asked about tan accelerators and 8 per cent reported that they had used them (13 per
cent of women, 4 per cent of men). This was not related to sunburn.
There is no clear evidence to suggest these behaviours are having any adverse impact on sun exposure.
5.2.2.2.5 Sun protection behaviour
The Sun Survey (see Table 5.3) shows that more and more people are taking steps to protect themselves against
sun damage.
Primary prevention of skin cancer in Australia
41
Table 5.3:
Sun protection measures between 11am and 3pm on the
previous Sunday
1988
%
1989
%
1990
%
1992
%
1995
%
Wore a wide brimmed hat between
11am and 3pm on Sunday
9
15
16
18
20
Used sunscreen between
11am and 3pm on Sunday
19
25
24
27
34
Chose to stay out of the su
between 11am and 3pm on Sunday
n/a
n/a
30
33
41
RE
Source: ACCV Sun Surveys 1988, 1989, 1990, 1992, 1995.
Acute pain management:
information for consumers
SC
The Sun Survey (see Table 5.3) shows an increase in the proportion of people who report seeking shade, using hat
and sunscreen, covering up and choosing not to go out in the sun between 11am and 3pm. Although all groups
report increases in a variety of sun protection measures, there are some differences in reported behaviour by
different groups. For example, (i) people over 30 are more likely to use a range of sun protection measures than
are young people, (ii) women are more likely to put on sunscreen, to seek shade and stay out of the sun, and men
are more likely to wear a hat, (iii) country residents are less likely than city residents to stay out of the sun in the
middle of the day, (iv) there is no indication that education level is related to sun protection (Montague et al.,
1995b; Cappiello et al., 1995).
IN
5.2.2.2.6 Young people
As a high risk group, young people have shown some interesting trends in the annual post-campaign survey in
behaviour and attitude change. Awareness of the program is high, with consistently high levels of accurate reporting
of the campaign messages. Sun protection behaviour has increased, attitudes to sun exposure and suntanning have
altered, but sunburn incidence, extent and severity have not significantly changed since the initial effect. Table 5.4
shows that 12 to17 year old school students sampled in Victoria have become more negative in their attitudes to
suntans, although these are still not as negative as the total population figures given in Table 5.1.
DE
Virtually all Victorian secondary school students are aware of the issue of sun protection, are likely to receive
education approximately three times during their schooling, and become increasingly knowledgeable as they
proceed through school. Their attitudes to sun protection methods are generally positive, and those most likely to
burn have the most positive attitudes to sun protective behaviours (Broadstock et al., 1996).
Table 5.4:
D
No data have been collected directly from pre-school or primary school children. Reports by parents of children
under age 16 have indicated that over 90 per cent had tried to get someone else, including children, to protect
themselves from the sun (Segan & Borland, 1994).
Preference for a suntan by school students
in 1990 and 1993
Do you like to get a sun tan?
Answer—No
1990
%
1993
%
16
14
12
30
How deep a tan do you like to get
(% of total respondents)
Light
Moderate
46
38
Dark
21
13
Very dark
4
4
Source: ACCV SSAS Surveys 1990 and 1993.
Primary prevention of skin cancer in Australia
42
5.2.2.2.7 Experience of sunburn
For research purposes, sunburn is defined initially as ‘any reddening of the skin after being outside.’ This is then
broken down into: ‘red but not tender’, ‘red and tender’, or ‘red, tender and blistered’.
Since 1988, the Sun Survey has collected data on people’s experience over the previous weekend, and since 1991,
the post-campaign survey has looked at people’s experience over the previous summer.
As shown in Table 5.5, the downward trend in sunburn in the first two years of the SunSmart Program, compared
to a baseline in 1987/88, has not continued. Sunburn in 1994/95 is significantly lower than 1987/88, but not
different to subsequent years, so it would be hasty to conclude that there has been a deterioration or reversal of
trend. It does, however, suggest that sunburn rates have plateaued. However, the ratio of mild to more severe
burns has increased.
Adjusteda percentage sunburnt on previous weekend
Acute pain management:
(any
reddening of the skin)
RE
Table 5.5:
information for consumers
Men
Women
1987/88
1988/89
1989/90
1994/95
15
13
9
12
9
7
5
7
SC
ns
p<.05
(a) Adjusted for UV, temperature, month of summer, skin type and age.
Source: Sun Survey data.
IN
5.2.2.2.8 Making extra sun protection efforts
The proportion of people who claim to be making extra efforts to protect their skin from the sun throughout the
summer has risen from 49 per cent in 1989 to 65 per cent in 1995.
DE
A recent detailed analysis (Dixon & Borland, 1995) was performed on data from those questioned during the
annual post-campaign survey between 1992 and 1995. The results showed that there were only minor differences
in awareness, attitudes and sun protection behaviour between groups classified in terms of English or non-English
speaking background, socioeconomic status, education level, and rural or metropolitan residence. The main factors
affecting sun exposure and sun protection behaviour are sex, age and skin type. Sun exposure and sun protection
was reported less by males as well as those in the 14-29 age group, while sun protection was more evident among
those who reported their skin didn’t tan easily.
D
5.2.2.2.9 Links between the campaign and sun protection behaviour
There is converging evidence consistent with the conclusion that the Slip! Slop! Slap! and SunSmart campaigns have
contributed significantly to the changes in sun protection behaviour documented here. There is a widely held belief
in the community that the SunSmart campaign has been the main influence on the sun protection behaviour of
Victorians. In 1994, 91 per cent of respondents interviewed agreed that the SunSmart campaign was the main reason
people are now more likely to protect themselves from the sun. Also, respondents who had seen or heard the phrase
SunSmart (46 per cent compared with 27 per cent who had not), were more likely to report they would protect
themselves less often if it wasn’t for sun protection advertising. This finding suggests that these people see the
advertising as encouraging them to do what they know they should, that is, protect themselves from the sun (Capiello
et al., 1995).
5.2.3 Implications for prevention
•
The protection of young children (under age 12) must be a priority and the available evidence, although poor,
suggests that this is the area where sun protection efforts are most systematic. The vast majority of parents are
actively ensuring their young children do not get overexposed (Segan & Borland, 1994) and many child care
centres and primary schools have implemented sun protection policies (Montaque et al., 1995a; CBRC,
Primary prevention of skin cancer in Australia
43
unpublished data). However, there are no data on actual behaviour of young children and collection of such
data must be a priority. Even with high levels of apparent action, more can be done; enforced policies need
to be put in place where they do not already exist and some parents need extra reminders. Unless sun protection
is seen as an activity for everybody, gains in early childhood will be lost as children become more independent.
Except for help with policy development, limited targeting is needed because people interpret population
focused warnings in this area as being of most relevance to children. This may be because facts about the
susceptibility of young skin to sun exposure are well demonstrated.
In Victoria, more work is needed in secondary schools. Currently, children move from largely SunSmart
primary schools to secondary schools where sun protection is often not a policy issue. Other areas where
improvement could be made is in the provision of shade over focused outdoor activities (eg basketball).
•
In deciding priorities and their cost effectiveness, we need to be aware that we do not know which strategies
will achieve further progress given our successes to date in generating public concern and improved
behaviour.Acute pain management:
•
information
for consumers
School activity
needs
to continue to integrate curriculum and structural strategies, a model that is integral to
the notion of health-promoting schools.
•
SunSmart has been designed to be multi-faceted and this seems to have been successful. Education has
resulted in a population motivated to protect themselves, but not at too much cost to enjoyment of an outdoor
lifestyle. Providing shade allows people to improve their protection while doing what they want to do.
Similarly, scheduling outdoor activity away from the 11am to 3pm period whenever possible allows people
to do things they want to while minimising exposure. This minimises the need for reliance on personal
protection.
•
Integration of sun protection into the Australian lifestyle in the long-term will require environmental contexts
that facilitate protection and continuing motivation of the public to undertake other important health
promoting activities, such as sport and exercise.
•
Change in sun safe behaviour clearly needs to be ‘life-long’. At this point in time, we do not know what will
be needed to sustain adequate sun protection in the long-term. This may vary geographically (ie due to ambient
UV levels).
DE
IN
SC
RE
•
5.3 Case Study 2: ME NO FRY Campaign
5.3.1 Background
D
The Me No Fry (MNF) campaign was first implemented in New South Wales in the summer of 1990/91 and has
run every summer since then. In 1994/95 and 1995/96, the campaign was also implemented in Western Australia.
The campaign uses a combination of social marketing strategies, including mass media advertising, sponsorship
by sporting bodies, local activities, the endorsement of role models and policy changes to get the MNF message
across.
The MNF campaign is directed specifically at an adolescent target group and hence, has attempted to fit into
rather than challenge the preferred fashions and assumptions of the Australian youth culture. Adolescence is a
time at which most people strive to appear fashionable and attractive to their peers, seeking to conform to dominant
norms and values. The messages of MNF were developed with this in mind, aiming for a ‘hip’ ambience.
5.3.2 Aims and objectives of MNF
MNF is a campaign to promote the adoption of sun protection behaviours among young people aged 11 to 16
years. The main objective of the MNF campaign was to change a sun worship culture to a sun protection culture.
To achieve this objective, the following broad aims were addressed by the campaign:
•
to associate MNF with youth culture and fashion;
•
to achieve extensive media exposure of MNF;
•
to generate support for and promotion of MNF by all sections of media that influence young people;
Primary prevention of skin cancer in Australia
44
•
to associate MNF with activities and events that occur in situations of sun exposure; and
•
to enlist support from those who influence young people in the form of role modelling and advocacy for sun
protection behaviours.
More specifically, the campaign attempted to:
increase knowledge of the health consequences of sun exposure;
•
increase knowledge of individual behaviour required to provide sun protection;
•
increase knowledge of short-term consequences of sun protection for physical appearance;
•
increase the desirability and fashionability of sun protection;
•
increase the association of MNF with fashionable clothing that provides sun protection;
•
reduce the association of being tanned with being an ‘outdoors person’;
•
raise the profile of
sun protection
as a community issue; and
information
for consumers
•
increase the sun protection behaviours among 11–16 year olds.
RE
•
Acute pain management:
5.3.3 Campaign strategies
SC
The campaign strategies included:
mass media—print media, including posters, flyers, newsletters, stickers and magazine advertorials, radio,
electronic media;
•
sponsorship—including the Bodyboarding Association, the Surf Life-Saving Association and the Sydney
Olympic Soccer Team;
•
public relations—launch events, news coverage, celebrity involvement, media endorsement;
•
area and regional Health Promotion Unit MNF activities; and
•
construction of shade shelters.
5.3.4 Evaluation of the MNF campaign
DE
IN
•
The impact of the campaign on adolescents’ knowledge, attitudes and sun protection behaviour was assessed by
undertaking surveys of randomly selected samples of adolescents in high schools. Sun protection was assessed by
completion of a self-report diary of protection used on the previous weekend, with the level of sun protection
being determined using a coding schedule (Foot et al., 1993; Girgis et al., 1993; Girgis et al., 1994).
D
In Western Australia, the campaign was introduced in 1994/95, and an evaluation indicated no significant changes
in knowledge, attitudes and sun protection behaviour following the first year of the campaign. In New South
Wales, evaluations have been undertaken since 1991/92. The following is a brief report of the findings of these
evaluations. For more detailed information about evaluations and their results, a number of evaluation reports
have been produced (Sanson-Fisher, 1992, 1993, 1994, 1995).
5.3.4.1
Exposure of adolescents to sun protection messages
A large percentage of the target group was exposed to messages about sun protection in the four years of the MNF
evaluation, as indicated in Table 5.6. There was a significant increase across the first three time periods in the
proportion of the sample who identified such messages as being associated with the MNF campaign. Almost all of
the sample who had heard advertising in the 1993/94 period identified it as MNF (18 per cent increase from the
1991/92 period), indicating an improvement in the ability of this campaign to reach the identified target group.
However, there was a significant 10 per cent decrease in the proportion who identified the advertising as MNF
following the most recent campaign. This finding may reflect the greater exposure of this target group to sun
protection campaigns other than the MNF campaign, eg the UVOD (UV overdose) campaign which was introduced
in the 1994/95 summer period. The widest coverage of the MNF campaign was achieved through advertising on
television, on posters and on the radio.
Primary prevention of skin cancer in Australia
45
Table 5.6:
Percentage of the sample who were exposed to any advertising
related to sun protection, and who identified it as MNF in 1991/92,
1992/93, 1993/94 and 1994/95
1991/92
%
1992/93
%
1993/94
%
1994/95
%
Saw/heard advertising about sun protection recently
89
93
92
86
Identified it as MNF slogan
80
95
98
88
Effects of the campaign on knowledge
RE
5.3.4.2
A total knowledge
was calculated for each participant in each of the evaluation periods. The proportion of
Acutescore
pain management:
the target groupinformation
who answered
66 per cent (ie two-thirds) or more of the knowledge items correctly significantly
for consumers
increased from 55 per cent in 1991/92 to 80 per cent in 1992/93, but a slight deterioration was evident in 1993/94
and 1994/95 (73 per cent and 76 per cent with 66 per cent or more correct answers, respectively). This suggests
that the overall knowledge of this target group is high but may have reached a ceiling where further increases in
knowledge may be difficult to achieve.
SC
Knowledge about specific issues, such as the number of Australians who die of skin cancer, and of the association
between skin colour and the likelihood for developing cancer remains poor across the years. Furthermore, there
was significant deterioration in knowledge regarding how common skin cancer is in Australia and about the
length of time an average Australian can stay unprotected in the sun without burning. It is evident that future
campaigns should focus on specific items of knowledge where there has clearly been no improvement.
Effects of the campaign on attitudes
IN
5.3.4.3
DE
A total attitudes score was calculated for each person. The highest score (5) was given if the person gave the
‘desirable’ response, and the lowest score (1) was given if the response was the ‘undesirable’ response. The results
indicate a significant reduction in the proportion of the sample who scored in the bottom third of the attitude
scores from 16 per cent in 1991/92 to only 1 per cent in 1992/93 and 1993/94 and to 2 per cent in 1994/95. There
was also a significant improvement in the proportion of adolescents with very positive attitudes (top third of
attitudes scores) from 42 per cent in 1991/92 to 57 per cent and 58 per cent in 1992/93 and 1993/94, respectively.
However, this was not maintained following the campaign in 1994/95, with a reduction to 51 per cent. These
results suggest that while significant improvements have been observed in attitudes, the level of positive attitudes
remains relatively low, with less than two-thirds of the target group recorded as having highly positive attitudes
about sun protection and skin cancer issues.
D
With respect to comparison across the years of responses to individual items, significant deterioration of desirable
attitudes occurred in five items relating to the use of sun protection, reflecting a possible decrease in the desire to
use hats, sun protective clothes and zinc. Furthermore, there has been a progressive increase since 1992/93 in the
proportion of the sample who indicated that covering up in the sun is too much hassle. This suggests that further
efforts are required to make sun protective gear (eg hats, clothing, sunscreen) more accessible and desirable for
this target group, in an effort to reduce the perceived ‘hassle’ factor in using it.
The data suggests that there may have been a significant decrease in parental efforts to encourage sun protection,
with reductions of 8 per cent and 7 per cent respectively in the proportion of adolescents reporting that their
parents tell them to protect their skin from the sun, and that their parents always take sunscreen along on family
outings and use it. This decline is of concern given the potential for parents to have an important influence on their
children’s behaviour both by role modelling and by actively encouraging the desired behaviour. Future campaigns
may consider focusing on this dimension.
There is an apparent decrease in adolescents’ perceptions of the severity of skin cancer and their likelihood of
developing it, as reflected by deterioration in four of the attitude items. This is also of concern given the increasing
rates of skin cancer in Australia.
Primary prevention of skin cancer in Australia
46
5.3.4.4
Effects of the campaign on sunburn/suntan
These issues have only been assessed since 1993/94. In 1994/95, 40 per cent of the sample indicated that they had
a sore or tender sunburn during the summer, compared to 49 per cent who reported this in 1993/94, suggesting an
improvement in behaviour which resulted in sunburn.
There has been no change since 1993/94 in the proportion of the target group who indicated they would try to get
a medium to dark tan next summer. Significantly more adolescents indicated they would not even think about
tanning next summer (20 per cent in 1994/95 compared to 14 per cent in 1993/94). Although there were no
measurable changes in attitudes relating to tanning, it appears that intentions regarding tanning may be improving
over time. However, the significant decrease in the proportion of the target group indicating that they will try to
protect themselves from the sun as much as possible, suggests that more effort is warranted to reduce the ‘hassle’
involved with sun protection by this target group.
RE
5.3.4.5
management: on sun protection
Effects ofAcute
thepain
campaign
information for consumers
The percentage of participants who were using a high level of sun protection during exposure periods (ie when
outdoors and when it was not raining) is summarised in Table 5.7. Sun protection was defined as adequate if a
protection score of 12 or more out of a maximum of 16 was obtained from the diary measure.
SC
The reported results indicate that the campaign was associated with a number of improvements in the levels of sun
protection in subsets of the target group. The most notable trend in the data across the four time periods is a progressive
improvement in the sun protection levels of female adolescents, with a 10 per cent increase in the proportion of
females aged 14–16 years who used adequate sun protection in 1994/95 compared to the previous year; and a 7 per
cent increase in the overall proportion of females who used adequate sun protection in 1994/95 compared to the
previous year.
5.3.5 Implications for prevention
IN
The proportion of adolescents rated as ‘highly protected’ increased annually from 39 per cent in 1991/92 when the
campaign started, to 57 per cent in 1994/95, suggesting the important contribution of this campaign in increasing
protection amongst adolescents. However, the overall level of sun protection remains less than optimal, reinforcing
the need for further efforts to target this group.
While the ‘Me No Fry’ program has focused on 11 to 16 year old adolescents, there is certainly a need for
programs to begin targeting much younger children. The ideal is to make sun protection a normal part of life
for youth and this is most likely to occur if they learn to apply it habitually from an early age.
•
Further work is needed to facilitate sun protection in different settings, so that it is not associated only with
being outdoors in recreational settings. Hence, a focus on schools and pre-schools is important. However,
more effort is required in the area of policy implementation in schools and sporting clubs, where youth in
particular spend a large proportion of their time.
•
The results of the MNF evaluations suggest that males and females have responded at different levels to the
messages. Furthermore, consideration of the barriers to using protection suggests that these may be different
for males and females. It may be appropriate to tailor some of the sun protection messages specifically for the
different genders, especially with respect to making sun protection items, such as hats, more ‘trendy’ for the
female adolescents. The evidence suggests that there is already a high use of hats (caps) by male adolescents.
The use of appropriate role models may be a useful strategy for promoting sun protection in this group.
•
The cancer organisations have always promoted sunscreen as an adjunct to other forms of sun protection such
as hats, clothing and shade; hence the value of promoting shade and/or staying out of the sun. This is
particularly important in public and recreational settings, such as parks, swimming pools, sports fields, etc.
Various activities to encourage provision of shade by local councils are currently underway. More efforts are
required in these areas to facilitate sun protection at the community as well as at the individual level.
•
Activities such as the National Skin Cancer Action Campaign (formerly National Skin Cancer Awareness
Week) are a good way of focusing media attention on sun protection issues. However, it is important that this
be recognised as a focus for promotions, rather than as the week for undertaking the sun protection programs.
As suggested earlier, the greatest benefits are likely to be achieved if sun protection is seen as appropriate in
a range of settings and throughout the year.
D
DE
•
Primary prevention of skin cancer in Australia
47
Table 5.7:
Percentage of adolescents with exposure periods who used a high
level of protection in 1991/92, 1992/93, 1993/94 and 1994/95, ie score
of 12/16
1991/92
%
1992/93
%
1993/94
%
1994/95
%
53
59
63
62
49
51
1
56
2
59
11–13 years:
Male
Female
45
Total
47
55
57
42
46
583
57
23
39
4
5,6
5414
31
427
528
56
48
52
609
59
36
43
4810,11
5515
39
4712
5413
57
Male
RE
14–16 years:
Female
Total
Acute pain management:
information for consumers
44
Combined age groups:
Male
Total
SC
Female
Significant difference between males & females 11–13 years in 1993/94 (Z = 4.39).
2
Significant difference from 1991/92 to 1992/93 (Z = 3.19).
3
Significant difference from 1992/93 to 1993/94 (Z = 4.71).
4
Significant difference from 1991/92 to 1992/93 (Z = 3.44).
5
Significant difference from 1991/92 to 1992/93 (Z = 4.43).
6
Significant difference between males & females 14–16 years (Z = 5.41).
7
Significant difference from 1991/92 to 1992/93 (Z = 3.40).
8
Significant difference from 1992/93 to 1993/94 (Z = 5.35).
9
Significant difference from 1992/93 to 1993/94 (Z = 4.20).
10
Significant difference from 1991/92 to 1993/94 (Z = 3.67).
11
Significant difference between males & females (Z = 6.38).
12
Significant difference from 1991/92 to 1992/93 (Z = 3.48).
13
Significant difference from 1992/93 to 1993/94 (Z = 4.99).
14
Significant difference from 1993/94 to 1994/95 (Z = 3.02).
15
Significant difference from 1993/94 to 1994/95 (Z = 2.86).
D
DE
IN
1
5.4 Case Study 3: Evaluation of Interventions to Improve Solar
Protection in Primary Schools (Girgis et al., 1993)
A study was undertaken in New South Wales to: (a) develop an accurate and valid self-report diary to assess the
prevalence of solar protection behaviours in school children aged 9 to 11 years; (b) assess the differential
effectiveness of two interventions aimed at changing the knowledge, attitudes, and solar protection behaviours of
this age group, compared to a control group; and (c) identify predictors of use of a high level of solar protection.
The study was conducted using a randomised control trial with 648 students from Years 5 and 6 from 11 government
schools in the Hunter Region of New South Wales. The students’ ages ranged from 9 to 11 years. There were two
intervention (intensive and standard) groups, and a control group. Each selected school was randomly allocated to
one of the treatment groups. Student numbers in each group were n=247 (intensive intervention), n=180 (standard
intervention) and n=185 (control).
