Skin Cancer Prevention Programs Research Articles

Implications of climate change for skin cancer prevention in Australia

It is estimated that nearly 450,000 Australians get skin cancer every year. Ultraviolet (UV) radiation from sunlight has been identified as the cause of more than 95% of skin cancers in Australia. Accordingly, the focus of skin cancer prevention programs is reducing exposure to UV radiation. In Victoria, improvements in sun protection behaviours and reductions in sunburn and melanoma incidence rates among younger people have been observed since the SunSmart program was established in 1988. However, climate change has the potential to undermine these successes. First, surface UVB radiation is dependent on stratospheric total ozone amounts. While signs of impact of international restrictions on the production of ozone-depleting substances have been observed, improvements have not yet returned ozone to pre-1970s levels. Interactions between ozone depletion and climate change may slow the recovery of the ozone layer and compound increases in UV radiation at some latitudes. Before recovery, it is expected that higher levels of UV radiation will continue in most Australian regions, with an associated higher risk of skin cancer. Indeed, recent data show increases in surface UV radiation throughout Australia since the 1970s. Second, mean temperatures in Australia have increased over the past 30 years and are projected to rise further by 2030. Australian data shows that with higher temperatures, adults spend more time outdoors, are less likely to wear covering clothing and more likely to be sunburnt. Hence, rising temperatures can be expected to result in increases in sun exposure, sunburn and correspondingly, skin cancer risk.

Abstract PL05-05: The Australian skin cancer prevention experience: Lessons learned and global challenges ahead

Abstract Australia has one of the highest skin cancer incidence and mortality rates in the world. The reason for these high rates is due in part to the high ambient UV radiation levels, combined with a predominantly susceptible fair-skinned population. To address this problem, since 1980, Australians have been exposed to social marketing campaigns like SunSmart to raise awareness of skin cancer prevention. These campaigns have used advocacy to influence legislative reforms and mass media alongside interventions in schools, workplaces, and in the community to motivate sun protective behavior. As a result of these interventions it can be demonstrated that social marketing campaigns can be a very effective method to not only motivate behavior change, reduce sunburn, and increase awareness but more importantly, reduce melanoma rates. In addition to this, we have been able to demonstrate that for every $1 the government invests in skin cancer prevention over a 20-year period, it will yield a $2.30 return. This makes skin cancer control a remarkably good investment in public health. However, long-term investment in this area is required otherwise any population gains in behavior are very likely to be quickly eroded. In more recent years, skin cancer prevention programs worldwide have faced significant challenges in particular from the sunbed industry as well as increased awareness by the general population of vitamin D and its potential positive health benefits. To address these issues, Australia now has a comprehensive approach to manage sunbed operations that include legislative requirements to restrict under 18 access, ban people with skin type 1, and the licensing of operators. Due to these intervention and increased awareness, there has been a decrease of up to 50% in the number of sunbed operators in Australian cities, a downturn not seen anywhere else in the world. In addition to this, considerable effort has gone into managing the issues associated with vitamin D to the point now where the SunSmart program is an authoritative voice to advise people when they should use sun protection, but also when they should not. Citation Information: Cancer Prev Res 2010;3(12 Suppl):PL05-05.

Marital status and stage at diagnosis of cutaneous melanoma

We evaluated the effect of marital status on risk of late-stage cutaneous melanoma diagnosis. Information about melanoma patients was obtained from Surveillance Epidemiology and End Results (SEER), 1973-2006. A multivariable logistic regression model was used to estimate relative risks of late-stage disease at diagnosis. After exclusion criteria, 192,014 adult melanoma patients remained for analyses. After adjustment for age, race, year of diagnosis, tumor histology, anatomic site, socioeconomic status, and SEER site, the relationship between estimated risk of late-stage melanoma diagnosis and marital status was dependent on sex (P < .0001 for interaction). Although unmarried patients had a higher risk of being diagnosed at a late stage among men and women, the magnitude of the effect varied by sex. Moreover, among married, single, and divorced or separated patients, men had more than a 50% increase in risk of late-stage diagnosis when compared with women. Widowed men and widowed women, however, were not statistically different in their stage at diagnosis. Results from this study are important and may be used by clinicians and public health practitioners interested in increasing the proportion of melanoma patients diagnosed at an early stage through screening, perhaps by specifically targeting unmarried individuals in addition to having broad-based skin cancer prevention programs.