Primary prevention of skin cancer in Australia
48
The intensive intervention consisted of the SKIN SAFE program, developed by the New South Wales Cancer
Council in collaboration with the New South Wales Department of School Education. One aim of this program
was to assist children to increase knowledge levels, and to develop the attitudes and skills to reduce their risk of
skin cancer. The program was run over a four week period as part of the school curriculum. The standard intervention
consisted of a 30 minute lecture by a New South Wales Cancer Council education officer that was delivered to all
classes in this treatment group. Students in the control group received no intervention.
A written questionnaire was used to assess students’ knowledge and attitudes regarding skin cancer and solar
protection issues. Solar protective behaviour was assessed using a solar protection diary, which was developed
and validated during a pilot study. Information was collected at pre-test, and two post-test periods (four weeks and
eight months after pre-test).
RE
Students in the intensive intervention group were significantly more likely to have used a high level of solar
protection at both post-test periods than were the control and standard intervention groups. There was no significant
difference between theAcute
levelpain
of management:
solar protection in the standard intervention and control groups. This suggests that
the minimal intervention
was
not
effective in changing students’ solar protection behaviour.
information for consumers
Significant predictors of high solar protection levels at both post-test periods were intervention group status (higher
in intensive intervention), and baseline level of solar protection (higher when baseline level of solar protection
was high). Students with an increased number of opportunities to protect themselves were less likely to do so at
the second post-test period.
SC
5.4.1 Implications for prevention
As for Case study 2.
•
Given that the history of sun safe behaviours is related to further increases in preventive activities, sun
protection should be encouraged at a very young age in order to facilitate continued protection as children get
older.
•
Intensive and comprehensive interventions may be more effective in improving sun protection practices.
School communities (including staff, students and parents) should be encouraged to implement comprehensive
approaches to health education, including sun protection. A number of initiatives may be important.
IN
•
The potential effectiveness of the model of the health-promoting school is currently being evaluated in
New South Wales in a grant funded by the NHMRC. This model has the potential to empower the schools
to tailor policies and practices to meet their specific needs.
–
The Department of School Education in New South Wales has developed a memorandum for schools,
which includes guidelines to assist them to implement the student welfare policy. Such endorsement of
sun protection policies as part of an overall welfare policy in schools should be encouraged and
facilitated.
–
Agencies producing resources for schools should consider providing some level of training to optimise
the uptake and use of resources by teachers.
D
DE
–
5.5 Projects Recently Completed: Skin Cancer and Teenagers
(SCAT) Project
5.5.1 Introduction
The Skin Cancer and Teenagers (SCAT) Project is an intersectoral intervention which provides some guidelines
for rigorous evaluation of primary prevention interventions. Preliminary studies with primary and secondary
school students showed that knowledge of skin cancer and necessary preventive measures was extremely high,
even among the youngest students. However, skin protection behaviours were not uniformly practised (Lowe et
al., 1993) leading to concerns about the need to educate young people about over exposure to the sun. The project
involved Central and Regional Education Department personnel, University of Queensland researchers, the
Queensland Cancer Fund, and Central and Regional Health Department personnel.
Primary prevention of skin cancer in Australia
49
The project was originally funded by Queensland Health as a two and a half year school-based intervention study
which tracked Year 8 students in 1992 through to the beginning of Year 10. Subsequently, an extension to the
original project of equal duration was funded by the NHMRC through the Public Health Research and Development
Project Grant Scheme. The projects were designed to track the entire secondary school career of the 1992 cohort
through to the end of 1996. Only the original project, funded by Queensland Health, is reported here. The aims of
the study were to:
•
Determine the short-term (three months post-intervention) effect of an educational intervention on the use of
sunscreen, hats and other protective clothing, shade and avoidance of sun during peak hours by students; and
•
Assess the impact of the intervention on specific knowledge, self-awareness, self-image, self-efficacy and
interpersonal decision making skills.
RE
5.5.2 Methods
Acute pain management:
The study was based on a matched design involving 26 State government high schools of which 13 were randomly
information for consumers
allocated to an intervention group and 13 to a control group. A total of 3 341 students participated in the study.
Schools were matched according to geographic location, size, and socioeconomic status. The evaluation format
adopted a pre- and post-test design. Students entering their first year of high school (Year 8, approximately 13
years old) in 1992 constituted the cohort which was tracked into the beginning of Year 10.
SC
The primary theoretical influence was drawn from the Health Belief Model, Social Cognitive Theory and Stages
of Change, although aspects of a range of other behavioural theories and evaluation research were included. The
lesson program incorporated the concepts of severity, susceptibility, consequences, barriers and benefits, selfefficacy, modelling, reinforcement, and the stages from pre-contemplation to maintenance. In addition,
characteristics of youth and the school environment were considered important to the development of the resources.
The intervention consisted of two skin cancer prevention lessons to be introduced sequentially in the first two
years of high school (grades 8 and 9) when the average student age is 13 to 14 years.
IN
Grade 8 Teaching Module: The grade 8 teaching resource focused on cognitive strategies designed to capitalise on
the habits reinforced in primary schools, largely as a result of the ‘no hat, no play’ policies.
DE
Grade 9 Teaching Module: The preliminary research pointed out the increasing role of peer pressure and interests
in personal image during grade 9. As a result, the focus was on personal self-image and the role of the mass media
in favouring certain images.
The intervention modules were delivered by the regular classroom teachers (n=39) following inservice training
workshops. Long-term behavioural evaluation data (intervention and control schools) and short-term impact data
(intervention schools only) were collected throughout the study, concluding early in the cohort’s Year 10. The
focus of these measures was on the long-term objectives of the study in the areas of behavioural intentions and
change, and attitudinal shifts; few knowledge based items were included in these measures.
D
The outcome surveys were administered twice each year, prior to the term 4 intervention and at the start of the
next school year.
Process measures included: (a) in-class observer feedback obtained through the use of independent observers who
sat in on a random number of pre-assigned classes across all intervention schools; (b) school background surveys
completed by the heads of the department in each intervention school and by the project coordinator in the control
schools which included information on the general background of each school and the level of sun safety policy
development and implementation; and (c) outdoor class activity observations conducted by teacher aids or other
teaching staff in intervention and control schools at the beginning of term 4 each year. The purpose of this was to
provide an indicator of sun safety behaviour in relation to outdoor physical education classes.
In the interest of maintaining the integrity of the study, a range of confounding variables were considered throughout
the study. These included the operation of concurrent skin cancer prevention initiatives within communities. In
order to minimise this effect, the research team entered into an agreement with the key organisations for skin
cancer prevention, being Queensland Health and the Queensland Cancer Fund, which highlighted the importance
of maintaining a State-wide focus for any campaigns. In addition, networks were set up to identify any research
projects which may affect the study.
Primary prevention of skin cancer in Australia
50
To address the possibility that the weather may provide an important intervening variable, weather reports were
obtained. These reports contained information regarding temperature, cloud cover and rainfall, and were obtained
from the participants, and also from the Bureau of Meteorology where possible.
The impact variables consisted of short-term knowledge and attitude items which were investigated separately. In
order to analyse the outcome variables which were primarily related to sun protection behaviour, students were
asked about their use of hats, sunscreen, shade and long sleeves for specific periods of the day (before 9am,
9am–12 noon, 12 noon–2pm, 2pm–4pm and after 4pm). Two days in particular were targeted, Sunday and Monday,
to assess behaviour both on weekends and at school. From these responses, a Sun Protection Behavioural Index
(SPBI) for the weekend and one for school was created for each student with a possible scale of 0 (bad sun
protection behaviour) to 100 (excellent sun protection behaviour). Repeated measures analysis was performed on
the mean SPBI for Year 9 and Year 10 with ‘schools’ as the unit of measurement.
RE
5.5.3 Results (to
date)
Acute pain management:
information
forYear
consumers
Overall, intervention lessons
for
8 and Year 9 were well received. Teachers commented that the lessons were
able to accommodate a range of student ability and were well pitched to student level. Compliance was high for
both the Year 8 and Year 9 intervention lessons. Each in-class observer used a checklist to monitor the teaching of
each component of the lesson.
SC
In terms of impact evaluation, intervention and control groups were compared on a number of knowledge and
attitude items (which were specific to the Year 8 intervention) at baseline (Year 8, September 1992) and appeared
similar in terms of the variables of interest. However, the intervention group performed consistently better than
the control group following the Year 8 intervention. Similarly, those in the intervention group performed considerably
better than those in the control group following the Year 9 intervention. Looking specifically at the intervention
group before and after the Year 9 intervention (a within group comparison), a significant improvement was found.
IN
The Sun Protection Behavioural Index (SPBI) was calculated for Sunday (weekend behaviour) and Monday
(behaviour at school) separately. An increase in the SPBI indicates improvement in sun protection behaviour.
Preliminary analysis of outcomes showed a potential behavioural effect, predominantly between students moving
from Year 8 to Year 9.
DE
5.6 Projects in Progress: Cancer Action in Rural Towns (CART)
Project
D
The CART project, a research project which is jointly funded by the NHMRC and the New South Wales Cancer
Council, is being undertaken by the Cancer Education Research Program (CERP) team in Newcastle, New South
Wales. The primary aim of this project is to explore the effectiveness of a community action program designed to
increase community rates of preventive and screening behaviours relating to breast, cervical, smoking-related and
skin cancers. Twenty rural New South Wales communities have been selected for inclusion in the study and
randomly assigned within pairs to either control or intervention groups. The intervention program involves working
through Cancer Council facilitators who are allocated to each of the intervention towns, to encourage communities
themselves to initiate and control the intervention process and to utilise existing networks in order to promote
long-term structural changes.
The intervention, which is two years in duration, was due for completion at the end of 1996. The effectiveness of
the community action program in improving the rates of sun protection in the intervention towns compared with
the control towns will be assessed by comparing baseline versus post-intervention levels of sun protection, assessed
in a number of ways:
•
School based surveys—surveys of adolescents in high schools will be undertaken to determine changes in the
levels of sun protection and related knowledge and attitudes; and
•
Direct observation—changes in weekend sun protection behaviour of community members will be assessed
by direct observation at outdoor recreational areas such as parks, swimming areas and sports fields.
Post-test data collection is scheduled to be undertaken during January to March 1997.
Primary prevention of skin cancer in Australia
51
5.7 International
5.7.1 Overview
RE
In Australia and overseas, the majority of primary prevention interventions have been effective in increasing
knowledge or awareness (Borland, 1990; Girgis, 1993; Mermelstein & Reisenberg, 1992), and changes in attitudes
are not unusual across studies, although attitudes towards tanning appear to be particularly resistant in overseas
studies. The (social) benefits of a tan appear to outweigh the perceived costs (Miller et al., 1990). Among the few
evaluated interventions, modest levels of behaviour change have been reported (Borland et al., 1991; Girgis et al.,
1994; Lombard et al., 1991; Taylor et al., 1982). Most of these studies claim behaviour change in the very short
term, but in Australia, longer-term behaviour changes are now evident (see Table 5.3). Self-reported changes in
protective behaviours are more commonly reported than objective measures (Buller & Buller, 1991; Cameron &
McGuire, 1990; Ramstack et al., 1986).
Acute pain management:
SC
Knowledge-based
methods
have had limited success in changing attitudes and behaviour related to adolescent
information
for consumers
tanning (Arthey & Clarke, 1995). Adolescents have high knowledge levels, especially in Australia (Lowe et al.,
1993), but this knowledge tends not to translate into comparable levels of protective behaviour (Cockburn et al.,
1989). Level of knowledge of skin cancer or sun protection is not a strong predictor of intention to get a tan, nor
of actual suntan level attained (Arthey et al., 1993). Knowledge has been associated with increases in self-reports
of sun protection, but may be an artefact of social desirability rather than true increases in sun safe behaviour
(Bennetts et al., 1991).
IN
Perceptions of the negative consequences of sun exposure are considered too far in the future to invoke appropriate
behaviour change in the general community. In general, the community, especially young people, tends to attribute
greater salience to short-term risks compared to long-term risks (Svenson, 1984). Skin cancer prevention messages
may be more effective if promoted in terms of a reduced time-frame (less than 10–15 years) for consequences,
with increased urgency regarding the short-term dangers and more immediate rewards for covering up. Studies of
sun exposure in different health contexts suggest that the size of the reward appears to be less important than its
immediacy (McReynolds et al., 1983).
Studies conducted overseas have implications for the development of Australian programs, in particular, the
selected studies reviewed below. More detailed information on some of these programs is available in reviews by
Arthey and Clarke (1995), Loescher et al. (1996) and Morris and Elwood (1995).
DE
In summary, there have been a number of international studies that have evaluated intervention programs designed
to improve the sun protection behaviours, knowledge and/or attitudes of the target audience. These programs,
often aimed at a specific subgroup of the population, have used a variety of media to convey their message. Some
programs are designed to influence whole communities through mass media, while others rely on a single lecture
or video presentation.
D
The reported success of these international programs is varied. Significant improvements in behaviour and attitudes
have been reported following the majority of intervention programs. However, the evaluation of some programs
is restricted by difficulties in the study design, for example, lack of a control group or follow-up assessment. A
summary of the intervention programs conducted overseas is presented in the following tables.
Primary prevention of skin cancer in Australia
Staff of 674 nursery schools
in Sweden.
275 mothers of healthy
newborns in Yale, USA.
Students in grades 4–6 from
Arizona, Pre (n=162), post
(n=124) and follow-up
(n=137).
Community members
of four Texas cities
Pre (n=250) and post
intervention.
1 261 primary school
children aged 9–12 from
England.
543 adolescents (12–16 years)
from seven schools in England.
Bolognia et al.,
(1991)
Buller et al.,
(1994)
Boutwell, (1995)
Fidler & Lambert,
(1995)
Hughes et al.,
(1993)
Sample and settingy
Boldeman et al.,
(1991)
Authors (Year)
P
G
G
G
Cat
PE
L
G
G
M
T
Q
D
D
D
S
D
S
Q
Q
T
Post-test
only.
Control, low/
high level
intervention
(longitudinal).
Control/
intervention,
pre, post and
follow-up
(longitudinal).
B
ABK
Design
K
Mod DCM Mea
ABK
AK
B
Control/four
interventions,
pre-post
(longitudinal).
Control/
intervention.
pre-post
(longitudinal).
Pre-post
community
intervention
(cross-sectional).
Lectures,
mailed
material.
Intervention
Workbook,
video, posters,
discussions.
One health
education
lesson of 30
minutes.
UV readings,
risk reduction
messages.
School
curriculum over
5 weeks in 50
minute sessions.
Brochures,
sunscreen, hats.
information for consumers
M
OP
P
PL
Med
International intervention studies
Acute pain management:
D
DE
IN
SC
RE
Table 5.8
• Difference in knowledge and
attitudes compared with control
group.
• No difference in reported
behaviour.
• Behaviour associated with
attitude.
• Increases in skin cancer
related knowledge and
attitudes.
• No behaviour change.
• Sun avoidance increased.
• No change in reported
sunscreen, hat or clothing use.
• No control group.
• Knowledge and attitudinal
change.
• Less behavioural change.
• Both interventions reduced
amount of time newborns and
mothers in sun, and the amount
of unprotected time in the sun.
• Face to face more effective
in increasing sun awareness
than mailed information alone.
Findings/Limitations
52
Primary prevention of skin cancer in Australia
318 students from three
elementaryschools in
Tucson, USA.
150, four year olds from 12
preschools/day-care centres
in Arizona.
Swimmers at two private pools
in Virginia.
286 (pre) and 345 (post)
students from 10 schools in
New Zealand.
1 703 adolescents from schools
in Chicago.
Loescher et al.,
(1996)
Lombard et al.,
(1991)
McGee &
Williams, (1992)
Mermelstein &
Riesenberg, (1992)
Cat
G
G
Med
P
O
D
Primary prevention of skin cancer in Australia
EL
P
PO
G
P
G
S
Q
D
S
D
D
Q
M
O
Q
ABK
Mod DCM Mea
Design
ABK
B
B
AK
Intervention
Control/t2
interventions,
pre-post-followup (longitudinal).
Leaflets, posters.
Poster,
brochures,
lifeguard.
Curriculum.
Control/
Video on
intervention, predangers of skin
post (longitudinal). cancer.
Pre-post
intervention
(cross-sectional).
Pre-post
intervention
(cross-sectional).
Intervention/
control, pre-post
(longitudinal).
Sunsafety
fair/one lesson.
information for consumers
DE
cited in Loescher
et al., (1995)
Sample and settingy
Acute pain management:
IN
SC
Authors (Year)
International intervention studies (continued)
RE
Table 5.8
• Knowledge and perceived
susceptibility to skin cancer
increased.
• No change in behavioural
intentions.
• Sun protection scores increased.
• 44% reported sunbathing less
often.
• 56% reported using sunscreen
more.
• Children, adolescents and adults
increased their use of sun
protective behaviours.
• Significant effects on
knowledge and comprehension
components of cognition.
• No evidence of behavioural
change.
• Both interventions had greatest
effect on knowledge.
• Full length version better than
one day version on attitudinal
change.
• No intentions to change
behaviour were reported at
immediate follow-up, few
behavioural changes after 3 months
Findings/Limitations
53
DCM Data collection method:
Mea Measures:
Med Medium:
Cat Catchment:
Mod Modality (target):
1 016 beachgoers on three
beaches on Rhode Island.
1 042 patients with non-melanoma PL
removed, USA.
Robinson, (1992)
G
G
PE
G
I
Q
M
D
D
D
S
I
B
Mod DCM Mea
Pre-post
community
intervention
(cross-sectional).
Design
Interventions at 2
weeks, 2 months
and 6 months
(longitudinal).
B
Cross-sectional.
Pre-post
intervention
(longitudinal).
ABK
B
Comic book.
Intervention
• Change in knowledge and selfreported behaviour in respect to
skin cancer prevention.
Variety.
• Results not yet available.
Written materials, • 56% changed habits of outdoor
discussions, skin activities.
examination.
• 62% started to use sunscreen.
Knowledge
awareness based
curricula.
• A substantial proportion of
readers improved sun protection
behaviour after reading the comic
book.
• Knowledge levels increased.
• No control group.
Findings/Limitations
M=Mass media; P=Print; E=Electronic; L=Lecture/oral presentation; O=Other
I=Individual; G=Group; C=Community; P=Population
S=Strengthen community action; E=Enable, mediate, advocate; D=Develop personal skills; R=Reorient health services;
B=Build healthy public policy
I=Interview; T=Telephone survey; M=Mail survey; Q=Questionnaire (personally given to respondent); O=Observation
C=Contemplation; B=Behaviour; A=Attitude; K=Knowledge; I=Intention
D
DE
P
C
Cat
information for consumers
Rossi et al., (1994)
Students (Grades 4–8) from
Arizona schools.
Ramstack et al.,
(1986)
P
Adults interviewed in Hawaii
pre (n=318) and post (n=304)
intervention.
Putnam &
Yanagisako, (1985)
Med
Sample and settingy
Authors (Year)
International intervention studies (continued)
Acute pain management:
IN
SC
RE
Table 5.8
54
Primary prevention of skin cancer in Australia
55
5.8 Recommendations
It is recommended that:
12. Australian schools (secondary and primary) and child care services that have not already done
so should implement policies which facilitate a comprehensive approach to sun protection,
including teaching sun protection in the class room, reducing exposure during outdoor activity,
involving teachers, parents and the community in sun protection and environmental changes
(ie in a manner consistent with the notion of health promoting schools).
RE
13. State governments support the monitoring and publishing of information on the adoption and
implementation of sun protection policies and programs by schools, child-care services,
community
organisations and local services (eg sporting clubs).
Acute pain management:
SC
information
for consumers
14. Studies
be funded
to further test the benefits of multifaceted, comprehensive strategies such as
policy development and implementation, intersectoral collaboration, educational strategies,
media strategies, and economic incentives in availability of protective products and aids, and
further inform the development of best-practice principles. This will involve more extensive
evaluation and research on innovative programs as well as more traditional intervention
studies. Single approaches, like one classroom lesson, or a pamphlet or even one advertisement
in the absence of other strategies are not recommended.
15. Sun protection programs focus on the development of strategies to ensure that changes are
sustained in the longer-term, particularly for those subgroups within the population (such as
adolescents) who are placing themselves at risk.
IN
16. Research projects be funded to investigate the long-term impact of intervention programs
shown to be effective in the short term.
17. Studies be undertaken to ascertain the feasibility of disseminating information from successful
sun protection interventions, and of adapting comprehensive programs to new settings.
DE
18. Research in the field of skin cancer be undertaken to address the effect of policies regarding
exposure to the sun. This needs to be documented to provide information about the impact of
sun safe policies on sun exposure by the individual, group or community.
19. All Government departments (Commonwealth and State) review their programs to determine
their contribution to sun safety in their workforce and the community.
20. Sun protection programs continue their intersectoral effort to generate those environmental
and structural changes, eg shade creation and rescheduling sporting events, that facilitate
protective behaviours.
D
21. Sun protection program managers place greater priority on program evaluation (at a level
relevant to the size of the program), including pre- and post-intervention monitoring (see
Recommendation 8).
Primary prevention of skin cancer in Australia
57
Section Six
Conclusions
6.1 Introduction
RE
The specific terms of reference for the Sun Protection Programs Working Party were to:
Acute pain management:
Review and
reportforonconsumers
the state of scientific knowledge;
information
•
Identify gaps in knowledge, research needs and preventive action;
•
Identify the special needs of high risk population groups, as well as the needs of the general population;
•
Review and determine measurable and qualitative indicators of program performance;
•
Recommend guidelines for evidence-based best practice;
•
Advise on the administrative and legislative options to implement recommendations; and
•
Assess the implications of recommendations for workforce development.
SC
•
The purpose of this chapter is to summarise the Working Party’s conclusions with respect to these terms of reference.