Individual and setting level predictors of the implementation of a skin cancer prevention program: a multilevel analysis

BackgroundTo achieve widespread cancer control, a better understanding is needed of the factors that contribute to successful implementation of effective skin cancer prevention interventions. This study assessed the relative contributions of individual- and setting-level characteristics to implementation of a widely disseminated skin cancer prevention program.MethodsA multilevel analysis was conducted using data from the Pool Cool Diffusion Trial from 2004 and replicated with data from 2005. Implementation of Pool Cool by lifeguards was measured using a composite score (implementation variable, range 0 to 10) that assessed whether the lifeguard performed different components of the intervention. Predictors included lifeguard background characteristics, lifeguard sun protection-related attitudes and behaviors, pool characteristics, and enhanced (i.e., more technical assistance, tailored materials, and incentives are provided) versus basic treatment group.ResultsThe mean value of the implementation variable was 4 in both years (2004 and 2005; SD = 2 in 2004 and SD = 3 in 2005) indicating a moderate implementation for most lifeguards. Several individual-level (lifeguard characteristics) and setting-level (pool characteristics and treatment group) factors were found to be significantly associated with implementation of Pool Cool by lifeguards. All three lifeguard-level domains (lifeguard background characteristics, lifeguard sun protection-related attitudes and behaviors) and six pool-level predictors (number of weekly pool visitors, intervention intensity, geographic latitude, pool location, sun safety and/or skin cancer prevention programs, and sun safety programs and policies) were included in the final model. The most important predictors of implementation were the number of weekly pool visitors (inverse association) and enhanced treatment group (positive association). That is, pools with fewer weekly visitors and pools in the enhanced treatment group had significantly higher program implementation in both 2004 and 2005.ConclusionsMore intense, theory-driven dissemination strategies led to higher levels of implementation of this effective skin cancer prevention program. Issues to be considered by practitioners seeking to implement evidence-based programs in community settings, include taking into account both individual-level and setting-level factors, using active implementation approaches, and assessing local needs to adapt intervention materials.

Analysis of Participatory Photojournalism in a Widely Disseminated Skin Cancer Prevention Program

This article describes the content of pictures submitted to a photo contest as part of a nationally disseminated skin cancer prevention program called Pool Cool. The aims of this analysis are to describe sun-safety behaviors and environmental supports depicted in the photos and to gain insight into pool staff perceptions of the program. A directed approach was used to assess the content of 1,886 photos submitted in 2005 and 2006. Staying in the shade and applying sunscreen were the most common sun-safety behaviors shown among children. Among adults and lifeguards, wearing sunglasses and a shirt with sleeves were most common. Most photos contained at least one sun-safety support, and half showed use of Pool Cool program materials. Most photos promoted the use of Pool Cool materials, sun-safety behaviors, or sun-safe pool environments. Participatory photojournalism is a low-cost and effective way to generate widespread interest and support for community health promotion programs.

Internet based health promotion campaign against skin cancer – Results of www.skincheck.ch in Switzerland

Conventional skin cancer prevention programs appeal to limited populations, and the middle aged male population responds less frequently. Our objective was to establish a complementary health promotion campaign tool for skin cancer prevention. Internet-based education, instruction for self assessment and teledermatological evaluation of skin lesions by an expert commission of dermatologists was used. Compliance and clinical diagnosis was assessed in a subgroup. 12,000 users visited the educational website. There was strong interest among the middle aged male population (53% (N = 262): male; mean age: 42). 28.5% of examined lesions (N = 494) were considered suspicious. Email requests, sent to the group whose lesions where considered suspicious, were answered by 46.0% of females (N = 29) and 59.7% of males (N = 46) with a female distribution predominantly in younger ages (52.6% of females with known age: < 30 years). Males were predominantly represented over 30 years (86.2% of all males). According to user's declarations, at least 8 (8.5%) malignant lesions (1 melanoma in situ, 1 squamous cell carcinoma, 4 basal cell carcinomas, 2 malignant lesions without declared diagnosis) were finally diagnosed by physicians. We conclude that internet-based, interactive, educational programs, in addition to existing health promotion campaigns, can enhance public participation in the middle aged male population in skin cancer prevention.