IN
6.2 Directions for Preventive Action
DE
The epidemiology of the effects of sunlight confirms the link between exposure to sunlight and a number of health
effects, most importantly, skin cancer and eye disease. Clearly, childhood exposure is an important cause of skin
cancer. Prevention of exposure in the early stages of life is likely to have a greater impact on the incidence of skin
cancer than strategies to reduce exposures in adulthood, though programs targeting adults are also required.
D
The epidemiological evidence also provides important points for the development of programs. The nature of the
exposure to solar radiation is important. The intermittent exposure hypothesis for the relationship of sunlight to
melanoma suggests that infrequent exposure of untanned skin to intense sunlight increases the risk of melanoma.
Therefore, as the total exposure level of the community is reduced, care must be taken in sun protection programs
to remind the community of the risk associated with high and intermittent exposure. In terms of health promotion,
the occurrence of sunburn provides immediate feedback to the individual about their harmful exposure. On a
longer time frame, naevi may provide early biological markers of subsequent risk of melanoma.
6.3 Indicators of Program Performance
The fundamental aim of sun protection campaigns is to reduce the population’s exposure to the sun. Along with
measures of the occurrence of the disease, measures of exposure to the sun and sun protection behaviours are key
indicators of program performance. Australia (and other countries) has not established agreement on standard evaluation
measures, nor on the interpretation of existing measures. Clearly, further research and discussion are required to
establish national benchmarks for the purpose of program evaluation. Further, a national evaluation framework
needs to be developed that includes short, medium and long-term program measures. Appendix A includes such a
framework developed by New South Wales Cancer Council and New South Wales Health. Information was provided
on all major sun protection programs currently undertaken in Australia. One of the disappointing aspects of the
information provided was the patchy level of program evaluation. Where programs are truly innovative, there is a
need for more than the usual resources for evaluation and research to help better understanding of how they work.
This is important both for facilitating adaption to new contexts and for further refinement of strategies.
Primary prevention of skin cancer in Australia
58
6.4 Evidence-based Practice for Facilitating Behaviour Change
To encourage changes in skin protection behaviours that will result in reduced UV exposure requires a mix of
educational and structural programs. There is a broad consensus that people should minimise time in the sun
during the peak UV hours [about 2 hours each side of true (solar) noon], but when they do go out, they need to
protect themselves with clothes, hats, sunglasses, sunscreens and use of shade. Combinations of these measures
are particularly important when the period of exposure is likely to be long and/or the ambient UV levels are high.
If people need to be outside for most or all of the four hour period around solar noon, they may need to take
extraordinary care, using total blockout (eg zinc cream) on the most exposed areas (eg nose) as well as adopting
all other practical protective measures.
RE
Behaviour change can be facilitated by providing resources and structures, and appropriately organising activities.
Providing shade at and over outdoor venues, making sure sunscreen is available and scheduling outdoor events
away from peak UV periods are examples. Such structural changes make it easier for people to behave in sun
Acute pain management:
protective ways. However, unless there are education programs to motivate such behaviour, there is a risk that
for consumers
people will not use theinformation
sun protection
opportunities that have been provided. It should also be recognised that
education campaigns provide the social climate within which structural and policy changes may occur.
SC
In reviewing the empirical evidence of behaviour change, it needs to be understood that measurement of sun
protection behaviour did not occur until some time after the risks were identified and often after programs were in
place. It is likely that there was behaviour change in response to the dangers before any measurement occurred.
Therefore, it may be true that much of the easy to achieve change had occurred beforehand and that we are now
taking measurements during a period in which change is harder to achieve. It would be unwise to assume that
there had been no change prior to measures being taken, especially in a context where programs had been in place
similar to those subsequently associated with or shown to produce behaviour change. Because of the evidence that
sun protection programs can change behaviour, caution is also needed in generalising about findings from times
and places with pre-existing programs in place compared to those without such programs.
DE
IN
Issues related to undertaking an economic evaluation of the sun protection programs were considered by the
Working Party. The primary problems lie in determining the level of reduction in sun exposure required to reduce
the incidence of skin cancer, and the relative contribution of any sun protection programs to that reduction in sun
exposure. These issues need to be assessed in considering the feasibility of undertaking an economic evaluation.
6.5 Administrative and Legislative Options
D
On the one hand, Australia is among the world leaders in efforts to prevent skin cancer. There have been a number
of innovative research studies and comprehensive programs, which set a benchmark for community-wide activity.
On the other hand, much more needs to be done. In Australia to date, there has been no national approach to
primary prevention for skin cancer that includes, amongst others, links between cancer organisations and
government. While specific activities or programs in some communities or States and Territories have been well
planned and implemented, across the country as a whole the application of programs has been ad hoc and limited
in scale.
Not all communities have benefited from participation in programs shown to be effective. The ‘Slip, Slop, Slap’
programs have focused on the protection of children, either directly or through their parents. Similarly, a number
of programs have been targeted towards teenagers and adults. Given the epidemiological evidence of the impact
of exposure in childhood, there is a need to continue to focus on preventing exposure to solar radiation in this age
group.
The Working Party also noted that there are differences across the county in the targets chosen, and in the
comprehensiveness of effort. Furthermore, Australia has limited means by which it may track its progress in the
implementation of prevention efforts. Apart from the evaluated intervention programs reviewed in Section 5 of
this report, evidence of the success of these programs is sparse and inconsistent. Evaluated Australian programs
have demonstrated some changes in sun safe attitudes and behaviours. Such campaigns have built upon existing
community-based efforts and indicate the need for sustained commitment of effort and investment to achieve the
desired community-wide change.
Primary prevention of skin cancer in Australia
59
Evaluated Australian programs have demonstrated some changes in sun safe attitudes and behaviours. Taking
Victoria’s program as a benchmark, significant change is occurring with an annual investment in sun protection
health promotion programs of at least $1 million annually. Extrapolating nationally, the Working Party considers
that a national expenditure on efficacious programs of upwards of $4 million per annum is a threshold level below
which behavioural and social change would not be significant. This represents less than 2.3 per cent of the estimated
direct treatment costs of melanoma and other skin cancers.
6.6 Workforce Development
RE
The emphasis of this report has been on the scientific and technical aspect of coordination and evaluation of sun
protection programs. As such, the evidence considered in the report primarily focuses on program directions. The
framework for intervention in skin cancer prevention is similar to other health promotion programs, and as such is
dependent on the
generic
health promotion skills of the public health workforce. However, skin cancer prevention
Acute
pain management:
is fundamentally
an
intersectoral
issue, and can possibly involve a wide cross-section of the community, including
information for consumers
diverse community organisations. Therefore, skills in implementing sun protection strategies, need to be developed
not only among health professionals but also in the community.
SC
6.7 Recommendations
It is recommended that:
IN
22. Health promotion funding bodies ensure that funding of sun protection programs is at a level
to ensure meaningful changes in the community, beyond a higher profile for the issue. Further,
funding needs to be provided for a sufficient number of years to maintain and improve on the
adoption of sun protective strategies in the community. Dedicated funding to enhance program
evaluation needs to be considered by funding agencies. The evaluation and research budgets
should be supplemented (by Governments if necessary) to ensure that achievements and
processes are well documented.
DE
23. Australian efforts on skin cancer prevention be coordinated through an intersectoral National
Sun Protection Strategy that links Cancer Organisations, State, Territory and Commonwealth
Health Departments and other relevant sectors.
D
24. Assessment of the feasibility of undertaking an economic evaluation should occur based on our
current knowledge of the effectiveness of primary prevention programs. The work must
provide insight into models for economic evaluation that can be applied to current and new
programs. As this is outside the scope of this report, an economist should be commissioned to
conduct this assessment.
25. Commonwealth and State Governments liaise with tertiary institutions and professional
organisations, such as medical faculties and colleges, Divisions of General Practice, the Institute
of Environmental Health, Schools of Education, Architecture, Town Planning, Nursing and
Public Health to incorporate information on sun exposure, sun protective programs, intervention
studies and relevant research into vocational education, training and continuing education.
26. The NHMRC update triennially the available information provided in this report, and its
recommendations.
Primary prevention of skin cancer in Australia
61
Section Seven
Bibliography—Primary Prevention of
Skin Cancer
RE
Agin PP, Levine DJ. Sunscreens retain their efficacy on human skin for up to 8h after application. Journal of
Photochemistry and Photobiology 15:371–4, 1992.
Acute pain management:
information
for consumers
Anderson PJ, Lowe
JB, Stanton
WR, Balanda KP. Skin cancer prevention: A link between primary prevention and
early detection? Australian Journal Public Health 18(4):417–20, 1994.
Anti-Cancer Council of Victoria. SunSmart Evaluation Studies #1, Skin Cancer Control Program 1988–89.
Anti-Cancer Council of Victoria, 1989.
SC
Anti-Cancer Council of Victoria. SunSmart Evaluation Studies #2, Skin Cancer Control Program 1989–90.
Anti-Cancer Council of Victoria, 1992.
Anti-Cancer Council of Victoria. SunSmart Evaluation Studies #3, Skin Cancer Control Program 1990/91, 1991/
2, 1992/3. Anti-Cancer Council of Victoria, 1994.
Anti-Cancer Council of Victoria. SunSmart Evaluation Studies #4, Anti-Cancer Council of Victoria, 1995.
Anti-Cancer Council of Victoria. Sample SunSmart Policy for Primary Schools, Anti-Cancer Council of Victoria, 1995.
IN
Anti-Cancer Foundation. SunSmart advice for Primary schools, Anti-Cancer Foundation, South Australia, 1992.
Anti-Cancer Foundation. Prevention and education secondary schools newsletter, number 1, 1993.
Anti-Cancer Foundation. The Anti-Cancer Foundation Annual Report 1994, Anti-Cancer Foundation, South
Australia, 1994a.
DE
Anti-Cancer Foundation. Prevention and education secondary schools newsletter, number 2, 1994b.
Anti-Cancer Foundation. SunSmart Policy Development for Secondary Schools, South Australia, 1994.
Anti-Cancer Foundation. Skin Cancer Control Program: South Australia, The Anti-Cancer Foundation, 1995.
Armstrong BK, English DR. Cutaneous malignant melanoma. In Schottenfeld D, Fraumeni JF (Eds). Cancer
Epidemiology and Prevention. Second Edition, New York, Oxford University Press, 1996.
D
Armstrong B, Kricker A. How much melanoma is caused by sun exposure? Melanoma Research 3:395–401, 1993.
Armstrong BK, de Klerk NH, Holman CDJ. Etiology of common acquired melanocytic nevi: Constitutional
variables, sun exposure and diet. Journal of National Cancer Institute 77:329–35, 1986.
Arthey S, Clarke V, Hill D. Explaining Adolescent Students: Suntanning Intentions and Behaviour during the
Summer School Holidays. Melbourne: Melbourne Centre for Behavioural Research in Cancer, ACCV, 1993.
Arthey S, Clarke VA. Suntanning and sun protection—A review of the psychological literature. Social Science
and Medicine 40(2):265–74, 1995.
Ashton JF, Laura RS. Environmental factors and the etiology of melanoma. Cancer Causes and Control 4:59–62, 1993.
Astbury J. Estimating the costs of getting a suntan: Perceptions of risk among child care workers and mothers of
pre-school children. Cancer Forum 11(3):85–8, 1987.
Augustsson A, Stiener U, Rosdahl I, Suurkttner P, Weiss J. et al. Associated factors in the prevalence of more than
50 common melanocytic nevi, atypical melanocytic nevi, and actinic lentigines: Multicenter case-control
study of the Central Melanoma Registry of the German Dermatologica Society. Journal of Investigative
Dermatology 102:700–5, 1994.
Primary prevention of skin cancer in Australia
62
Australian Cancer Society. National Cancer Prevention Policy 1993, Australian Cancer Society, 1993.
Australian Institute of Environmental Health (NSW). Sun Protection Policy for NSW, Australian Institute of
Environmental Health (NSW), 1993.
Australian Radiation Laboratory. Solar UVR: Protection by Clothing. Information sheet, Yallambie Victoria, 1994a.
Australian Radiation Laboratory. Materials and Protection against Ultraviolet Radiation (UVR), Yallambie Victoria,
1994b.
Autier P, Dore J-F, Schifflers E, Cesarini JP, Bollaerts A, Koelmel KF, Gefeller O, Liabeuf A, Lejeune F,
Lienard D. Melanoma and use of sunscreens: An EORTC case-control study in Germany, Belgium and
France. International Journal of Cancer 61:749–755, 1995.
RE
Baade PD. Changes in sun-related behaviours and attitudes amongst Queenslanders: 1988/89–1991/92. MMedSc
thesis. University of Queensland, 1993.
Acute pain management:
Baade PD, Balanda KP, Lowe JB. Changes in skin protective behaviour: In a population with the highest incidence
information for consumers
of skin cancer in the world. Cancer Detection and Prevention in press, 1996.
Banks BA, Silverman RA, Schwartz RH, Tunnessen Jr WW. Attitudes of teenagers towards sun exposure and sun
screen use. Paediatrics 89:40–2, 1992.
SC
Bech-Thomsen N, Wulf HC. Sunbathers’ application of sunscreen is probably inadequate to obtain sun protection factor
assigned to the preparation. Photodermatology, Photoimmunology and Photomedicine 9:242–4, 1992/3.
Bennetts K, Borland R, Swerissen H. Sun protection behaviour of children and their parents at the beach. Psychology
and Health 5:279–87, 1991.
Beral V. Epidemiology of skin cancer. In Preventing Cancer. Tattersall M. (Ed.) Australian Professional Publications
61–7, 1988.
IN
Beral V, Robinson N. The relationship of malignant melanoma, basal and squamous cell cancers to indoor and
outdoor work. British Journal of Cancer 44:886–91, 1981.
Berwick M, Chen YT. Reliability of reported sunburn history in a case-control study of cutaneous malignant
melanoma. American Journal of Epidemiology 141:1033–7, 1995.
DE
Berwick M, Fine JA, Bolognia JL. Sun exposure and sunscreen use following a community skin cancer screening.
Preventive Medicine 21:302–10, 1992.
Bissett D, Hannon D, Orr T. Wavelength dependence of histological, physical and visible changes in chronological
UV-irradiated hairless mouse skin. Photochemistry and Photobiology 50:763–9, 1989.
Bladon G, Borland R, Broadstock M, Cardiff D, Fletcher G, Hill D, Johnson L, Kearney M, Marks R, Noy S,
Pfeiffer W, Rassaby J, Reading D, Sweeney M, Theobald T, White V. SunSmart Evaluation Studies #2,
Anti-Cancer Council of Victoria, 1992.
D
Boldeman C, Jansson B, Holm LE. Primary prevention of malignant melanoma in a Swedish urban pre-school
sector. Journal of Cancer Education 6(4):247–53, 1991.
Boldeman C, Ullen H, Mansson-Brahme E, Holm LE. Primary prevention of malignant melanoma in the Stockholm
Cancer Prevention Programme. European Journal of Cancer Prevention 2(6):441–6, 1993.
Bolognia JL, Berwick M, Fine JA, Simpson P, Jasmin M. Sun protection in newborns. A comparison of educational
methods. American Journal of Diseases in Children 145(10):1125–9, 1991.
Bonner M. Report of Work Done and Major Findings of the Local Government Skin Cancer Project: Executive
Summary, Australian Institute of Environmental Health, 1991.
Borland R. Pre and post SunSmart campaign surveys. SunSmart Evaluation Studies 1. The Anti-Cancer Council’s
Skin Cancer Control Program 1988–89, Melbourne, 1989.
Borland R. Public awareness and reported effects of the 1989–90 SunSmart campaign. SunSmart Evaluation
Studies #2. The Anti-Cancer Council’s Skin Cancer Control Program, Melbourne, 1990.
Borland R. 1989 Spring Sun Survey: Preliminary findings. SunSmart Evaluation Studies #2. The Anti-Cancer
Council’s Skin Cancer Control Program 1989–90, Melbourne, 1992.
Primary prevention of skin cancer in Australia
63
Borland R. A summary of Household Survey results 1990–1993. SunSmart Evaluation Studies #3. Anti-Cancer
Council of Victoria, Melbourne, 1994.
Borland R, Hill D, Noy S. Being sunsmart: Changes in community awareness and reported behaviour following
a primary prevention program for skin cancer control. Behaviour Change 7(3):126–35, 1990.
Borland RM, Hocking B, Godkin GA, Gibbs AF, Hill DJ. The impact of a skin cancer control education package
for outdoor workers. Medical Journal of Australia 154:686–8, 1991.
Borland R, Karazija B, Keeler C, Knowles R, Marks R, Murphy B, Noy S, Reading D, Sweeney M. SunSmart
Evaluation Studies #1, Anti-Cancer Council of Victoria, 1989a.
Borland R, Karazija B, Keeler C, Knowles R, Marks R, Murphy M, Noy S, Reading D, Sweeny M. SunSmart
Activities Report: Summer 1988/89, Anti-Cancer Council of Victoria, 1989b.
RE
Borland R, Marks R, Noy S. Public knowledge about characteristics of moles and melanomas. Australian Journal
Acute
pain management:
of Public
Health
16(4):370–5, 1992.
information for consumers
Borland R, Noy S. Public Reaction to the SunSmart Campaign and Reported Sun Protection Behaviour over the
Summer of 1990/91. Anti-Cancer Council of Victoria, Melbourne, 1991.
Borland R, Noy S, Gies P. Public awareness of solar ultraviolet radiation levels (letter). Medical Journal of
Australia 156:28,1992.
SC
Borland R, Pratt K, Noy S. A survey of SunSmart policies and practices among local councils in Victoria. SunSmart
Evaluation Studies #3, Anti-Cancer Council of Victoria, Melbourne, 1994.
Borland R, Theobald T. A picture of sun protection behaviour. Cancer Forum 14:171–4, 1990.
Bourke J, Healsmith M, Graham-Brown R. Melanoma awareness and sun exposure in Leicester. British Journal
of Dermatology 75:657–60, 1995.
IN
Boutwell WB. The under cover skin cancer prevention project: A community-based program in four Texas cities.
Cancer 75:657–60, 1995.
Broadstock M. Sun protection at the cricket. Medical Journal of Australia 154:430, 1991.
DE
Broadstock M, Borland R, Gason R. Effects of suntan on judgements of healthiness and attractiveness in adolescents.
Journal of Applied Social Psychology 22(2):157–72, 1992a.
Broadstock M, Noys S, Borland R. Skin cancer management: Evaluation of a booklet for general practitioners.
Cancer Forum 16(3):161–4, 1992b.
Broadstock M, Borland R, Hill D. Knowledge, attitudes and reported behaviours relevant to sun protection and
suntanning in adolescents. Psychology and Health 11:527–39, 1996.
Buller D, Buller M. Approaches to communicating preventive behaviours. Seminars Oncology Nursing 7:53, 1991.
D
Buller M, Loescher L, Buller D. ‘Sunshine and skin health’: A curriculum for skin cancer prevention education.
Journal of Cancer Education 9:155–62, 1994.
Clarke VA, Williams T, Arthey S. Skin type and optimistic bias in relation to the sun protection and sun tanning
behaviours of young adults. Journal of Behavioural Medicine In press.
Cameron I, McGuire C. ‘Are you dying to get a tan?’ The pre- and post- campaign survey results. Health Education
Journal 49:166, 1990.
Campbell HS, Birdsell JM. Knowledge, beliefs, and sun protection behaviors of Alberta adults. Preventive Medicine
23(2):160–6, 1994.
Cancer Foundation of Western Australia. Skin Cancer Prevention Programs for Young People. Annual Report
1993/94, Cancer Foundation of Western Australia, 1994.
Cancer Foundation of Western Australia. ‘Me No Fry’ Campaign Evaluation, Cancer Foundation of Western
Australia, 1995a.
Cancer Foundation of Western Australia. Skin Cancer Prevention Program for Young People. Final Report
1995, Cancer Foundation of Western Australia, 1995b.
Primary prevention of skin cancer in Australia
64
Cancer Relief Macmillan Fund. Public Attitudes to and Knowledge of Cancer in the UK, Cancer Relief Macmillan
Fund, 1988.
Cappiello M, Dixon H, Borland R. Reaction to the 1994–1995 SunSmart Campaign: Results from a Representative
Household Survey of Victorians, in press, 1995.
Carmel S, Shani E, Rosenberg L. The role of age and an expanded health belief model in predicting skin cancer
protective behaviour. Health Education Research 9(4):433–47, 1994.
Cascinelli N, Krutmann J, MacKie R, Pierotti M, Prota G, Rosso S, Young A. European School of Oncology advisory
report. Sun exposure, UVA lamps and risk of skin cancer. European Journal of Cancer 30A(4):548–60, 1994.
Chapman S, Marks R, King M. Trends in tans and skin protection used by models in Australian fashion magazines,
1982 through 1991. American Journal of Public Health 82(12):1677–80, 1992.
RE
Chen MS Jr, Minton JP, Adams B. Changing college students’ lifestyles in favor of cancer prevention: A case
Acute
pain management:
study. Journal of
Cancer
Education 4(1):49–54, 1989.
information for consumers
Chick J. Sun protection education in Australia: Australian Journal of Dermatology 26:65, 1985.
Clarke V. Secondary school policies and practices regarding sun protection: Victorian data. SunSmart Evaluation
Studies #3. Anti-Cancer Council of Victoria, Melbourne, 1994.
SC
Cockburn J, Hennrikus D, Scott R, Sanson-Fisher R. Adolescent use of sun-protection measures. Medical Journal of
Australia 151:136–40, 1989. Published erratum appears in Medical Journal of Australia 157(3):216, 1992.
Cockerell E, Freeman R, Knox J. Changes after prolonged exposure to sunlight. Archives of Dermatology
84:467–72, 1961.
Cody R, Lee C. Behaviours, beliefs and intentions in skin cancer prevention. Journal of Behavioural Medicine
13:373–89, 1990.
IN
Cole C, VanFossen R. Measurement of sunscreen UVA protection: An unsensitised human model. Journal of the
American Academy of Dermatology 26:178–84, 1992.
Commission of European Communities. Survey: Europeans and the Preventions of Cancer, Commission of the
European Communities, 1987.
DE
Commonwealth Department of Human Services and Health. Better Health Outcomes for Australians: National
Goals, Targets and Strategies for Better Health Outcomes into the Next Century, Australian Government
Printing Service, Canberra, 1994.
Concar D. The resistable rise of skin cancer. New Scientist 23–8, 1992.
Cooke KR, Fraser J. Migration and death from malignant melanoma. International Journal of Cancer
36:175–8, 1985.
D
Cooke KR, Skegg DCG, Fraser J. Socio-economic status, indoor and outdoor work, and malignant melanoma.
International Journal of Cancer 34:57–62, 1984.
Cooke KR, Spears GFS, Skegg DCG. Frequency of moles in a defined population. Journal of Epidemiology and
Community Health 39:48–52, 1985.
Coombs BD, Sharples KJ, Cooke KR, Skegg DCG, Elwood JM. Variation and covariates of the number of benign
nevi in adolescents. American Journal of Epidemiology 136:344–55, 1992.
Cox B. Trends in melanoma and projection of its future burden in New Zealand. In Elwood M & Glasgow H.
Melanoma. The prevention and early detection of melanoma in New Zealand. Cancer Society of New
Zealand, 1993.
Crane LA, Marcus AC, Pike DK. Skin cancer prevention in pre-schools and daycare centres. Journal of School
Health 63:232–4, 1993.
Cruickshanks KJ, Klein BE, Klein R. Ultraviolet light exposure and lens opacities: The Beaver Dam Eye Study.
American Journal of Public Health 82:1658–62, 1992.
Cruickshanks KJ, Klein R, Klein BE. Sunlight and age-related macular degeneration: The Beaver Dam Eye Study.
Archives of Opthalmology 111:514–8, 1993.
Primary prevention of skin cancer in Australia
65
Davidson M. The Mass Media Campaign: 1990–1993. SunSmart Evaluation Studies #4. The Anti-Cancer Council,
Melbourne, 1995.
de Gruijl FR. Action spectrum for photocarcinogenesis. Recent Results in Cancer Research 139:21–30, 1995.
Department of Architecture. University of Queensland. Shade for Public Schools: Planning for Sunsafe Outdoor
Environments in Queensland, Queensland Health, 1995.
Department of the Environment Sport and Territories. Summer Skin Cancer Alert, 1995.
Dennis L, White E, Lee J. Recent cohort trends in malignant melanoma by anatomic site in the United States.
Cancer Causes and Control 4:93–100, 1993.
Devenish-Meares B. Report on the Cancer-Free-Kids Project Evaluation, The Anti-Cancer Foundation of the
Universities of South Australia, 1991.
RE
Diffey BL. Ultraviolet radiation dosimetry with polysulphone film. Radiation Measurement in Photobiology,
Acute pain management:
London, Academic Press, 1989.
information for consumers
Diffey BL. Human exposure to ultraviolet radiation. Seminars in Dermatology 9:2–10, 1990.
Diffey BL. Ultraviolet radiation in medicine. Medical Physics Handbook 11, Bristol, Adam Hilder Ltd, 1992.
SC
Diffey BL, Gibson CJ, Haylock R, McKinlay AF. Outdoor ultraviolet exposure of children and adolescents. British
Journal of Dermatology 134:1030–4, 1996.
Diffey BL, Larko O. Clinical climatology. Photodermatology 1:30–7, 1984.
Diffey BL, Saunders PJ. Behavior outdoors and its effects on personal ultraviolet exposure rate measured using an
ambulatory datalogging dosimeter. Photochemistry and Photobiology 61(6):615–8, 1995.
DiGiovanna J. Prevention of skin cancer due to sun exposure. In Devita V, Hellman S, Rosenberg S (Eds). Cancer
Prevention, Philadelphia: Linppincott, 1–9, 1991.
IN
Dixon H, Borland R. Equity Access and the SunSmart Campaign: Results from Victorians 1992–1995. Centre for
Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Melbourne, 1995.
Dobes WL. Public education: An approach to a skin awareness project using the solar met. Journal of American
Academy of Dermatology 14:676–9, 1986.
DE
Dolin PJ. Ultraviolet radiation and cataract: Review of the epidemiological evidence. British Journal of
Ophthalmology 78:478–82, 1994.
Eaglstein WH, Taplin D, Mertz P, Smiles KA. An all-day test for the evaluation of a topical sunscreen. Journal of
American Academic Dermatology 2:513–20, 1980.
Eaton JW. UV-mediated cataractogenesis: A radical perspective. Documenta Ophthalmologica 88:233–42, 1994–95.
D
Education Department of Western Australia. Sun Protection Guidelines, Education Department of Western
Australia, 1994.
Eiser JR, Eiser C, Panwels P. Skin cancer: Assessing perceived risk and behavioural attitudes. Psychology and
Health 8:393–404, 1993.
Elwood JM, Williamson C, Stapleton PJ. Malignant melanoma in relation to moles, pigmentation and exposure to
fluorescent and other lighting sources. British Journal of Cancer 53(1):65–74, 1986.
English DR, Armstrong BK. Melanocytic naevi in children I. Anatomic sites and demographic and host factors.
American Journal of Epidemiology 139:390–401, 1994.
English DR, Armstrong BK. Cutaneous malignant melanoma. In Schottenfold DR, Fraumeni JF (Eds). Cancer
Epidemiology and Prevention (2nd Edition). New York: OUP, 1996.
Epidemiology and Health Information Branch & Health Advancement Branch. Queensland Sun Survey Summer
1991/1992: Information circular No. 12, Queensland Health, 1994.
Fears TR, Scotto J, Schneiderman MA. Mathematical models of age and ultraviolet effects on the incidence of
skin cancer in the United States. American Journal of Epidemiology 105:420–7, 1977.
Primary prevention of skin cancer in Australia
66
Fidler W, Lambert JW. Fatal Attraction: The Sun and Skin Cancer. The Keith Durrant Project Report, 1995.
Fisher K, Lowe JB, Gillespie AM, Balanda KP, Baade P, Stanton WR. The relationship between Australian students’
perceptions of parental behaviour, school policies and sun protection behaviours. Journal of Health
Education, in press 1996.
Fitzpatrick TB, Sober AJ. Sunlight and skin cancer. New England Journal of Medicine 313(13):818–9, 1985.
Fletcher G, Noy S, Johnson M, Kearney M, Cardiff D. SunSmart Evaluation Studies #3. The Anti-Cancer Council,
Melbourne, 1994.
Foltz A. Parental knowledge and practices of skin cancer prevention: A pilot study. Journal of Paediatric Health
Care 7:220–5, 1993.
RE
Foot G, Girgis A, Boyle CA, Sanson-Fisher RW. Solar protection behaviours: A study of beachgoers. Australian
Journal of Public Health 17(3):209–14, 1993.
Acute pain management:
Friedman LC, Webb JA, Bruce S, Weinberg AD, Cooper HP. Skin cancer prevention and early detection intentions
information for consumers
and behavior. American Journal of Preventive Medicine 11(1):59–65, 1995.
Fritschi L, Battistutta D, Struton GM, Green A. A non-invasive measures of photoageing. International Journal of
Epidemiology 24:150–4, 1995.
SC
Gallagher CH. Sunshine, sunscreens and skin cancer. In Martin Tattersall (Ed) Preventing Cancer. Australian
Professional Publications 72–6, 1988.
Gallagher RP, Elwood JM, Hill GB. Risk factors for cutaneous malignant melanoma: The Western Canada Melanoma
Study. Recent Results in Cancer Research 102:38–55, 1986.
Gallagher RP, Elwood JM, Rootman J, Spinelli JJ, Hill GB, Threlfall WJ, Birdsell JM. Risk factors for ocular
melanoma: Western Canada melanoma study. Journal of National Cancer Institute 74:775–8, 1985.
IN
Gallagher RP, Hill GB, Bajdik CD, Fincham S, Coldman AJ, McLean DI, Threlfall WJ. Sunlight exposure,
pigmentary factors, and risk of nonmelanocytic skin cancer I. BCC. Archives of Dermatology
131:157–63, 1995a.
DE
Gallagher RP, Hill GB, Bajdik CD, Coldman AJ, Fincham S, McLean DI, Threlfall WJ. Sunlight exposure,
pigmentation factors, and risk of nonmelanocytic skin cancer II. SCC. Archives of Dermatology 131:164–
9, 1995b.
Gallagher RP, McLean DI, Yang CP, Coldman AJ, Silver HK, Spinelli JJ, Beagrie M. Suntan, sunburn and
pigmentation factors and the frequency of acquired melanocytic nevi in children. Similarities to melanoma:
The Vancouver Mole Study. Archives of Dermatology 126:770–6, 1990.
D
Garbe C, Buttner P, Weiss J, Soyer HP, Stocker U, Kruger S, Roser M, Weckbecker J, Panzizon R, Bahmer F, et al.
Associated factors in the prevalence of more than 50 common melanocytic naevi, atypical melanocytic naevi,
and actinic lentigines: Multicentre case-control study of the Central Malignant Melanoma Registry of the
German Dermatological Society, Journal of Investigative Dermatology 102(5): 700–5, 1994.
Garland CF, Garland FC, Gorham ED. Rising trends in melanoma. An hypothesis concerning sunscreen
effectiveness. Annals of Epidemiology 3(1):103–10, 1993.
Gies HP, Roy CR, Elliot G. Ultraviolet radiation protection factors for personal protection on both occupational
and recreational situations. Radiation Protection in Australia 10(3):59–66, 1992.
Gies HP, Roy CR, Elliot G, Wang Z. Ultraviolet radiation protection factors for clothing. Health Physics
67(2):131–9, 1994.
Gies HP, Roy CR, Toomey S, Tomlinson D. The ARL solar UVR measurement network: Calibration and results.
SPIE Proceedings, UVR Technology, San Diego, 2282:274–84, 1994.
Giles GG. Skin Cancer: An Australian health hazard. Cancer Statistics, Anti-Cancer Council of Victoria, 1983.
Giles G, Armstrong BK, Smith LR. Cancer in Australia, 1982 (Scientific Publication No. 1) Canberra: Australian
Association of Cancer Registries and Australian Institute of Health, 1987.
Primary prevention of skin cancer in Australia
67
Giles GG, Marks R, Foley P. Incidence of non-melanocytic skin cancer treated in Australia. British Medical
Journal 296:13–7, 1988.
Giles GG, Armstrong BK, Burton RC, Staples MP, Thursfield VJ. Has mortality from melanoma stopped in
Australia? Analysis of trends between 1931 and 1994. British Medical Journal 312:1121–5, 1996.
Gilchrest BA. Sunscreens—a public health opportunity. New England Journal of Medicine 329:1193–4, 1993.
Gilchrest B. Relationship between actinic damage and chronological aging in keratinocyte cultures of human
skin. Journal of Investigative Dermatology 72:219–23, 1979.
Gilchrest B, Szabo G, Flynn E, Goldwyn R. Chronologic and actinically induced ageing in human facial skin.
Journal of Investigative Dermatology 80:81S–5S, 1983.
RE
Gillespie AM, Lowe JB, Balanda KP, Del Mar CB. Qualitative methods in adolescent skin protection. Health
Promotion Journal of Australia 3(3):10–14, 1993.
Acute pain management:
Girgis A, Sanson-Fisher RW, Tripodi DA, Golding T. Evaluation of intentions to improve solar protection in
information for consumers
primary schools. Health Education Quarterly 20(2):275–87, 1993.
Girgis A, Sanson-Fisher RW, Watson A. A workplace intervention for increasing outdoor workers’ use of solar
protection. American Journal of Public Health 84(1):77–81, 1994.
SC
Goldsmith MF. Paler is better, say skin cancer fighters. Journal of the American Medical Association
257(7):893–5, 1987.
Goldstein B, Lesher J. The effect of a school-based intervention on skin cancer prevention knowledge, attitude
and behaviour. Journal of the American Academy of Dermatology 24:116, 1991.
Green A. Incidence and reporting of cutaneous melanoma in Queensland. Australian Journal of Dermatology
23:106–9, 1982.
IN
Green A, Bain C, McLennan R, Siskind V. Risk factors for cutaneous melanoma in Queensland. Research Results
in Cancer Research 102:76–95, 1986.
Green A, Battistutta D. Incidence and determinants of skin cancer in a high-risk Australian population. International
Journal of Cancer 46:356–61,1990.
DE
Green A, MacLennan R, Youl P, Martin N. Site distribution of cutaneous melanoma in Queensland. International
Journal of Cancer 53:232–6, 1993.
Green AC, O’Rourke MGE. Cutaneous malignant melanoma in association with other skin cancers. Journal of
National Cancer Institute 74:977–80, 1985.
Green A, Siskind V, Bain C. Sunburn and malignant melanoma. British Journal of Cancer 51:393–7, 1985.
D
Greenberg ER, Baron JA, Stevens MM, Stukel TA, Mandel JS, Spencer SK, Elias PM, Lowe N, Nierenberg DN,
Bayrd G. The skin cancer prevention study: Design of a clinical trial of beta-carotene among persons at
high risk for nonmelanoma skin cancer. Controlled Clinical Trials 10(2):153–66, 1989.
Grey J. Sun protection activities—the Cancer Council of Tasmania, 1995.
Grob JJ, Guglielmina C, Gouvernet J, Zarour H, Noe C, Bonerandi JJ. Study of sunbathing habits in children and
adolescents: Application to the prevention of melanoma. Dermatology 186:94–8, 1993.
Grob JJ, Gouvernet J, Aymar D, Mostaque A, Romano MH, Collet AM, Noe MC, Diconstanzo MP, Bonerande JJ.
Count of benign melanocytic naevi as a major indicator of risk for nonfamilial nodular and superficial
spreading melanoma. Cancer 66(2):387–95, 1990.
Harding JJ. The untenability of the sunlight hypothesis of cataractogenesis. Documenta Ophthalmologica
88:345–9, 1994.
Harris R. Factors Affecting Sunburn in Primary School Age Children, University of Melbourne, 1991.
Harrison SL, MacLennan R, Speare R, Wronski I. Sun exposure and melanocytic naevi in young Australian
children. Lancet 344:1529–32, 1994.
Health Promotion Unit—NSW Health Department. Saving our Skins: The ‘Me No Fry’ Campaign, 1990–1994
NSW Health Department.
Primary prevention of skin cancer in Australia
68
Herlihy E, Gies PH, Roy CR, Jones M. Personal dosimetry of solar UVR for different outdoor activities.
Photochemistry and Photobiology 60:288–94, 1994.
Hill D. ACCV Sun Survey. Anti-Cancer Council of Victoria, Melbourne, 1988.
Hill D. Preliminary Report on the Sun Protection Beliefs and Behaviours of Melbourne and Sydney Residents.
Victoria: Centre for Behavioural Research in Cancer, 1989.
Hill D, Borland R. Methodological issues in research on primary and secondary prevention of malignant melanoma.
In Mackie RM (Ed). Primary and Secondary Prevention of Malignant Melanoma Pigment Cell. Basel,
Karger 11:1–21, 1996.
Hill D, Rassaby J, Gardner G. Determinants of intentions to take precautions against skin cancer. Community
Health Studies 8(1):33–44, 1984.
RE
Hill D, Theobald T, Borland R, White V, Marks R. Summer Activities, Sunburn, Sun-related Activities and
Acute pain
management:
Precautions Against
Skin
Cancer: A survey of Melbourne residents in the summer of 1987/1988. Centre for
informationin
forCancer,
consumers1990.
Behavioural Research
Hill D, White V, Borland R, Cockburn J. Cancer related beliefs and behaviours in Australia. Australian Journal of
Public Health 151:14–23, 1991.
SC
Hill D, White V, Marks R, Borland R. Changes in sun-related attitudes and behaviours and reduced sunburn prevalence
in a population at high risk of melanoma. European Journal of Cancer Prevention 2:447–56, 1993.
Hill D, White V, Marks R, Theobald T, Borland R, Roy C. Melanoma prevention: Behavioural and nonbehavioural
factors in sunburn among an Australian urban population. Preventive Medicine 21:654–69, 1992.
Hobbie C. Sun protection. Journal of Paediatric Health Care 8:91–2, 1994.
Holborow PL. Melanoma: The Missing Links—does Diet have a Role, Independent Publishing, 1994.
IN
Holly EA, Aston DA, Char DH, Kristiansen JJ, Ahn DK. Uveal melanoma in relation to ultraviolet light exposure
and host factors. Cancer Research 50:5773–7, 1990.
Holly EA, Ashton DA, Cress RD, Ahn DK, Kristiansen JJ. Cutaneous melanoma in women. I. Exposure to sunlight,
ability to tan and other risk factors related to ultraviolet light. American Journal of Epidemiology
141(10):923–33, 1995.
DE
Holman CDJ, Armstrong BK. Cutaneous malignant melanoma and indicators of total accumulated exposure to the
sun: An analysis separating histogenetic types. Journal of the National Cancer Institute 73:75–82, 1984.
Holman CDJ, Armstrong BK, Heenan PJ. Relationship of cutaneous malignant melanoma to individual sunlightexposure habits. Journal of National Cancer Institute 76:403–14, 1986.
D
Holman CDJ, Gibson IM, Stephenson M, Armstrong BK. Ultraviolet irradiation of human body sites in relation to
occupation and outdoor activity: Field studies using personal UVR dosimeters. Clinical and Experimental
Dermatology 8:269–77, 1983.
Holman CDJ, Mulroney CD, Armstrong BK. Epidemiology of pre-invasive and invasive malignant melanoma in
Western Australia. International Journal of Cancer 25:317–23, 1980.
Hughes AS. Sun protection and younger children. Lessons from living with the sunshine program. Journal of
School Health 64(5):201–4, 1994.
Hughes BR, Altman DG, Newton JA. Melanoma and skin cancer: Evaluation of a health education programme for
secondary schools. British Journal of Dermatology 128:412–7, 1993.
Hunter DJ, Colditz GA, Stampfer MJ, Rosner B, Willett WC, Speizer FE. Risk factors for BCC in a prospective
cohort of women. Annals of Epidemiology 1:13–23, 1990.
Hurwitz S. The sun and sunscreen protection: Recommendations for children. Journal of Dermatologic Surgery
and Oncology 14:657–60, 1988.
Iammarino NK, Weinberg AD. Cancer prevention in the schools. Journal of School Health 55:86–95, 1985.
Insight Evaluation and Decision Support Services. Safe Summer ’95: Evaluation Report, 1995.
Primary prevention of skin cancer in Australia
69
International Agency for Research on Cancer. IARC Monographs on the Evaluation of Carcinogenic Risks to
Humans, Solar and Ultraviolet Radiation, Vol 55, 1992.
Iverson DC, Scheer JK. School-based cancer education programs: An opportunity to affect the national cancer
problem. Health Values 6(3):27–35, 1982.
Jackson A. Prevention, early detection and team management of skin cancer in primary care: Contribution to the
health-of-the-nation objectives. British Journal of General Practice 45:97–101, 1995.
Jarrett P, Sharp C, McLelland J. Protection of children by their mothers against sunburn. British Medical Journal
306:1448, 1993.
Javitt JC, Taylor HR. Cataract and latitude. Documenta Ophthalmologica 88:307–25, 1994–95.
RE
Jelfs P. Cancer, et al. in Australia 1988–1990 Canberra: Australian Institute of Health and Welfare (AIHW) and
Australasian Association of Cancer Registries,1996.
Acute pain management:
Jemec GB. Primary prevention of malignant melanoma: To know may not be enough. Journal of the American
information for consumers
Academy of Dermatology 28(5):799–800, 1993.
Jetvic AP. The sun protective effect of clothing including beachwear. Australiasian Journal of Dermatology
31:5–7, 1990.
SC
Johnson EY, Lookingbill DP. Sunscreen use and sun exposure. Archives of Dermatology 120:727–31, 1984.
Jones JL, Leary MR. Effects of appearance-based admonitions against sun exposure on the intentions of young
adults. Health Psychology 13(1):86–90, 1994.
Jones ME, Shugg D, Dwyer T, Young B, Bonett A. Interstate differences in incidence and mortality from melanoma:
A re-examination of the latitudinal gradient. Medical Journal of Australia 157:373–7, 1992.
IN
Kaidbey K, Kligman A. Sunburn protection by longwave ultraviolet radiation-induced pigmentation. Archives of
Dermatology 114:46–8, 1978.
Kamin CS, O’Neill PN, Ahearn MJ. Developing and evaluating a cancer prevention teaching module for secondary
education: Project SAFETY (Sun Awareness for Educating Today’s Youth). Journal of Cancer Education
8(4):313–8, 1993.
DE
Katz L, Ben-Tuvia S, Steinitz R. Malignant melanoma of skin in Israel: Effect of migration. In Magnus K (Ed).
Trends in Cancer Incidence: Causes and Practical Implications, Hemisphere: Washington, 1982.
Katz R, Jernigan S. Brief report: An empirically derived educational program for detecting and preventing skin
cancer. Journal of Behavioural Medicine 14:421–8, 1991.
Keesling B, Friedman HS. Psychosocial factors in sunbathing and sunscreen use. Health Psychology
6(5):477–93, 1987.
D
Kelly JW, Rivers JK, MacLennan R, Harrison S, Lewis AE, Tate BJ. Sunlight: A major factor associated with the
development of melanocytic nevi in Australian schoolchildren. Journal of the American Academy of
Dermatology 30(1):40–8, 1994.
Kerekovic S. Fun in the sun—at a price. Australian Journal of Pharmacy 73:606–8, 1992.
Khlat M, Vail A, Parkin M, Green A. Mortality from melanoma among migrants to Australia: Variation by age at
arrival and duration of stay. American Journal of Epidemiology 135:1103–13, 1992.
King PH, Murfin GD, Yanagisako KL, Wagstaff DA, Putnam GL, Hajas FL, Berger SC. Skin cancer/melanoma
knowledge and behaviour in Hawaii: Changes during a community-based cancer control program. In Mettlin
C, Murphy GP (Eds). Progress in Cancer Control IV: Research in the Cancer Center. Progress in Clinical
and Biological Research 130:135–44, 1983.