Economic evaluation of skin cancer prevention in Australia

Objectives Australia has the highest incidence of skin cancer in the world, despite prevention campaigns being implemented since the early 1980s. This study assesses the cost-effectiveness of a skin cancer prevention program (named SunSmart) since it was introduced, together with its potential cost-effectiveness as an upgraded and ongoing national program. Methods The reduction in melanoma incidence attributable to SunSmart was modelled as the primary end-point. Historical expenditures on SunSmart were obtained from representative Australian states in three latitude zones. Melanoma incidence rates from these states were used to model key health outcomes. Non-melanoma skin cancer was modelled separately based on national survey results. Results We estimate that SunSmart has averted 28,000 disability-adjusted life-years (DALYs), equivalent to 22,000 life-years saved, in the state of Victoria since its introduction in 1988, as well as saving money from cost offset in skin cancer management (dominant). An upgraded national program for the next 20 years is estimated to avert 120,000 DALYs, with associated reductions in the use of health care resources. It remains a dominant intervention in which every dollar invested in SunSmart will return an estimated AU$2.30. Conclusions This study demonstrates that a sustained modest investment in skin cancer control is likely to be an excellent value for money.

Linking Agents' Activities and Communication Patterns in a Study of the Dissemination of an Effective Skin Cancer Prevention Program

Linking agents connect program developers with end users, enhancing implementation and sustainability of health promotion programs. However, little is known about how linkage systems work in practice and research settings. This article describes the activities and communication patterns of field coordinators in a 4-year, national study of the dissemination of an effective skin cancer prevention program. Descriptive and content analyses were completed for all e-mails between field coordinators and program staff and for field coordinator activity logs. A total of 5,215 e-mails were sent to or from 62 field coordinators from 2003 to 2006. E-mails most often concerned program administration, data collection, and management of program materials. The most common activities recorded in activity logs were communication with program staff and study sites, management of surveys, and delivery and management of program materials. Field coordinators carried out activities related to program administration and data collection across a large number of study sites. The high volume of e-mails and their emphasis on program administration issues demonstrate the importance of communication between program staff and field coordinators. It is recommended that public health researchers and practitioners implement similar linkage systems when taking effective programs to scale.

A Multi-Method Process Evaluation for a Skin Cancer Prevention Diffusion Trial

This article describes process evaluation methods for the Pool Cool diffusion trial across 4 years. Pool Cool is a skin cancer prevention program that was found to improve behaviors and environments for sun protection at swimming pools in a randomized efficacy trial, which was followed by a national diffusion trial. The process evaluation focus shifted from measuring program satisfaction to assessing widespread program implementation, barriers and facilitators to implementation, and program maintenance and sustainability. Data collection methods include training surveys, database tracking, field coordinator activity logs, e-mails, surveys of parents, lifeguards and pool managers, and process evaluation interviews and site visits. The data revealed high levels of implementation of major program components when disseminated in the diffusion trial, including sun safety lessons, sun safety signs, and sunscreen use. This article describes program features and participant factors that facilitated local implementation, maintenance and sustainability across dispersed pools such as linkage agents, a packaged program, and adaptations of program elements.