Kirkpatrick CS, Lee JA, White E. Melanoma risk by age and socioeconomic status. International Journal of
Cancer 46:1–4, 1990.
Kligman A. Solar elastosis in relation to pigmentation. In T Fitzpatrick (Ed). Sunlight and Man. Tokyo, University
of Tokyo Press, 1974.
Primary prevention of skin cancer in Australia
70
Kligman L, Sayre R. An action spectrum for ultraviolet induced elastosis in hairless mice: Quantification of
elastosis by image analysis. Photochemistry and Photobiology 53:237–42, 1991.
Koh MK. Cutaneous melanoma. New England Journal of Medicine 3257:171–82, 1991.
Kopf AW. Prevention and early detection of skin cancer/melanoma. Cancer 62:1791–5, 1988.
Kopf AW, Lazar M, Bart RS, Dubin N, Bromberg J. Prevalence of nevocytic nevi on lateral and medical aspects of
arms. Journal of Dermatology, Surgery and Oncology 4:153–8, 1978.
Kricker A. Sun Exposure and Non-melanocytic Skin Cancer. Thesis presented for the degree of Doctor of Philosophy
of the University of Western Australia, Perth, 1992.
Kricker A, Armstrong BK, English DR. Sun exposure and non-melanocytic skin cancer. Cancer Causes and
Control 5(4): 367–92, 1994.
RE
Kricker A, Armstrong BK, English DR, Heenan PJ. Pigmentary and cutaneous risk factors for non-melanocytic
Acute pain management:
skin cancer: A case control study. International Journal of Cancer 48:650–62, 1991.
information for consumers
Kricker A, Armstrong BK, English DR, Heenan PJ. A dose-response curve for sun exposure and BCC. International
Journal of Cancer 60:482–8, 1995a.
SC
Kricker A, Armstrong BK, English DR, Heenan PJ. Does intermittent sun exposure cause BCC? A case-control
study in Western Australia. International Journal of Cancer 60:489–94, 1995b.
Kricker A, English DR, Randell PL, et al. Skin cancer in Geraldton, Western Australia: A survey of incidence and
prevalence. Medical Journal of Australia 152:399–407, 1990.
Kripke ML. Effects of UVR on tumor immunity. Journal of National Cancer Institute 82:1392–6, 1990.
Lamb K. Case Study: NSW Local Government Sun Protection Project, NSW Health, 1992.
IN
Lancaster HO. Some geographical aspects of the mortality from melanoma in Europeans. Medical Journal of
Australia 1:1082–7, 1956.
Lew RA, Sober AJ, Cook N, et al. Sunburn, sun exposure and melanoma skin cancer. Journal of Dermatologic
Surgery and Oncology 9:981–6, 1983.
DE
Lipton T, Murphy M. SunSmart TV Campaign:1993. Evaluation of Alternative Concepts, Centre for Behavioural
Research in Cancer, 1993.
Loescher LJ, Buller MK, Buller DB, Emerson J, Taylor AM. Public education projects in skin cancer—the evolution
of skin cancer prevention education for children at a comprehensive cancer center. Cancer 75(2 Suppl
S):651–6, 1995.
Loescher LJ, Emerson J, Taylor AM, Christensen DH, McKinney M. Educating pre-schoolers about sunsafety.
American Journal of Public Health, in press, 1996.
D
Lombard D, Neubauer TE, Canfield D, Winett RA. Behavioural community intervention to reduce the risk of skin
cancer. Journal of Applied Behaviour Analysis 24:677–86, 1991.
Lowe JB, Balanda KP, Gillespie AM, Del Mar CB, Gentle AF. Sun related attitudes and beliefs among Queensland
school children: The role of gender and age. Australian Journal of Public Health 17(3):202–8, 1993.
Lupton D, Gaffney D. Discourse and practices related to suntanning and solar protection among young Australians.
Health Education Research, Theory and Practice 11(2):147–59, 1996.
Mackie RM, Osterlind A, Ruiter D, et al. Report on consensus meeting of the EORTC Melanoma Group on
educational needs for primary and secondary prevention of melanoma in Europe. Results of a workshop
held under the auspices of the EEC Europe against Cancer programme in Innsbruck, European Journal of
Cancer 27(10):1317–23, April 1991.
MacKenzie FD, Hirst LW, Battistutta D, Green A. Risk analysis in the development of pterygia. Ophthalmology
99:1056–61, 1992.
Maducdoc LR, Wagner RF, Wagner KD. Parents’ use of sunscreen on beach-going children. Archives of Dermatology
128:628–9, 1992.
Primary prevention of skin cancer in Australia
71
Magnus, K. Habits of sun exposure and risk of melanoma. Cancer. 48:2329–35, 1981.
Mallory SB, Watts JC. Sunburn, sun reactions and sun protection. Pediatric Annals 16:78–84, 1987.
Marks R. Skin cancer: A major preventable health problem in Australia. Australian Family Physician 14:1145, 1985.
Marks, R. Skin cancer: Childhood protection affords lifetime protection. Medical Journal of Australia
147:475–6, 1987.
Marks R. Skin cancer control in Australia: Have we made any difference? Australian Journal of Public Health
(Editorial) 18(2):127–8, 1994.
Marks R. Role of childhood in the development of skin cancer. Australian Paediatric Journal 24(6):337–8, 1988.
RE
Marks R. Freckles, moles, melanoma and the ozone layer: A tale of the relationship between humans and their
environment. Medical Journal of Australia 151:611–3, 1989.
Acuteprevention
pain management:
Marks R. Primary
of skin cancer. British Medical Journal 309:285–6, 1994.
information for consumers
Marks R, Foley PA, Jolley D, Knight KR, Harrison J, Thompson SC. The effect of regular sunscreen use on
vitamin D levels in an Australian population—results of a randomized controlled trial. Archives of
Dermatology 13(4):415–21, 1995.
SC
Marks R, Hill D. Behavioural change in adolescence: A major challenge for skin cancer control in Australia.
Medical Journal of Australia 149:514–5, 1988.
Marks R, Jolley D, Doroveitch AP, Selwood TS. The incidence of non-melanocytic skin cancers in an Australian
population: Results of a five-year prospective study. Medical Journal of Australia 150:475–8, 1989.
Marks R, Jolley D, Lectsas S, Foley P. The role of childhood exposure to sunlight in the development of solar
keratoses and non-melanoma skin cancer. Medical Journal of Australia 152:62–6, 1990.
IN
Marks R, Staples M, Giles GG. Trends in non-melanocytic skin cancer treated in Australia: The second national
survey. International Journal of Cancer 53:585–90, 1993.
Marshall D. The clinical and pathological effects of prolonged solar exposure. Australian and New Zealand
Journal of Surgery 34:161–72, 1965.
DE
Martin RH. Relationship between risk factors, knowledge and preventive behaviour relevant to skin cancer in
general practice patients in South Australia. British Journal of General Practice 45:361–7, 1995.
McGee R, Williams S. Adolescence and sun protection. New Zealand Medical Journal 105:401–3, 1992.
McGee R, Williams S, Cox B, Elwood M, Bulliard JL. A community survey of sun exposure, sunburn and sun
protection. New Zealand Medical Journal 108:508–10, 1995.
McLean DI, Gallagher RP. Sunburn freckles, cafe-au-lait macules, and other pigmented lesions of schoolchildren
—the Vancover mole study. Journal of the American Academy of Dermatology 32(4):565–70, 1995.
D
McLeod GR, Davis NC, Little HJ, Green A, Chaini D. Das Maligne Melanoma in Queensland, Australia:
Erfahrungen del Queensland Melanoma Projekt. In Balch CM, Milton GW, Haut-Melanome Springer
Verlag, 250–8.
McReynolds W, Green L, Fisher E. Self-control as choice management with reference to the behavioural treatment
of obesity. Health Psychology 2:261, 1983.
Mechanic D, Cleary PD. Factors associated with the maintenance of positive health behavior. Prevention Medicine
9:805–14, 1980.
Melia J, Bulman A. Sunburn and tanning in a British population. New Zealand Medical Journal 17,(2):223–229, 1995.
Melia J, Ellman R, Chamberlain J. Meeting the health of the nation target for skin cancer—problems with tackling
prevention and monitoring trends. Journal of Public Health Medicine 16(2):225–32, 1994.
Melville SK, Rosenthal FS, Luckman R, Lew RA. Quantitative ultraviolet skin exposure in children during selected
outdoor activities. Photodermatology, Photoimmunology and Photomedicine 8:99–104, 1991.
Mera S, Lovel C, Russell-Jones R, Davis J. Elastic fibres in normal and sun-damaged skin: An immunohistochemical study. British Journal of Dermatology 117:21–7, 1987.
Primary prevention of skin cancer in Australia
72
Mermelstein R, Reisenberg LA. Changing knowledge and attitudes about skin cancer risk factors in adolescents.
Health Psychology 11(6):3716, 1992.
Miller A, Ashton W, McHoskey J, Gimbel J. What price attractiveness? Stereotype and risk factors in suntanning
behaviour. Journal of Applied Social Psychology 20:1272, 1990.
Miller DR, Geller AC, Koh HK. Survey of knowledge of and awareness about melanoma—United States Morbidity
and Mortality Weekly Report 45(17):346–9, 1996.
Mitchell R. The skin of the Australian aborigine: A light and electromicroscopical study. Australasian Journal of
Dermatology 9: 314–28, 1968.
Montague M, Borland R, Whitty F. SunSmart policies and practices in local government in Victoria 1990–1993.
SunSmart Evaluation Studies #4, Anti-Cancer Council of Victoria, Melbourne, 1995a.
RE
Montague M, Segan C, Borland R. Reaction to the 1993–94 SunSmart campaign: Results from a representative
Acute pain
management: SunSmart Evaluation Studies #4. Anti-Cancer Council of Victoria,
Household Survey
of Victorians.
information for consumers
Melbourne, 1995b.
Morales-Suarez-Varela M, Llopis-Gonzalez A, Ferrer-Caraco E. Non-melanoma skin cancer: An evaluation of
risk in terms of ultraviolet exposure. European Journal of Epidemiology 8(6):838–44, 1992.
SC
Moran J, Hollows FC. Pterygium and ultraviolet radiation: A positive correlation. British Journal of Ophthalmology
68:343–6, 1984.
Morris J, Elwood M. How Effective are Sun Exposure Modification Programmes? Hugh Adam Cancer
Epidemiology, Department of Preventive and Social Medicine, University of Otago, New Zealand, 1995.
Murphy, M. Older People and their Skin. Report of Focus Group Discussions for National Skin Cancer Awareness
Week Campaign, 1992, Anti-Cancer Council of Victoria, 1992.
IN
Murphy M. SunSmart Women’s Magazine Study: Magazine Content and Reader Surveys, Centre for Behavioural
Research in cancer, 1993.
Murphy M. SunSmart Primary Schools Study: Stage 2. Teacher interviews and discussions. SunSmart Evaluation
Studies #3, Anti-Cancer Council of Victoria, Melbourne, 1994.
DE
Murphy M, Broadstock M, Noy S. Skin Cancer Early Detection—A Pretest of Resources for the 1991 National Skin
Cancer Awareness Campaign. Centre for Behavioural Research in Cancer, Anti Cancer Council of Victoria, 1991a.
Murphy M, Broadstock M, Noy S. Skin Cancer Early Detection—Research Using Focus Groups. Centre for
Behavioural Research in Cancer, Anti Cancer Council of Victoria, 1991b.
Murphy GF, Elder DE. Atlas of Tumour Pathology. Third Series, Fascicle 1. Non-melanocytic Tumours of the
Skin. Armed Forces Institute of Pathology, Washington, DC, 1991.
D
Murphy M, Noy S. National Women’s Magazine Study: Sun Protection, Skin Cancer and Tanning, Centre for
Behavioural Research in Cancer, Anti-Cancer Council of Victoria, 1992a.
Murphy M, Noy S. Skin Cancer Early Detection: Development of Resources for 1991 National Skin Cancer
Awareness Campaign, Anti-Cancer Council of Victoria, 1992b.
Murphy M, Segan C. Tourists: A Study of Sunburnt Holiday Makers, Anti-Cancer Council of Victoria, 1992.
National Child care Accreditation Council. Quality Improvement and Accreditation System Handbook, National
Child care Accreditation Council, 1993.
National Health and Medical Research Council. Effective School Health Promotion—Towards health promoting
schools, AGPS, 1997.
Naylor MF, Boyd A, Smith DW, et al. High sun protection factor sunscreens in the suppression of actinic neoplasia.
Archives of Dermatology 131:170–5, 1995.
Nelemans PJ, Groenendal H, Kiemeneny LA, Rampen FH, Ruiter DJ, Verbeek AL. Effects of intermittent exposure
to sunlight on melanoma risk among indoor workers and sun sensitive individuals. Environmental Health
Perspectives 101:252–5, 1993.
Primary prevention of skin cancer in Australia
73
NSW Health Department and NSW Cancer Council. Health Promotion Strategic Plan: Skin Cancer Control in
New South Wales 1995–2000, NSW Cancer Council and NSW Department of Health,1995.
Northern Territory Department of Education. Measures Adopted by the Northern Territory Department of
Education, Northern Territory Department of Education, 1995.
Noy S, Houston J. A New Initiative in Public Education about Skin Cancer: National Skin Cancer Awareness
Week 1985, Anti-Cancer Council of Victoria, 1986.
Noys S, Houston J. National Skin Cancer Awareness Week 1985—a new initiative in public education about skin
cancer. Cancer Forum 10(3):88–91, 1986.
Oakley A, Bendelow G, Barnes J, Buchanan M, Husain OAN. Health and cancer prevention—knowledge and
beliefs of children and young people. British Medical Journal 310:1029–33, 1995.
RE
Odio MR, Veres DA, Goodman JJ, Irwin C, Robinson LR, Martinez J, Kraus AL. Comparative efficacy of sunscreen
Acute pain
management:
reapplication
regimens
in children exposed to ambient sunlight. Photodermatology, Photoimmunology and
information10(3):118–25,
for consumers
Photomedicine
1994.
Outnan GL, Yanagisko KL. Skin cancer comic book: Evaluation of a public education vehicle. Cancer Detection
and Prevention 5:349–456, 1982.
Pailthorpe MT. Textiles and Sun Protection: The Current Situation, University of New South Wales, 1994.
SC
Pathak MA. Sunscreens: Topical and systemic approaches for protection of human skin against harmful effects of
solar radiation. Journal of American Academic Dermatology 7:285–312, 1982.
Pathak MA, Fitzpatrick TB, Greiter FJ, Kraus EW. Principles of photoprotection in sunburn and suntanning, and
topical and systemic photoprotection in health and diseases. Journal of Dermatology, Surgery and Oncology
11:575–9, 1985.
IN
Pierce JP, Macaskell P, Hill D. Long-term effectiveness of mass media led anti-smoking campaigns in Australia.
American Journal of Public Health 80:565–9, 1991.
Pincus MW, Rollings PK, Craft AB, Green A. Sunscreen use on Queensland beaches. Australasian Journal of
Dermatology 32:21–5, 1991.
DE
Pope DJ, Sorahan T, Marsden JR, Ball PM, Grimley RP, Peck IM. Benign pigmented nevi in children. Prevalence
and associated factors: The West Midlands, United Kingdom Mole Study. Archives of Dermatology
128:1201–6, 1992.
Pratt K, Borland R. Predictors of sun protection among adolescents at the beach. Australian Psychologist
29(2):135–9, 1994.
Purchase M, Borland R. Public reaction to the 1992–93 SunSmart Campaign. SunSmart Evaluation Studies #3,
Anti-Cancer Council of Victoria, Melbourne, 1994.
D
Putnam GL, Yanagisako KL. Skin cancer comic book: Evaluation of a public educational vehicle. Journal of
Audiovisual Media and Medicine 8(1):22–5, 1985.
Queensland Health. Policy on the Prevention and Early Detection of Skin Cancer (Discussion Paper), Queensland
Health, 1995a.
Queensland Health. Work in Progress Workshop: Cancer Prevention Research Program, Commissioned Research,
Queensland Health, 1995b.
Ramstack J, White SE, Hazelkorn KS, Meyskens FL. Sunshine and skin cancer: A school based skin cancer
prevention project. Journal of Cancer Education 1:169–76, 1986.
Rassaby GL, Larcombe I, Hill D, Wake FR. Slip! Slop! Slap! Health education about skin cancer. Cancer Forum
7:63–9, 1982.
Rhodes AR. Public education and cancer of the skin—what do people need to know about melanoma and
nonmelanoma skin cancer. Cancer 75:613–36, 1995.
Rivers JK, Gallagher RP. Public education projects in skin cancer: Experience of the Canadian dermatology
association. Cancer 75:661–6, 1995.
Primary prevention of skin cancer in Australia
74
Robinson JK. Behaviour modification obtained by sun protection education coupled with removal of a skin cancer.
Archives of Dermatology 126:477–81, 1990.
Robinson JK. Compensation strategies in sun protection behaviours by a population with nonmelanoma skin
cancer. Preventive Medicine 21:574–765, 1992.
Rockley PF, Trieff N, Wagner RF, Tyring SK. Nonsunlight risk factors for malignant melanoma: 2. Immunity,
genetics, and workplace prevention. International Journal of Dermatology 33(7):462–7, 1994.
Rooney JF, Bryson Y, Mannix ML, Dillon M, Wohlenberg CR, Banks S, Wallington CJ, Notkins AL, Straus SE.
Prevention of ultraviolet-light-induced herpes labialis by sunscreen. Lancet 338:1410–22, 1991.
RE
Rosmini F, Stazi MA, Milton RC, Sperduto RD, Pasquini R, Maraini G. A dose-response effect between a sunlight
index and age-related cataracts. Italian-American Cataract Study Group. Annals of Epidemiology
4:266–70, 1994.
Acute pain management:
Rossi JS, Blais LM, Weinstock
MA. The Rhode Island sun smart project—skin cancer prevention reaches the
information
for consumers
beaches. American
Journal
of Public Health 84(4):672–4, 1994.
Sackett DT, Haynes RB. Compliance with Therapeutic Regimens. Baltimore MD, Johns Hopkins University,
Press (Eds), 1–134, 1976.
Sanson-Fisher RW. Me No Fry Evaluation Report, NSW Department of Health, 1992.
SC
Sanson-Fisher RW. Me No Fry 1992/93 Summer Campaign: Evaluation Report, NSW Department of Health, 1993.
Sanson-Fisher RW. Me No Fry 1993/94 Summer Campaign: Evaluation Report, NSW Department of Health, 1994.
Sanson-Fisher RW. Me No Fry Evaluation Report, NSW Department of Health, 1995.
Sanson-Fisher RW, Redman S. The challenge of community health. In King NJ, Remenyi (Eds). Health Care.
A Behavioural Approach, Sydney: Grune & Stratton, 1986.
IN
Sayre RM, Kollias N, Ley RD, Baqer AH. Changing the risk spectrum of injury and the performance of sunscreen
products throughout the day. Photodermatology, Photoimmunology and Photomedicine 10(4):148–53, 1994.
Sayre RM, Powell J, Rheins LA. Product application technique alters the sun protection factor. Photodermatology,
Photoimmunology and Photomedicine 8:222–4, 1991.
DE
Schofield MJ, Coxall A, Sanson-Fisher R. Skin cancer: Do early child care centres provide protection? Health
Promotion International 8:243–7, 1993.
Schofield MJ, Tripodi DA, Girgis A, Sanson-Fisher RW. Solar protection issues for schools: Policy, practice and
recommendations. Australian Journal of Public Health 15(2):135–41, 1991.
Scotto J, Fears TR. The association of solar ultraviolet and skin melanoma incidence among Caucasians in the
United States. Cancer Investigation 5:275–83, 1987.
D
Screiber MM, Moon TE, Meyskens FL, Murdon JA. Solar ultraviolet radiation and skin cancer: A public education
program. Arizona Medicine 40:467–72, 1983.
Seddon J, Gragoudas ES, Glynn RJ, et al. Host factors, UVR, and risk of uveal melanoma. Archives of
Ophthalmology 108:1274–80, 1990.
Segan C. Determinants of Sun Protection in Tourists, Unpublished honours thesis, 1991.
Segan C. Issues Surrounding the Development and Dissemination of a SunSmart Tourist Brochure. Report prepared
for the National Skin Cancer Awareness Week Committee, Centre for Behavioural Research in Cancer,
Anti-Cancer Council of Victoria, 1994.
Segan C, Borland R, Sweeney M. Evaluation of Participants in the Royal Life Saving Society’s ‘Splash’ Program.
Final Report of the SunSmart Sponsorship of the Royal Life Saving Society 1991–92 Season, Anti-Cancer
Council of Victoria, 1992a.
Segan C, Borland R, Sweeney M. Evaluation of the SunSmart Tennis in Schools Program. Final report of the SunSmart
Sponsorship of the Victorian Tennis Association 1991–92 Season, Anti-Cancer Council of Victoria, 1992b.
Primary prevention of skin cancer in Australia
75
Segan C, Borland R. Public reaction to the SunSmart Campaign and reported sun protection behaviour over the
summers of 1990/91 and 1991/92. SunSmart Evaluation Studies #3, Anti-Cancer Council of Victoria,
Melbourne, 1994.
Sinclair C, Borland R, Davidson M, Noy S. From Slip! Slop! Slap! to SunSmart. A Profile of a Health Education
Campaign, Anti-Cancer Council of Victoria, 1994a.
Sinclair C, Borland R, Davidson M, Noy S. From Slip! Slop! Slap! to SunSmart: A profile of a health education
campaign. Cancer Forum 18(3):183–7, 1994b.
Siskind M. Analysis of Media Beach Survey of Slip Slop Slap has got Serious. July 1992, Health Advancement
Branch, Queensland Health, 1992.
RE
Siskind M. Queensland Sun Protection Survey Summer 1992—At Risk Groups, Outdoor Activities on Weekends,
and Outdoor workers, Queensland Health, 1993.
Acute
Siskind M, Booth
J. pain
Sunmanagement:
Protection Study on Sun Protection Behaviour on Queensland Beaches and Pools. 1991/
information
for consumers Branch, Queensland Health, 1992.
1992, Health
Advancement
Siskind M, Dabelstein J. Evaluation of the 1991/92 Queensland Sun Protection Campaign: Slip Slop Slap has got
Serious, Queensland Department of Health, 1992.
SC
Skolnick AA. Sunscreen protection controversy heats up. Journal of American Medical Association
265:3218–20, 1991.
Sliney DH. Physical factors in cataracotgensis: Ambient ultraviolet radiation and temperature. Investigative
Ophthalmology and Visual Science 27:781–90, 1986.
Sliney DH, Wolbarst M. Safety with Lasers and Other Optical Sources: A Comprehensive Handbook. New York,
Plenum, 1980.
IN
Stenberg C, Larko O. Sunscreen application and its importance for the sun protection factor. Archives of Dermatology
121:1400–2, 1985.
Stern RS, Weinstein MC, Baker SG. Risk reduction for nonmelanoma skin cancer with childhood sunscreen use.
Archives of Dermatology 122:537–45, 1986.
DE
Svenson O. Time perception and long-term risk. Cancer Journal of Operational Research and Information
Processing 22:196, 1984.
Sweeney M. The SunSmart Sponsorship Program. SunSmart Evaluation Studies #4, The Anti-Cancer Council’s
Skin Cancer Control Program 1993–94, Melbourne, 1995.
Swerdlow AJ, English JS, Mackie RM, O’Doherty CJ, Hunter JA, Clark J, Hole DJ. Fluorescent lights, ultraviolet
lamps, and risk of cutaneous melanoma. British Medical Journal 297(6649):647–50, 1988.
D
Tasmanian Department of Community and Health Services. Health goals and targets for Tasmania: State Health
Plan Position Paper 2, Tasmanian Department of Community and Health Servcies, 1992.
Tasmanian Department of Community Services and Health. Sun Protection Programs, 1995.
Taylor HR. The biological effects of UV-B on the eye. Photochemistry and Photobiology 50:489–92, 1989.
Taylor HR. Ocular effects of UV-B exposure. Documenta Ophthalmologica 88:285–93, 1994–95.
Taylor HR, West S, Munoz B, Rosenthal FS, Bressler SB, Bressler NM. The long-term effects of visible light on
the eye. Archives of Ophthamology 110:99–104, 1992.
Taylor HR, West SK, Rosenthal FS, Munoz B, Newland HS, Abbey H, Emmett EA. Effect of ultraviolet radiation
on cataract formation. New England Journal of Medicine 319:1429–33, 1988.
Taylor HR, West SK, Rosenthal FS, Munoz B, Newland HS, Emmett EA. Corneal changes asociated with chronic
UV irradiation. Archives of Ophthalmology 107:1441–84, 1989.
Taylor S, Thompson S. Stalking the elusive ‘vividness’ effect. Psychology Review 89:155, 1982.
The Roy Morgan Research Centre. Sun Protection Survey, The Roy Morgan Research Centre Pty. Ltd., 1992.
Primary prevention of skin cancer in Australia
76
Theobald T, Marks R, Hill D, Dorevitch A. ‘Goodbye Sunshine’: Effects of a television program about melanoma
beliefs, behavior, and melanoma thickness. Journal of the American Academy of Dermatology
25(4):717–23, 1991.
Thompson SC, Jolley D, Marks R. Reduction of solar keratoses by regular sunscreen use. New England Journal of
Medicine 329:1147–51, 1993.
Threlfall T. Sunglasses and clothing—an unhealthy correlation? Australian Journal of Public Health 16:192–6, 1992.
Thursfield V, Giles G, Staples M. Skin Cancer CANSTAT, Anti-Cancer Council of Victoria, Melbourne, 1994.
Tucker MA, Shields JA, Hartge P, Augsburger J, Hoouer RN, Fraumeni JF Jr. Sunlight exposure as a risk factor
for introcular malignant melanoma. New England Journal of Medicine 313:789–92, 1985.
RE
Vail-Smith K, Felts WM. Sunbathing: College students’ knowledge, attitudes, and perceptions of risks. Journal of
American College Health 42(1):21–6, 1993.
Acute pain management:
Valgero D, Ringback G,
Kiviranta H. Melanoma and other tumours of the skin among office, indoor and outdoor
information for consumers
workers in Sweden. British Journal of Cancer 53:507–12, 1986.
Vitasa BC, Taylor HR, Strickland PT, Rosenthal FS, West S, Abbey H, Ng SK, Munoz B, Emmett EA. Association
of non-melanoma skin cancer and actinic keratosis with cumulative solar ultraviolet exposure in Maryland
watermen. Cancer 65:2811–7, 1990.
SC
Wakefield M, Bonnett A. Preventing skin cancer in Australia. Medical Journal of Australia 152:60–1, 1990.
Wakefield M, Esterman A. Re-analysis of the Cancer-Free-Kids Programme Evaluation, Report to Dr Lyn Roberts,
Coordinator, Cancer Prevention and Education Unit, The Anti Cancer Foundation of the Universities of
South Australia, 1991.
Watson A. Sunscreen effectiveness: Theoretical and practical considerations. Australian Journal of Dermatology
24:17–22, 1983.
IN
Watts B. Operation Cover-up: A nursing intervention with a difference. The Australian Nurses Journal 17:56, 1987.
Watts WS, Byrnes T, Hare JW. Skin cancer awareness campaigns: Are men getting the message? Health Promotion
Journal of Australia 3(3):40–1, 1993.
DE
Webb G. Solar radiation protection for outdoor workers. Journal of Occupational Health and Safety—Australia
and New Zealand 8:479–85, 1992.
Weinstock M. Assessment of sun sensitivity by questionnaire: Validity of items and formulation of a prediction
rule. Journal of Clinical Epidemiology 45:547–52, 1992.
Weinstock MA, Colditz GA, Willett WC, et al. Melanoma and the sun: The effect of swimsuits and a ‘healthy’ tan
on the risk of nonfamilial malignant melanoma in women. American Journal of Epidemiology
134:462–70, 1991.
D
Weinstock MA, Stampfer MJ, Lew RA, Willett WC, Sober AJ. Case-control study of melanoma and dietary
vitamin D: Implications for advocacy of sun protection and sunscreen use. Journal of Investigative
Dermatology 98(5):809–11, 1992.
Welsh C, Diffey BL. The protection against solar actinic radiation afforded by common clothing fabrics. Clinical
Experiment in Dermatology 6:577–82, 1981.
Westerdahl J, Olsson H, Masback A, Ingvar C, Jonsson N. Is the use of sunscreens a risk factor for malignant
melanoma. Melanoma Research 5(1):59–65, 1995.
Wheeler CE Jr. Pathogenesis of recurrent herpes simplex infections. Journal of Investigative Dermatology
65:341–6, 1975.
White AD. The use of sunscreens in Australia. Journal of Clinical Medicine 33(1):27–39, 1990.
White E, Kirkpatricks CS, Lee JAH. Case-control study of malignant melanoma in Washington State:
1. Constitutional factors and sun exposure. American Journal of Epidemiology 139:857–68, 1994.
White V, Mackenzie B, Gaffney D, Pry J. NSW Local Government Report 1993, Anti-Cancer Council of Victoria, 1993.
Primary prevention of skin cancer in Australia
77
Whiteman DC, Frost CA, Whiteman CA, Green AC. A survey of sunscreen use and sun protection practices in
Darwin. Australian Journal of Public Health 18:47–50, 1994.
Whiteman D, Green A. Melanoma and sunburn. Cancer Causes & Control 5(6):564–72, 1994.
Whitty F. The SunSmart Community Program. SunSmart Evaluation Studies #4, The Anti-Cancer Council’s Skin
Cancer Control Program 1993–94, Melbourne, 1995.
Wichstrom L. Predictors of Norwegian adolescents’ sunbathing and use of sunscreen. Health Psychology
13(5):412–20, 1994.
Williams CL. Primary prevention of cancer beginning in childhood. Preventive Medicine 9:275–80, 1980.
Williams CL, Carter BJ, Eng A. The ‘Know Your Body’ program: A developmental approach to health education
and disease prevention. Preventive Medicine 9:371–83, 1980.
RE
Williams P, Hocking
B. Prevention of skin cancers in the workplace. Radiation Protection Australia
Acute pain management:
3:87–93,information
1988. for consumers
Wolf P, Donaho CK, Kripke ML. Effect of Sunscreen on UVR-induced enhancement of melanoma growth in
mice. National Cancer Institute 86(2):99–105, 1994.
Wolff SP. Cataract and UVR. Documenta Ophthalmologica 88:201–4, 1994–95.
D
DE
IN
SC
Primary prevention of skin cancer in Australia
79
Appendix A
A STRATEGIC PLAN FOR THE
PREVENTION OF SKIN CANCER
RE
Source Document
Acute pain management:
NSW Health Department
and NSW Cancer Council. Health Promotion Strategic Plan: Skin Cancer Control in
information for consumers
New South Wales
1995–2000. NSW Cancer Council and NSW Department of Health, 1995.
Key Strategic Aims
SC
•
Concentrate on changing attitudes that are
predictors of sun protection behaviour.
•
Refocus efforts on the provision of
supportive physical environments
particularly in the area of shade provision.
•
Assist and train organisations in the
implementation of comprehensive sun
protection policies.
LONG-TERM HEALTH OUTCOME
A reduction in the incidence of,
and mortality from, skin cancer
IN
Goals
An increase in the number of children,
adolescents and adults who practise sun
protection behaviour.
•
Provide the community with an environment
that supports sun protection, including
organisational, physical and social aspects.
.
•
Work more closely with product
manufacturers and distributors and the
fashion industry to ensure the delivery of sun
protection products that are acceptable,
fashionable and easy to obtain and use.
DE
•
•
Tailor activities to target high risk groups.
D
Primary prevention of skin cancer in Australia
80
SETTINGS
Educational Institutions
Childcare Centres / Preschools
Program
Activity
Lead Organisations
and Partners *
Priority (1) within next 2 years
RE
1.1 Develop shade provision
guidelines
Acute pain management:
• CC, DOH, DSE, PD, FC, DPW, AIEH, GA,
KU, Manufacturers
information for consumers
• CC, DOH, LGSA, DPW, AIEH,
Manufacturers
1.3 Assist preschool and child care management in the
implementation of sun protection policies focusing
on structural change
• CC, DOH, KU, LGSA
1.4 Negotiate inclusion of sun protection policy and
shade requirement in preschool/child care centre
licensing and building applications
• CC, DOH, LGSA
IN
SC
1.2 Develop shade provision measurement tool/service
1.5 Lobby to include sun protection policy and shade
requirement in child care centre accreditation
• CC, DOH
Priority (2) within next 2 years
2.2 Encourage and assist in education of carers and
teachers of young children through existing training courses
DE
2.1 Train and assist with use of shade provision
guidelines and measurement tool/service
• CC, DOH, TAFE, LGSA, Universities
• CC, LGSA, DPW, AIEH, KU
D
Priority (3) within next 5 years
3.1 Conduct Shade and Sun Protection Policy Awards
Scheme
• CC, DOH
3.2 Conduct Shade and Sun Protection Expo
• CC, DOH, All relevant stakeholders
3.3 Encourage and assist in the provision of appropriate training for those working in design, architecture and town planning to ensure child care centre
and preschool environments are sun protective
• CC, DOH, TAFE, AIEH, Universities
* Abbreviations for lead organisations and partners are listed on pages 97–98
Primary prevention of skin cancer in Australia
81
Health Promotion Outcomes
(A)
(B)
Implementation of shade guidelines
(C)
Increase in adequate provision of sun protective shade
Increase in children’s sun
protection behaviour
Positive change in attitudes,
knowledge and skills towards
sun protection policies and
behaviours among carers,
teachers, parents and
management
Increase in role model’s
sun protection behaviour
Shade measurements conducted
Purchase of shade products by child
care centres / preschools
Sun protection policies implemented
with emphasis on structural change
RE
Full accreditation
of child care centres
Acute pain management:
to require suninformation
protection
policies and
for consumers
shade provision
Increase in children’s use
of shade
Positive change in knowledge, attitudes and skills of
children
SC
Inclusion of sun protection education in
training for carers and teachers of
young children
Child care centres and preschools
involved in Shade and Policy Award
Scheme
DE
IN
Information on sun protective child
care centre / preschool environments
included in training for architects,
designers and town planners
Specific Targets
D
1. Increase in the number of child care centres with a formal written solar protection policy
(Baseline 18%; Schofield et al., 1993)
2. Increase in the number of child care centres with a timetable policy (Baseline 24%; Schofield et al.,
1993)
3. Increase in the number of child care centres with a shade policy (Baseline 14%; Schofield et al, 1993)
4. Increase in the number of children in child care centres observed wearing a hat on ten occasions (Baseline 1%; Schofield et al., 1993)
5. Increase in the number of children in childcare centres observed wearing a hat on at least one occasion
(Baseline 11%; Schofield et al., 1993)
Grouped Targets
(Detailed on page 94–95)
7. Beachgoers’ use of sun protection measures
Primary prevention of skin cancer in Australia
82
Primary and Secondary Schools
Program
Activity
Lead Organisations
and Partners *
Priority (1) within next 2 years
1.1 Review the NSW Department of School Education policy on
protection from the sun
• CC, DSE, Welfare Coordinators
RE
1.2 Assist schools in the effective implementation of school sun
Acute
pain management:
protection policies,
focusing
on structural change and
information for consumers
teachers as role models
• CC, DOH-AD, DSE, C&I Schools
1.3 Schools development of their own policy on protection from
the sun in consultation with the school community
• CC, DSE, C&I Schools,
P&C, FOSCO
SC
• CC, BOS, DSE, C&I Schools
1.5 Develop shade provision guidelines
• CC, DOH, PD, DSE, GA,
AIEH, DPW, Manufacturers
1.6 Develop shade provision measurement tool/service
• CC, DOH, AIEH, DPW, LGSA,
Manufacturers
IN
1.4 Encourage the inclusion of skin cancer education in primary
and secondary school curricula
1.7 Ensure new schools and those with renovations include
specified amount of shade and appropriate landscaping
design
• PD, DSE, DPW, LGSA,
C&I Schools
DE
• CC, DSE, C&I Schools
1.9 Encourage greater acceptance of hat wearing which complies
with CC guidelines
• CC, DSE, DOH-AD, P&C,
FOSCO, Individual school
communities
1.10 Encourage schools to adopt Sunsmart school uniforms /
protective clothing which complies with CC guidelines
• CC, DSE, C&I Schools,
P&C, FOSCO
D
1.8 Encourage use of existing buildings: verandahs, walkways,
classrooms, libraries, halls for passive use
Priority (2) within next 2 years
2.1 Train and assist schools with use of shade provision guidelines and measurement tool/service
• CC, DSE, DPW, LGSA, AIEH
2.2 Ensure relevant training of teachers through tertiary education and ongoing education and support
• CC, DSE, DOH-AD, Universities
2.3 Conduct workshops to discuss policy implementation ideas
and success
• DOH-AD, Individual school
communities
* Abbreviations for lead organisations and partners are listed on pages 97–98
Primary prevention of skin cancer in Australia
83
Program
Activity
Lead Organisations
and Partners *
Priority (3) within next 5 years
3.1 Raise funds and investigate concessions to increase available shade in schools
• DSE, C&I Schools,
Service Clubs, Corporate Sponsors
3.2 Conduct Shade and Sun Protection Policy
Awards Scheme
• CC, DOH
3.3 Conduct Shade and Sun Protection Expo
RE
• CC, DOH, All relevant
stakeholders
3.4 Encourage
and assist in the provision of appropriate
Acute pain management:
training information
for thoseforworking
in design, architecture and
consumers
town planning to ensure school environments are sun
protective
• CC, DOH, TAFE, AIEH, LGSA,
Universities
SC
* Abbreviations for lead organisations and partners are listed on pages 97–98
Health Promotion Outcomes
(A)
Implementation of shade guidelines
Increase in adequate
provision of sun protective
shade
IN
Shade measurements conducted
(B)
Existence of legislation about new
schools and schools with renovations to
include specified amount of shade
SunSmart School Policies implemented
with emphasis on structural change
Information in relation to sun protection and policy implementation available to teachers through education and
training programs
Purchase of shade products by schools
Information on sun protective school
environments included in training for
architects, designers and town planners
Primary prevention of skin cancer in Australia
Positive change in knowledge, attitudes and skills of
students
Increase in student’s sun
protection behaviour
Increase in role model’s
sun protection behaviour
Increase in student’s use
of shade
D
Primary and secondary schools
involved in Shade and Policy Award
Schemes
DE
Skin cancer education taught across
curriculum
Positive change in attitudes,
knowledge and skills towards sun protection
policies and behaviours
among teachers and principals
(C)
84
Specific Targets
Increase in the number of primary schools with a written solar protection policy (Baseline 64%;
Schofield et al., 1991)
2.
Increase in the number of secondary schools with a written solar protection policy (Baseline 39%;
Schofield et al., 1991)
3.
Increase in the percentage of adolescents reporting that their school required them to wear a hat
when playing outdoor sport (Baseline 32%; Sanson-Fisher, 1994)
4.
Increase in the percentage of adolescents reporting that their school required them to wear a hat
when outdoors at lunchtime (Baseline 21%; Sanson-Fisher, 1994)
5.
pain management:
Increase in theAcute
number
of primary schools with a shade policy (Baseline 10%; Schofield et al., 1991)
6.
Increase in the number of secondary schools with a shade policy (Baseline 0%; Schofield et al., 1991)
7.
Decrease in the amount of time spent outdoors in primary schools during the highest risk period of
the day (Baseline 83.7%; Schofield et al., 1991)
8.
Decrease in the amount of time spent outdoors in secondary schools during the highest risk period
of the day (Baseline 90.7%; Schofield et al., 1991)
9.
Increase in the number of primary school students using hats or shade (Baseline 62%;
Schofield et al., 1991)
10.
Increase in the number of secondary school students using hats or shade (Baseline 64%;
Schofield et al., 1991)
RE
1.
information for consumers
IN
SC
Grouped Targets
(Detailed on page 94–95)
Adolescents’ knowledge
2.
Adolscents’ attitudes and intentions to sun protection
4.
Adolescents’ level of protection
5.
Adolescents’ use of sun protection measures
7.
Beachgoers’ use of sun protection measures
D
DE
1.