Lifeguards' Sun Protection Habits and Sunburns

To examine associations among outdoor pool environments, social norms, pool policies, and participation in a sun safety program with lifeguards' sun protection habits and sunburn. Cross-sectional survey. Outdoor swimming pools across the United States. Lifeguards and aquatic instructors at pools participating in the Pool Cool skin cancer prevention program in 2001 (N = 699) and 2002 (N = 987). Sun protection habits and number of sunburns. Social norms supporting sun safety were associated with more sun protection habits (95% confidence intervals [CIs], 0.18-0.28 in 2001 and 0.17-0.26 in 2002), as were pool policies supporting sun safety (95% CI, 0.02-0.07 in 2001 and 0.002-0.04 in 2002). There was a trend toward fewer sunburns as social norms, pool policies, and participation in the Pool Cool program increased, but results differed across the 2 years. In 2001, lower social norms scores and pool policy scores were associated with more reported sunburns. In 2002, teaching Pool Cool sun safety lessons was associated with fewer sunburns. The pool environment is related to sun safety behaviors of outdoor pool staff, with social norms showing the strongest association.

Child sun protection: Sun‐related attitudes mediate the association between children's knowledge and behaviours

To describe and investigate the relationship among the sun-related knowledge, attitudes and behaviours of New Zealand primary schoolchildren and consider the roles of sex and school year level. A randomly selected, two-stage cluster sample of 488 children from 27 primary schools in five regions of New Zealand was surveyed regarding their sun-related knowledge, attitudes and behaviours. A scoring system was used to assign a knowledge, attitude and behaviour score to each child. Although knowledge increased with school year level, there was a decline in sun protective attitudes and behaviours. There was little variation in knowledge, attitudes and behaviour between boys and girls, but sex-year level interactions were found for knowledge and behaviour. When considering children's knowledge, attitudes and behaviours simultaneously, knowledge was only significantly associated with behaviours when mediated by attitudes. When targeting child sun protection and skin cancer prevention programmes, a focus on attitudes towards sun exposure and a suntan may prove beneficial in influencing sun-related behaviours.

Effectiveness of a Targeted, Peer-Driven Skin Cancer Prevention Program for Lifeguards

Lifeguards working at outdoor pools typically receive high amounts of sun exposure, increasing their risk for developing skin cancer. This study evaluates the effectiveness of a targeted, peer-driven intervention for skin cancer prevention among lifeguards. Nine pools received the targeted intervention, Pool Cool Plus, and five received the standard Pool Cool prevention program. Lifeguards completed surveys at the beginning and end of the summer. Lifeguards in both the targeted intervention and standard program groups increased their sun safety practices and reported more sun-safe pool policies and environments. Sunburn rates decreased among lifeguards participating in Pool Cool Plus. Future research should test the feasibility and effectiveness of disseminating the Pool Cool Plus program.

Increasing Sun Protection in Winter Outdoor Recreation: A Theory-Based Health Communication Program

Unprotected and excessive exposure to ultraviolet radiation (UVR) is the primary risk factor for skin cancer.A pair-matched, group-randomized, pre-test/post-test, quasi-experimental design, with ski resorts as the unit of randomization, tested the effectiveness of Go Sun Smart, a multi-channel skin cancer prevention program. Independent samples of guests were taken at baseline (2001) and follow-up (2002); data were analyzed in 2006.A total of 6516 adult guests at 26 ski areas in the western U.S. and Canada were recruited, consented, and interviewed on chairlifts. This study was nested within an occupational intervention for ski area workers.Ski areas were pair-matched and randomized to receive Go Sun Smart, which consisted of print, electronic, visual, and interpersonal skin cancer prevention messages.Sun-protection behaviors, sunburning, recall of sun-protection messages, and the association of message exposure to sun protection.The difference in recall of all sun-protection messages, messages on signs and posters, and the Go Sun Smart logo was significant between the intervention and control resorts. Reported use of sun-protection practices was higher by guests at intervention ski areas using more (a higher dose of) Go Sun Smart materials. Intervention-group guests who recalled a sun-safety message were more likely to practice sun safety than intervention-group guests who did not recall a message and control-group guests.While the mere implementation of Go Sun Smart did not produce sun-safety improvements, Go Sun Smart appeared to be effective for guests who encountered and remembered it. Many factors can work against message exposure. Signage seemed to produce the greatest increase in exposure to sun-safety messages.

Use of Sun-Protective Clothing at Outdoor Leisure Settings from