Primary prevention of skin cancer in Australia
85
Workplace
Program
Activity
Lead Organisations
and Partners *
Priority (1) within next 2 years
• Workcover, AIEH, CC, GA, MBA
1.2 Develop shade provision measurement tool/service
• Workcover, AIEH, CC, MBA,
Engineers, Universities
RE
1.1 Develop shade provision guidelines
Acute pain management:
• CC, SBCA, Employer Organisations,
NA, Unions
1.4 Establish tax deduction scheme and/or sun protection policies to cover volunteer workers, e.g. sports
umpires, surf lifesavers
• CC, Volunteer Associations
1.5 Lobby to have sun protection policies for outdoor
workers mandatory including shade structures
where feasible through establishment of code of
practice
• Workcover, CC, DOH, MBA, RACS
1.6 Develop and include sun protection education as
part of TAFE and training courses for outdoor
workers
• CC, TAFE, DOH, Workcover
IN
SC
for consumers
1.3 Lobby forinformation
work-related
sun protection products to
be tax deductible
Priority (2) within next 2 years
• Workcover, AIEH, CC, LGSA
DE
2.1 Train and assist with use of shade provision
guidelines and measurement tool/service
2.3 Conduct industry-based Shade and Sun Protection Policy Awards Scheme
• CC, DOH, Industry Associations
2.4 Conduct Shade and Sun Protection Expo
• CC, DOH, All relevant stakeholders
D
2.5 Educate employers and Occupational Health
and Safety (OH&S) committee members about
legal obligations and provide training in implementation of policies. Training should be linked
to other OH&S training
• Workcover, CC, NA, NSCA, Unions,
Employer Organisations
2.6 Access small businesses, contractors and trades
people as above
• Workcover, CC, SBCA, Government
Departments who subcontract work,
Large employers, Unions, Employer
Organisations, Trades Associations,
Licensing Bodies
2.7 Develop peer training programs and provide
information to employees about sun protection
• CC, DOH-AD,
Occupational Health Nurses
* Abbreviations for lead organisations and partners are listed on pages 97–98
Primary prevention of skin cancer in Australia
86
Program
Activity
Lead Organisations
and Partners *
Priority (2) within next 2 years (continued)
• CC, AIEH, TAFE, LGSA,
Professional Associations, Universities
2.9 Implement occupational health and safety
legislation in relation to sun protection through
Acute pain management:
training for workplace
inspectors following the
information for consumers
establishment of
a code of practice
• Workcover, NSCA, Unions, CC
2.10 Develop general audit checklist for sun protection
for occupational health and safety committees and
employers to be included as part of a code of
practice. This should include information on
“What is an outdoor worker?” and on the
purchase of sun protection equipment
• Workcover, CC, CERP, DOH
IN
SC
RE
2.8 Encourage and assist in appropriate training for
those working in design, architecture and town
planning to ensure work environments are
designed and planned to be sun protective
Priority (3) within next 5 years
3.2 Liaise with suppliers of sun protection equipment
to discuss design and promotional aspects
DE
3.1 Conduct promotional campaign targeting
employers and employees after establishment
of code of practice
• Workcover, CC, DOH
• CC, Workcover, Employer Organisations,
Universities, Unions
D
* Abbreviations for lead organisations and partners are listed on pages 97–98
Primary prevention of skin cancer in Australia
87
Health Promotion Outcomes
(A)
(B)
Increase in adequate
provision of sun protective
shade in workplaces
Implementation of shade guidelines
Shade measurements conducted
Workplaces involved in Shade and Policy
Awards Scheme
Sun protection products to be tax
deductible
RE
Information on legal obligations available
to employers Acute
and pain
OH&S
representatives
management:
information for consumers
Training programs conducted for
OH&S representatives and employers
Increase in number of sun protection and
shade policies implemented in workplaces
Increase in availability of
sun protection products for
outdoor workers
Increase in number of
workplaces rescheduling
work to avoid outdoor
exposure during the danger
hours
(C)
Increase in use of shade
by outdoor workers
Increase in sun
protection behaviour by
outdoor workers
Decrease in number of
outdoor work hours
scheduled between
11am and 3pm
SC
Positive change in
knowledge, attitudes and
skills of OH&S
representatives, employers
and employees
Increase in number of small business with
sun protection and shade policies
effectively implemented
Number of peer training and education
programs implemented in workplaces
IN
Inclusion of sun protection education as
part of TAFE and training courses for
outdoor workers
General audit sun protection checklist as
part of code of practice
D
Specific Targets
DE
Information on sun protective work
environments provided for those working
in design, architecture and town planning
1. Increase in the percentage of councils with a policy for outdoor workers (Baseline 42%;
White et al., 1993)
2. Decrease in the percentage of councils with no policy for outdoor workers (Baseline 45%;
White et al., 1993)
3. Decrease in the percentage of councils not scheduling activities to limit workers’ exposure between
11am and 3pm (Baseline 90%; White et al., 1993)
4. Increase in the percentage of councils providing some sort of portable shade construction for
outdoor workers when needed (Baseline 26%; White et al, 1993)
5. Increase in the percentage of councils providing long sleeved shirts for sun protection (Baseline 24%;
White et al., 1993)
6. Increase in the percentage of outdoor workers using a high level of solar protection (Baseline 49%,
Girgis et al., 1994)
Primary prevention of skin cancer in Australia
88
Sport, Recreation and Community
Program
Activity
Lead Organisations
and Partners *
Priority (1) within next 2 years
1.1 Develop and implement shade provision policy and
guidelines for local government, sport and recreation
groups and other public buildings and environments
• CC, LGSA, DLG, AIEH, DOH,
DSRR, GA, S&R Clubs/SLSC
RE
Acute pain
management:
1.2 Develop and market
shade
provision measurement
information for consumers
tool/service
• CC, DOH, DSRR, LGSA, DPW, AIEH,
Engineers, S&R Clubs/SLSC
1.3 Develop appropriate sun protection policies and train
and assist in implementation
• CC, DOH, DSRR, LGSA
SC
Priority (2) within next 2 years
• CC, DOH, AIEH, LGSA
2.2 Conduct Shade and Sun Protection Policy Awards
Scheme
• DOH, CC, AIEH
2.3 Conduct Shade and Sun Protection Expo
• CC, DOH, All relevant stakeholders
2.4 Lobby for shade provision to be included in retail,
sport and recreational development planning
DE
IN
2.1` Train and assist with use of shade provision
guidelines and measurement tool/service
• DOH CC, DSRR, AIEH, RACS
• CC, AIEH, LGSA, DOH,
Professional Associations
2.6 Develop community guidelines and information
about shade provision in the home environment
• CC, LGSA, MBA, NA
2.7 Provide the community with access to guidelines and
information about shade provision in the home
environment
• LGSA, MBA, NA, Media
D
2.5 Establish shade provision as a criterion to be met on
building applications and advertise through trade
journals
Priority (3) within next 5 years
3.1 Encourage and assist in appropriate training about
the need for sun protection in sport, community
recreation and other public use environments for
those working in design, architecture and town
planning
• CC, AIEH, TAFE, Universities, LGSA
* Abbreviations for lead organisations and partners are listed on pages 97–98
Primary prevention of skin cancer in Australia
89
Health Promotion Outcomes
(A)
(B)
Implementation of sun protection policies
and shade guidelines
Increase in adequate provision of sun protective shade
Shade measurements conducted
Positive change in attitudes,
knowledge and skills among
sport, recreation and
community groups
Sporting, recreation and community
groups involved in Shade and Policy
Awards Schemes
RE
Inclusion of shade provision in
development and building applications
Acute pain management:
Positive change in knowledge,
attitudes and skills of
participants in sport and
recreation
(C)
Increase in sport and
recreational sun protection
behaviour
Increase in sun protection
behaviour amongst trainers
and recreation leaders
Increase in use of shade by
sport and recreation
participants
information
for consumers agencies to
Local councils
and commercial
agree to provide shade in existing
recreation and outdoor community areas
SC
Guidelines and information on shade
provision for the home environment
available
Information on sun protective
environments included in training for
architects, designers and town planners
DE
Specific Targets
IN
Information in relation to sun protection
and policy implementation available to
sport, recreation and community groups
through education and training
D
1. Increase in the percentage of adolescents who agree that playing sport to avoid the hottest part of the day
is a good idea (Baseline 65%; Sanson-Fisher, 1994)
2. Increase in the percentage of adolescents who agree that sports clubs making members wear hats is a
good idea (Baseline 47%; Sanson-Fisher, 1994)
3. Increase in the percentage of adolescents reporting that sports clubs provide shade for spectators
(Baseline 62%; Sanson-Fisher, 1994)
4. Increase in the percentage of adolescents reporting that sports clubs provide shade for players
(Baseline 48%; Sanson-Fisher, 1994)
5. Increase in the percentage of adolescents reporting that sports clubs require members to wear a hat
while playing (Baseline 19%; Sanson-Fisher, 1994)
6. Increase in the percentage of councils with a policy for providing shade at pools and beaches
(Baseline 11%; White et al., 1993)
7. Increase in the percentage of councils with a formal policy regarding provision of shade in parks and
gardens (Baseline 15%; White el al., 1993)
Grouped Targets
2.
3.
4.
5.
(Detailed on pages 94–95)
Adolescents’ attitudes and intentions to sun protection
Adolescents’ attitudes to sun protection products
Adolescents’ level of protection
Adolescents’ use of sun protection measures
Primary prevention of skin cancer in Australia
6. Beachgoers’ level of protection
7. Beachgoers’ use of sun protection measures
8. Shade cover provided in the community
90
SUN PROTECTION PRODUCTS
Program
Activity
Lead Organisations
and Partners *
Priority (1) within next 2 years
• CC, Industry representatives
1.2 Encourage production of products for adolescents
that are sun protective and fashionable
• CC, FIA, Consumer Groups, Media
RE
1.1 Develop guidelines on shade structures and products
Acute pain management:
for consumers
1.3 Encourage design ofinformation
products
that are specialised for
sport and recreation activities
• CC, DSRR, S&R Clubs, SLSC
Consumer Groups
1.4 Encourage improved sun protection design and fabric
of clothing and hats
• CC, DOH, FIA, MF/MU, Manufacturers
SC
1.5 Develop rating scheme for clothing fabrics (and
possibly shade materials)
• Standards Australia
1.6 Encourage use of SPF15+ in moisturisers and
make-up
• CC, CTFAA, Manufacturers
IN
Priority (2) within next 2 years
2.1 Lobby for waiving of sales tax on clothing, hats and
shade products that meet specified criteria
2.3 Provide information and training to people selling sun
protection products
DE
2.2 Encourage wider distribution of sun protection
products at the retail level particularly at sport and
recreation retail outlets
• CC
• CC, SPSA, All Sports & Recreation Outlets,
RTA
• CC, CTFAA, MF/MU, PG
D
2.4 Ensure sun protective design issues are included in
training/education of designers and architects
• CC, TAFE, Universities
2.5 Establish patterns (dressmakers patterns for home
sewing market) for sun protective clothing
• CC, Industry Representatives
Priority (3) within next 5 years
3.1 Encourage design and marketing of portable shade
products and shade structures
• CC, DOH, Manufacturers
3.2 Encourage wider availability of shade products and
structures at both wholesale and retail level
• CC, RTA, Retailers and
Manufacturers
* Abbreviations for lead organisations and partners are listed on pages 97–98
Primary prevention of skin cancer in Australia
91
Health Promotion Outcomes
(A)
(B)
(C)
Development of guidelines on shade
structures and products
Increase availability of shade
products and structures
Agreement to manufacture and increase
availability of personal sun protection
products particularly for adolescents and
sport and recreation activities
Availability of wide range of
sun protection products
Increased sale and use of
shade and sun protection
products that meet
specified criteria
Ratings on clothing and
fabrics
Ratings scheme introduced for clothing
and fabrics
RE
Availability of clothing and
fabric products that meet
specified criteria
Acute pain management:
Legislation for waiving
of sales tax on
information for consumers
specified clothing, hat and shade
products
Increase in sales people’s
knowledge and skills
Agreement of wholesale and retail bodies
to manufacture and increase availability
of shade structures and products
SC
Positive change in public
knowledge, attitudes and
skills toward sun protection
products
Training programs and information
provided to sales people
DE
IN
Involvement of design and architect
schools in designing sun protective
clothing, hats and shade structures
Specific Targets
1. Increase in the percentage of adolescents who disagree that sunscreens cost too much money (Baseline 55%;
Sanson-Fisher, 1994)
2. Increase in the percentage of councils who encourage the supply of sun protection items through their sale
points (Baseline 70%; White et al., 1993)
3.
4.
5.
6.
7.
8.
(Detailed on pages 94–95)
Adolescents’ attitudes to sun protection products
Adolescents’ level of protection
Adolescents’ use of sun protection measures
Beachgoers’ level of protection
Beachgoers’ use of sun protection measures
Shade cover provided in the community
Primary prevention of skin cancer in Australia
D
Grouped Targets
92
PUBLIC AWARENESS
Program
Activity
Lead Organisations
and Partners *
Priority (1) within next 2 years
RE
1.1 Work with all media, particularly fashion, beauty,
sport and lifestyle media, to encourage coverage of
sun protection issues
• CC, ACD, MF/MU, SCF
Acute pain management:
• CC, DSRR, MF/MU
1.3 Conduct media campaigns targeting identified
barriers to sun protection such as acceptability of
hats and shirts particularly for adolescents
• CC, DOH, MF/MU
1.4 Conduct campaigns directed at reducing high dose
intermittent recreational exposure to UV radiation
(sunburn)
• CC, ACD, MF/MU, Tourism Industry
1.5 Educate advertising and marketing consultants and
television producers about their role in promoting
sun protection
• CC, DOH, ACD, MF/MU, Advertising,
Marketing and TV bodies
IN
SC
information for
consumers
1.2 Create links with sporting
media
and personalities to
promote sun protection
Priority (2) within next 2 years
2.2 Develop a speaker’s network
DE
2.1 Provide information and training about prevention to
health professionals
• CC, DOH, MF/MU, CN
• CC, DOH-AD, GP Groups, MF/MU
2.3 Continue and further develop community
action approaches
D
2.4 Provide information about sun protection to parents
of young children
• CC, CERP, DOH-AD
• CC, DOH-AD, GP Groups, MF/MU, KU,
NMAA, PG
Priority (3) within next 5 years
3.1 Conduct a state wide media campaign on shade
• CC, DOH, Media
3.2 Work with allied health and beauty therapists to
promote prevention
• CC, DOH-AD, MF/MU, TAFE, PA,
H&B, LGSA
* Abbreviations for lead organisations and partners are listed on pages 97–98
Primary prevention of skin cancer in Australia
93
Health Promotion Outcomes
(A)
(B)
Fashion, beauty, sport and leisure
industries join in promoting sun
protection
(C)
Positive change in general
public’s attitudes, knowledge
and skills in relation to sun
protection and sun protection
products
Advertising, marketing and TV
industries join in promoting sun
protection
Increase in sun protection
behaviour
Increase in use of shade
RE
Increased public interest and awareness
in sun protection particularly among
adolescents
Acute pain management:
information for consumers
Involvement of health professionals in
promoting sun protection
SC
Involvement of allied health and beauty
therapists in promoting sun protection
Media join in promoting use of shade
Involvement of community members in
promoting sun protection
DE
Specific Targets
IN
Information available to parents of young
children
1. Increase in media coverage of sun protection and skin cancer issues (Baseline 353 news items;
Sanson-Fisher, 1993)
1.
2.
3.
4.
5.
6.
7.
8.
(Detailed on pages 94–95)
Adolescents’ knowledge
Adolescents’ attitudes and intentions to sun protection
Adolescents’ attitudes to sun protection products
Adolescents’ level of protection
Adolescents’ use of sun protection measures
Beachgoers’ level of protection
Beachgoers’ use of sun protection measures
Shade cover provided in the community
Primary prevention of skin cancer in Australia
D
Grouped Targets
94
Grouped Targets
Group
Descriptor
Targets
1. Adolescents’ knowledge
•
Relevant
Program Activities
•
Increase in the percentage of 11–16
year olds in top third of a positive
attitudes score (Baseline 58%; Sanson-
•
Primary and
Secondary Schools
•
Sport, Recreation
and Community
•
Public Awareness
•
Sport, Recreation
and Community
•
Sun Protection
Products
•
Public Awareness
RE
Increase in the proportion of 11–16
year olds in top third of knowledge
score (Baseline 73%; Sanson-Fisher, 1994)
•
Primary and
Secondary Schools
Public Awareness
Acute pain management:
information for consumers
2. Adolescents’ attitudes
and intentions to sun
protection
•
Fisher, 1994)
SC
•
Increase in the percentage of
adolescents who have an intention to
try to protect themselves as much as
possible (Baseline 32%; Sanson-Fisher,
1994)
•
Increase in the percentage of adolescents who disagree that clothes that
protect you from the sun look daggy
IN
3. Adolescents’ attitudes to
sun protection products
(Baseline 47%; Sanson-Fisher, 1994)
Increase in the percentage of adolescents who agree that wearing a sunscreen is a good idea when playing
sport (Baseline 75%; Sanson-Fisher, 1994)
•
Increase in the proportion of
adolescents agreeing that providing
shade shelters for people playing or
watching sports is a good idea(Baseline
82%; Sanson-Fisher, 1994)
4. Adolescents’ level of
protection
•
D
DE
•
Increase in the percentage of adolescents aged 11–13 yrs who use a high
level of solar protection (Baseline Males
•
•
63%; Females 51%; Sanson-Fisher, 1994)
•
Increase in the pecentage of adolescents aged 14–16 yrs who use a high
level of solar protection (Baseline Males
•
•
Primary and
Secondary Schools
Sport, Recreation
and Community
Sun Protection
Products
Public Awareness
58%; Females 44%; Sanson-Fisher, 1994)
•
Decrease in the percentage of adolescents who had a sore or tender sunburn during summer (Baseline 49%;
Sanson-Fisher, 1994)
Primary prevention of skin cancer in Australia
95
Group
Descriptor
Targets
5. Adolescents’ use of sun
protection measures
Increase in the percentage of adolescents outdoors in the shade (Baseline
•
Primary and
Secondary Schools
•
Sport, Recreation
and Community
•
Sun Protection
Products
•
Public Awareness
SC
•
Relevant
Program Activities
•
Sport, Recreation
and Community
•
Sun Protection
Products
•
Public Awareness
•
•
Child care Centres /
Preschools
•
Primary and
Secondary Schools
•
Increase in the proportion of
beachgoers using the correct head
gear (Baseline 17%; <15yrs 11.1%;
Sport, Recreation
and Community
•
Sun Protection
Products
15–29yrs 22.4%; 30+ yrs 61.2%; Foot et al.,
1993)
•
Public Awareness
14%; Sanson-Fisher, 1994)
•
Increase in the percentage of adolescents wearing a recommended hat
(Baseline 6%; Sanson-Fisher, 1994)
•
Increase in the percentage of adolescents wearing shirt with a collar
RE
(Baseline 20%; Sanson-Fisher, 1994)
Acute pain management:
information for consumers
6. Beachgoers’ level of
protection
•
Increase in the percentage of adolescents wearing sunscreen on their face
(Baseline 39%; Sanson-Fisher, 1994)
•
Increase in the proportion of
beachgoers using a high level of protection
(Baseline 45%; Foot et al., 1993)
•
IN
Increase in the proportion of
beachgoers who have applied sunscreen with SPF 15+ on at least one
part of the body (Baseline 69%; <15 yrs
DE
7. Beachgoers’ use of sun
protection measures
Decrease in the proportion of
beachgoers not using any solar protection (Baseline 16%; Foot et al., 1993)
87%; 15–29yrs 55.5%; 30+ yrs 61.2%;
Foot et al., 1993)
•
D
•
Increase in the proportion of
beachgoers using the recommended
type of shirt (Baseline 3.4%; <15yrs
2.8%, 15–29 yrs 4.1%; 30+yrs 3.4%;
Foot et al., 1993)
Primary prevention of skin cancer in Australia
96
Group
Descriptor
Targets
8. Shade cover provided in
the community
•
•
Relevant
Program Activities
Increase in the percentage of councils
that reported at least some of the play
equipment in their parks had shade
cover (Baseline 21%; White et al., 1993)
Increase in the percentage of pools in
the highest shade level category
•
Sport, Recreation
and Community
•
Sun Protection
Products
•
Public Awareness
(Baseline 10%; White et al., 1993)
•
RE
Increase in the percentage of beaches
in the three highest shade level
categories (Baseline 7%; White et al.,
Acute pain management:
information for consumers
•
1993)
Decrease in the percentage of pools in
the lowest shade level category
(Baseline 38%; White et al., 1993)
Decrease in the percentage of beaches
in the lowest shade level category
SC
•
(Baseline 79%; White et al., 1993)
D
DE
IN
Primary prevention of skin cancer in Australia
97
Abbreviations for Lead Organisations and Partners
ACD .......................................................... Australasian College of Dermatologists
AIEH ........................................................ Australian Institute of Environmental Health
BOS .......................................................... Board of Studies
CC ............................................................. NSW Cancer Council
RE
CCR&CERU ............................................
NSW Cancer Council’s Central Cancer Registry and
Acute pain management:
information for consumers
Cancer Epidemiology Research Unit
CERP ........................................................ NSW Cancer Council’s Cancer Education Research Project
C&I Schools ............................................. Catholic and Independent Schools
SC
CN ............................................................. NSW College of Nursing
Consumer Groups ..................................... Australian Consumer Association and
Australian Federation of Consumer Associations
Corporate Sponsors .................................. Businesses able to support programs by financial or other means
IN
COTA ....................................................... Council on the Ageing
CTFAA ..................................................... Cosmetic, Toiletry and Fragrance Association of Australia
DLG .......................................................... Department of Local Government
DE
DOH ......................................................... Department of Health Head Office
DOH-AD .................................................. Department of Health Area and District Health Services
DPW ......................................................... Department of Public Works NSW
DSE .......................................................... Department of School Education
D
DSRR ........................................................ NSW Department of Sport, Recreation and Racing
Employer Organisations ........................... Employers Federation and industry-based employer organisations
Engineers .................................................. Engineers contacted on a consultancy basis
FIA ............................................................ Fashion Industries of Australia
FOSCO ..................................................... Federation of School and Community Organisations
GA ............................................................ Greening Australia
GP Groups ................................................ For example, Royal Australasian College of General Practitioners
Divisions of General Practice
Rural Doctors Resource Network
Australian Medical Association
Primary prevention of skin cancer in Australia
98
KU ............................................................ Children’s Services
LGSA ........................................................ Local Government and Shires Association and/or Local Councils
MBA ......................................................... Master Builders Association of NSW
MF/MU ..................................................... Melanoma Foundation of the University of Sydney and
the Hunter Melanoma Foundation and/or
the Newcastle and Sydney Melanoma Units
NA ............................................................ Nursery Industry Association of NSW
RE
NHMRC ................................................... National Health and Medical Research Council
Acute pain management:
NMAA ......................................................
Nursing Mothers’ Association of Australia
information for consumers
NSCA ....................................................... National Safety Council of Australia
PA ............................................................. Physiotherapy Association
SC
P&C .......................................................... Federation of Parents and Citizens’ Associations of NSW
PD ............................................................. Properties Directorate, Department of School Education
PG ............................................................. Pharmacy Guild and/or Pharmacies
RACGP ..................................................... Royal Australasian College of General Practitioners
IN
RACS ........................................................ Royal Australasian College of Surgeons
RTA ........................................................... Retail Traders’ Association of NSW
SBCA ........................................................ Small Business Combined Association of NSW
DE
SCF ........................................................... Skin and Cancer Foundation of NSW
Service Clubs ............................................ For example, Lions, Rotary, Apex, Country Womens’ Association
SLSC ........................................................ Surf Lifesaving Clubs
SPSA ........................................................ Swimming Pools and Spa Association
D
S&R Clubs ................................................ All outdoor sporting and recreation clubs and associations
TAFE ....................................................... NSW Technical and Further Education Commission
Workcover ............................................... Workcover Authority
Primary prevention of skin cancer in Australia
information for consumers
National
Child care
centres
ACT
Promote good quality care in
child care centres. Incorporates
one sun protection principle.
Promote school guidelines &
procedures using ACT Cancer
Society’s SUNSMART POLICY
GUIDELINES for schools.
Promotion of policies in local
government.
Primary prevention social
marketing to increase
sun protection amongst
adolescents.
Sun Protection
Policy
Sun Protection
Strategies for NSW
—A Guide for Local
Government
ME NO FRY
Program
Area Serviced &
Target Group
Quality Improvement
and Accreditation
System Handbook
D
Primary prevention of skin cancer in Australia
Adolescents
(11–16)
NSW
state wide
Local
government—
shires
NSW
Schools/ School
Boards
DE
Years
1993
1990 –
1995
annually
1993
1994
IN
Aims
Health Promotion
Branch,
Public Health
Division,
NSW Health
NSW Department of
Local Government
Co-operatives
ACT Cancer Society
ACT Department of
Education and
Training
National Child care
and Accreditation
Council
$360k
$1 100k
$800k
NSW Health
Information not
provided
Information not
provided
Information not
provided
Funding Source &
Agency & Other
Participating Agencies Funding Amount
SC
Project Name
Acute pain management:
Evaluated Primary Prevention Programs in Australia
RE
Appendix B
Qualitative Study in 1994—
report on disk.
—report on disks.
Series of tracking surveys.
(First in 1990/91, but data
incompatible with other years.)
Not Applicable.
12 months trial period—nil
information.
Not Applicable
Evaluation, Design, Outcome
99
Increase solar protection in
outdoor workers.
A workplace
intervention for
increasing outdoor
workers’ use of
solar protection
Primary prevention (and early
detection) SunSmart policy for
primary schools, SunSmart policy
for secondary school, Skin Cancer
Control in NSW Health Promotion
Strategic Plan 1995–96.
D
Improve sun protection related
knowledge, attitudes and beliefs.
NSW schools
NSW state wide,
NSW preschools
and child care
centres
First year
University
students
University of
Newcastle
1990
<1989
NSW Health and
many others
NSW Cancer
Council, Health
Promotion Unit
Not Applicable
Royal Newcastle
Hospital
NSW Cancer
Council—Hunter
region office
Cancer Education
Research Program
Cancer Education
Research Program
NSW Cancer
Council
Information not
provided
Information not
provided
Information not
provided
Funding Source &
Agency & Other
Participating Agencies Funding Amount
information for consumers
NSW Cancer
Council Schools
Project, Childhood
SunSmart Package,
Workplace project
Outdoor workers
in a local electrical supply
authority
NSW Hunter
region
<1994
<1993
II NSW government schools
9–11 year old
school students
Years
Area Serviced &
Target Group
Acute pain management:
Change in behaviour,
beliefs and intentions
for skin cancer
prevention
Interventions to improve solar
protection in primary schools.
Skin Safe
Aims
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IN
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RE
Project Name
Australian Programs (continued)
Monitoring outcomes, program
activity feedback.
Knowledge, attitudes and beliefs,
three groups design. (Information
vs emotional video vs control).
Randomised controlled trial,
Pre-test and post-test measures.
Increases in skin protection
intentions reported.
Significant increase in level of
solar protection used, but no
changes in attitude observed.
Randomised Controlled Trial:
two group, pre-test and post-test,
sun protection behaviour,
knowledge, attitudes and beliefs
assessed.
Randomised controlled trial:
group 1: intensive, group 2:
standard, group 3: control.
Pre-test, two post-test surveys
behaviour, knowledge, attitudes
and beliefs.
Evaluation, Design, Outcome
100
Primary prevention of skin cancer in Australia
Primary prevention of skin cancer in Australia
Safe Summer
Guidelines for
reducing exposure
to solar UV radiation
for school children
Increase provision of shade in
schools.
To encourage healthy lifestyle
habits re: skin protection, healthy
eating and no smoking to reduce
risk of cancer —promote policies
in schools and other health
professionals dealing with target
group.
SA Primary
schools
To promote positive health
messages and harm minimisation
in the areas of: A&D, Sexual
Health, Sun & Skin Care.
1988–91
Years
12–25 year olds
Southern Region
of Tasmania
All department
school and
colleges
TAS state wide
1995
1994
Funding Source &
Agency & Other
Participating Agencies Funding Amount
Anti-Cancer
Foundation, SA
The Link Youth
Health Service plus
community-based
organisations
Tasmanian
Department of
Education and
the Arts
Department of
Community
Health Services
—$19 000
Hobart City
Council—$1 000
Hobart Health
Promotion Group
—$1 225
HIV/AIDS Unit
—$2 000
Peg Putt, MHA
—$100
Information not
provided
Anti-Cancer
Foundation of
SA
information for consumers
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Cancer Free Kids
Area Serviced &
Target Group
Acute pain management:
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IN
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Aims
RE
Project Name
Australian Programs (continued)
Note: No firm evaluation.
Intervention: T-shirt design
competition, “Safe Summer Bus”,
information bags, radio plays,
skin checks, number of surveys
completed, number of items
distributed, qualitative nonsampled feedback.
Not Applicable
Note: Emphasis on policy (not
curriculum), secular trend
towards already having policies
so project did no better than nonproject schools.
Baseline survey (of Principals),
interview (Principal), post-project
survey, no significant
differences in project versus
other schools.
Evaluation, Design, Outcome
101
Primary prevention of skin cancer in Australia
Teenagers/
young adults,
adults in sporting groups,
outdoor workers
and migrant
families.
To produce resources to assist in
the reduction of skin cancer.
To assess the impact of the
interventions on knowledge and
attitudes.
To determine the effects of an
intervention on sun protective
measures in year 8–12 students.
Teenagers
QLD
Children, years
5–12
QLD
Ongoing:
1992/93
Commencement:
1991/92
QLD state wide
Media Campaign
1992–96
1991–95
CHPCPR
Queensland Health
QCF, Education
Department
QCF
CHPCPR
QCF, Education
Department,
Regional Health
Authorities,
EHIB, CPRC
HAB, Queensland
Health
NHMRC
QCF
Queensland
Health
$250 000
Education
Department
Department of
Tourism Sport
and Youth
Queensland
Health =
$412 000
HAB = $200 000
Randomised controlled trial
—in progress.
Guidelines only.
Report to Sun Protection
Working Party NHMRC 1995.
Needs Assessments, Pre- and
post-project surveys (e.g. pools
and beaches–HAB and CPRC),
Annual Reports. Queensland
Sun-Protection Survey, Summer
1992 (outdoors); Slip, Slop, Slap
Has Got Serious —Sun
Protection Campaign Evaluation
1991/92.
Evaluation, Design, Outcome
HAB = Health Advancement Branch; EHIB = Epidemiology and Health Information Branch
NOTE: CHPCPR = Centre for Health Promotion and Cancer Prevention Research (formerly CPRC = Cancer Prevention Research Centre); QCF = Queensland Cancer Fund; NHMRC = National Health Medical Research Council
SCAT—Skin Cancer
and Teenage Project
—high schools
Primary school
teaching resource
Education Dept.
Health Schools
Project funding
To facilitate action in relation to
sun protective policies, sun
protective environments, sun
protective behaviours and early
detection.
Funding Source &
Agency & Other
Participating Agencies Funding Amount
information for consumers
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Queensland Health
Skin Cancer
Prevention Program
Years
Area Serviced &
Target Group
Acute pain management:
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IN
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Aims
RE
Project Name
Australian Programs (continued)
102
Funding Source &
Agency & Other
Participating Agencies Funding Amount
QCF, Education
Department,
Regional Health
Authorities,
EHIB, CPRC
Ongoing:
1992/93
Teenagers/young
adults. Adults in
sporting groups,
and environments
for children, youth
and adults.
Outdoor workers,
children, sports
people, tourists
QLD
Outdoor workers
and migrants
1994–96
1991–
1995
CHPCPR
QCF
HAB, Queensland
Health
Commencement:
1991/92
QLD state wide
intersectoral
policies
Years
Queensland
Health Promotion
Council/Health
Department
$96 000
1992–95
$160 000
HAB,
Queensland
Health
Policy Guidelines.
Guidelines: Sunsafe Sports
Shade Creation Guidelines.
Discussion Paper:
Towards a Policy on the
Prevention and Early Detection
of Skin Cancer 1995.
Enhancing the Early Detection
of Melanoma in Queensland
(EHIB circular #23), CPRP
commissioned project reports.
Evaluation, Design, Outcome
NOTE: CHPCPR = Centre for Health Promotion and Cancer Prevention Research (formerly CPRC = Cancer Prevention Research Centre); QCF = Queensland Cancer Fund; HAB = Health Advancement Branch;
NHMRC = National Health Medical Research Council; QIMR = Queensland Institute of Medical Research; EHIB = Epidemiology and Health Information Branch; CPRP = Cancer Prevention Research Program
To develop a professional resource
document of exemplar policies.
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Primary prevention of skin cancer in Australia
Guidelines for the
Implementation of
a SunSmart Policy
To develop intersectoral policy and
implementation of strategies for
the prevention of skin cancer
across all sectors.
Intersectoral Skin
Cancer Prevention
Policies
Area Serviced &
Target Group
information for consumers
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Aims
Acute pain management:
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Project Name
Australian Programs (continued)
103
Increase awareness of campaign
messages. Reduce skin cancer
incidence, morbidity and mortality.
SunSmart 1988/89
Primary prevention of skin cancer in Australia
NOTE: CBRC = Centre for Behavioural Research in Cancer
Effects changes which facilitate
sun-protection behaviour.
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SunSmart 1989/90
Recognition of campaign features.
Change in hat wearing and use of
sunscreen.
Victoria
Adult public
General
population
General
population:
school students,
outdoor workers,
local government
authorities
Victoria
1988–89
inclusive
1980–86
inclusive
Victoria initially,
then National
Funding Source &
Agency & Other
Participating Agencies Funding Amount
CBRC
Anti-Cancer Council
Victoria
1989–90
inclusive
CBRC
Anti-Cancer Council
of Victoria
CBRC
Anti-Cancer Council
of Victoria
$473 000p.a.
Victorian Health
Promotion
Foundation
$480 000p.a.
Victorian Health
Promotion
Foundation
Anti-Cancer
Council of
Victoria
$50 000p.a.
information for consumers
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Slip, Slop, Slap
Campaign
Years
Area Serviced &
Target Group
Acute pain management:
IN
SC
Aims
RE
Project Name
Australian Programs (continued)
Media campaign, community
programs and school program
Conducted surveys showed
increased awareness of
campaign and change in
primary prevention behaviours.
Multifaceted public education
campaign with pre-post
campaign survey and sun
protection behaviours survey.
Pre-post campaign surveys.
Campaign included mass media
development of materials and
promotion (swimming pools,
beaches). Awareness of
campaign was high and primary
prevention activities increased.
Evaluation, Design, Outcome
104
Continuation of previous programs.
NOTE: CBRC = Centre for Behavioural Research in Cancer
Impact of a skin cancer control
education package for outdoor
workers (Telecom).
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Primary prevention of skin cancer in Australia
Cover yourself
against skin cancer
General
population:
school students
Victoria
Victoria
(Trialled in
Queensland)
All population
groups including
youth
Victoria
1992–93
inclusive
Years
Funding Source &
Agency & Other
Participating Agencies Funding Amount
1989–90
1993–94
inclusive
CBRC
Telecom Australia
Millionaire Marketing
CBRC
Anti-Cancer Council
of Victoria
CBRC
Anti-Cancer Council
of Victoria
Telecom
Australia
$480 000p.a.
Victorian Health
Promotion
Foundation
$480 000p.a.
Victorian Health
Promotion
Foundation
information for consumers
SunSmart 1993/94
Change in knowledge, attitudes
and beliefs to affect positive
choices relevant to skin cancer.
Development of environments
that reduce the risk of UV radiation.
Reduction in sunburn.
SunSmart 1992/93
Area Serviced &
Target Group
Acute pain management:
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IN
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Aims
RE
Project Name
Australian Programs (continued)
Pre-post campaign assessments.
Significant improvement in shirt
use and overall protection—no
effect on hat use or use of shade.
High awareness of campaign.
No change in levels of sun
protective behaviour or the
prevalence of sunburn among
cross-sectional population
samples. Concluded that
current amount of resources
will only maintain gains, not
produce greater change
Notes: 3 months following
“60 minutes” program on
melanoma (case study)—led to
increase in the use of pathology
services.
Extensive use of media, schools,
workplaces and local councils
targeting at risk groups (young
men and women, and high
leisure and work activities).
Evaluation as per previous
years. No further change in
protective behaviours or prevalence of sunburn. Schools
enacted SunSmart practices but
policies were scarce among the
schools.
Evaluation, Design, Outcome
105
Increase sun protection behaviour,
knowledge, attitudes and
beliefs.
Skin Cancer
Prevention Program
for Young People
WA
Schools
WA
D
Improve sun protection related
knowledge, attitudes and beliefs.
11–16 year olds
WA
12–15 year olds
via schools,
organised sport,
local government
1994/95
1992–95
and
ongoing
1994
Years
Funding Source &
Agency & Other
Participating Agencies Funding Amount
WA Education
Department
Cancer Foundation
of WA
Cancer Council of
WA
Information not
provided
$126 000
Healthway
Cancer
Foundation
$413 000 over
4 years
WA Health
Department,
Cancer Council
of WA, other
agencies
information for consumers
ME NO FRY
Campaign =
1994/95 element.
(From NSW Health)
Promotion of policy in schools.
Sun Protection
Guidelines
Area Serviced &
Target Group
Acute pain management:
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IN
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Aims
RE
Project Name
Australian Programs (continued)
High level of awareness of
campaign among target group—
additional details provided.
Surveys of target groups preand post-campaign.
Market research to test initially.
Pre-test and post-test survey
of school children in 1994/95—
details provided.
“Good acceptance” 1991/92,
1992/3—three surveys of young
people attending metro beaches.
Evaluation, Design, Outcome
106
Primary prevention of skin cancer in Australia
107
Appendix C
Submissions Received During Public Consultation
Introduction
RE
As part of the process of developing guidelines and advice about sun protection programs, the NHMRC Health
Advancement Standing Committee invited public submissions on its preliminary work program in April 1995.
Advertisements appeared in The Australian newspaper, and the Commonwealth Government Gazette, and were
Acute the
painStanding
management:
distributed through
Committee’s mailing list. Letters inviting assistance in meeting the objectives of
information
for consumers
the Sun Protection
Programs
Working party were also sent to State and Commonwealth Departments of Health,
Sport and Recreation, Child Care, State Health Promotion Managers, Local Government Departments and
Associations, and Bureaus of Meteorology as well as key organisations and peak bodies in the area of skin cancer
prevention. A total of 41 submissions were received.
SC
In September 1996, the draft report of the Sun Protection Programs Working Party, Primary Prevention of Skin
Cancer in Australia was released for public consultation from 10 October 1996–8 November 1996. The
advertisement inviting submissions on the draft recommendations about primary prevention of skin cancer appeared
in the The Weekend Australian newspaper and the Commonwealth Government Gazette.
The draft report was also sent to the people who had responded to the first stage of consultation, and other key
organisations and peak bodies in the area of skin cancer prevention. Seventeen submissions were received from
the second stage consultation process.
IN
List of submissions
Submissions from the first stage consultation were received from:
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Ms Jeanie McKenzie, Manager Health Promotion, New South Wales State Cancer Council.
2.
Mr Graham Harrington, Deputy Secretary (Education), Department of Eduction and the Arts, Hobart,
Tasmania.
3.
Mr Craig Sinclair, SunSmart Campaign Manager, Anti-Cancer Council of Victoria.
4.
Ms Caroline Dean, Education Officer, Cancer Foundation of Western Australia.
5.
JG Busch, Executive Director, Ministry of Sport and Recreation, Wembley, Western Australia.
6.
Ms Fran Hinton, Australian Capital Territory Department of Education and Training, Children’s and
Youth Services Bureau, Tuggeranong, Australian Capital Territory.
7.
Mr Colin Morrisson, Policy Branch, Office of Local Government, Department of Treasury and Finance,
Melbourne, Victoria.
8.
Ms Geraldine Dawes, Program Support Unit, Queensland Dept of Housing, Local Government &
Planning.
9.
Mr Maurice Swanson, Health Promotion Services, Health Department of Western Australia.
10.
Ms Fiona Mackie, Project Support Officer, Tasmanian Department of Tourism, Sport and Recreation.
11.
Director of Health Advancement Branch, Queensland Health Department.
12.
Ms Carol Procter, State/Local Government Relations Unit, Department of Housing and Urban
Development, Adelaide, South Australia.
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1.
Primary prevention of skin cancer in Australia
108
Mr Brendan Hartnett, Director Policy, Local Government and Shires Association of New South Wales.
14.
Mr Jim McMorrow, Office of the Director-General, New South Wales Department of Training and
Education Coordination.
15.
RF Roodenrys, Local Government Office, Department of Environment and Land Management,
Hobart, Tasmania.
16.
Mr John Waldock, Director, Policy and Research, Local Government Association of Queensland Inc.
17.
Mr Greg Black, Director–General, Education Department of Western Australia.
18.
Ms Addy Carroll, Director, Healthway, Western Australian Health Promotion Foundation.
19.
D Gauntlett, A/g Director of Meteorology, Bureau of Meteorology, Department of the Environment,
Sport and Territories, Melbourne, Victoria.
20.
Acute pain management:
Matti Urvet, Secretary,
Department of Sport and Recreation, Darwin, Northern Territory.
21.
Andy Turner, Environment Coordination and Liaison Branch, Department of the Environment, Sport
and Territories, Canberra, Australian Capital Territory.
22.
Neil McCormack, Principal Education Officer, Northern Territory Department of Education.
23.
Bob Maguire, Group Manager, School and Community Support Branch, Directorate of School
Education, Melbourne, Victoria.
24.
Anne Outram, Prevention and Early Detection Unit, Queensland Cancer Fund.
25.
Yvonne Robinson, Manager, Health Promotion Unit, South Australian Health Commission.
26.
Jo Grey, Health Promotion Manager, Cancer Council of Tasmania.
27.
Danielle McShane, Graduate Research Officer, Department of Health and Community Services, Hobart,
Tasmania.
28.
CJ Russell, Assistant Secretary-General, Local Government Association of South Australia.
29.
Michael Scott, Chief Executive, Office for Recreation, Sport and Racing, Brooklyn Park, South
Australia.
30.
Karin Puels, General Manager, Foundation South Australia.
31.
David Williams, Director-General, Department of Tourism, Sport and Youth, Brisbane, Queensland.
32.
Lyn Stoker, Manager, Health Promotion Branch, New South Wales Department of Health.
33.
Garry Payne, Director General, Department of Local Government and Cooperatives, Bankstown, New
South Wales.
34.
Jan Heslep & Noeleen Tunny, Health Promotion Unit, Blacktown and Mt Druitt Community Health
Services, New South Wales.
35.
Paul Katris, Lions Cancer Institute Inc, Perth, Western Australia.
RE
13.
information for consumers
D
DE
IN
SC
36/37 Dr Lyn Roberts, Manager, Cancer Prevention and Education Unit, Anti-Cancer Foundation, Unley,
South Australia.
38.
Professor Bruce Gray, Professor of Surgery, Medical Director, Lions Cancer Institute Inc, Perth,
Western Australia.
39.
Craig Sinclair, SunSmart Campaign Director, Anti-Cancer Council, Carlton South, Victoria.
40.
Elaine Henry, Executive Director, Cancer Council, Kings Cross, New South Wales.
41.
Dr Fedora Trinker, Executive Director, The Anti-Cancer Foundation of South Australia.
Primary prevention of skin cancer in Australia
109
Submissions from the second stage consultation were received from:
Dr Brendon Kearney, Chairman, NHMRC National Health Advisory Committee, Royal Adelaide Hospital,
South Australia.
2.
Dr Kerry Kirke, Member, NHMRC National Health Advisory Committee, SA Health Commission,
Adelaide, South Australia.
3.
J G Busch, Executive Director, Ministry of Sport and Recreation, Western Australia.
4.
Dr Lin Fritschi, Senior Research Fellow, Department of Epidemiology and Preventive Medicine, Monash
Medical School, Victoria.
5.
Dr Fedora Trinker, Executive Director and Dr Lyn Roberts, Manager, Cancer Prevention & Education Unit,
The Anti-Cancer Foundation of South Australia.
6.
Andrew Acute
Niven,
New South Wales.
painUltimo,
management:
7.
information for consumers
Mr Richard
S Blake, Managing Director, Hamilton Laboratories, Adelaide, South Australia.
8.
Helene Mountford, Hunters Hill, New South Wales.
9.
Mr Terry Slevin, Senior Manager, Education and Research, Cancer Foundation of Western Australia Inc,
Subiaco, Western Australia.
10.
Dr Ron Borland, Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Carlton
South, Victoria.
11.
Dr Michael Crampton, Assistant Secretary General, The Royal Australian College of General Practitioners,
Forrest Lodge, New South Wales.
12.
Rose Moroz, R/Director of Curriculum, Education Department of Western Australia, East Perth, Western
Australia.
13.
Mr Craig Sinclair, SunSmart Campaign Manager, SunSmart, Carlton South, Victoria.
14.
Ms Elizabeth C Percival, Executive Director, Royal College of Nursing Australia, Deakin, Australian
Capital Territory.
15.
Professor John McCaffrey, Queensland Cancer Fund, Queensland.
16.
Elaine Henry, Executive Director, New South Wales State Cancer Council, Kings Cross, New South Wales.
17.
Dr Diana Lange, Chief Health Officer, Queensland Health.
D
DE
IN
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RE
1.
Primary prevention of skin cancer in Australia
110
RE
Acute pain management:
information for consumers
D
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Primary prevention of skin cancer in Australia
111
The National Health and Medical
Research Council
RE
The National Health and Medical Research Council (NHMRC) is a statutory authority within the portfolio of
the Commonwealth Minister for Human Services and Health, established by the National Health and Medical
Research Council Act 1992. The NHMRC advises the Australian community and Commonwealth, State and
Territory Governments on standards of individual and public health, and supports research to improve those
standards.
Acute pain management:
The NHMRC advises
the
Government on the funding of medical and public health research
information
for Commonwealth
consumers
and training in Australia and supports many of the medical advances made by Australians.
The Council comprises nominees of Commonwealth, State and Territory health authorities, professional and
scientific colleges and associations, unions, universities, business, consumer groups, welfare organisations,
conservation groups and the Aboriginal and Torres Strait Islander Commission.
SC
The Council considers and makes decisions on reports prepared by committees and working parties following
wide consultation on the issue under consideration.
A regular publishing program ensures that Council's recommendations are widely available to governments, the
community, scientific, industrial and educational groups.
IN
The Council publishes extensively in the following areas:
• Child health • Clinical practice • Communicable diseases • Dentistry • Drugs and poisons • Drug and
substance abuse • Environmental health • Health ethics • Infection control • Mental health • Nutrition • Public
health • Women’s health.
The Publications Officer
NHMRC
GPO Box 9848
Canberra ACT 2601
Phone:(02) 6289 7646 (24 hour answering machine)
Fax: (02) 6289 8776
Internet: http://www.health.gov.au/nhmrc
Primary prevention of skin cancer in Australia
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A List of Current Publications is available from: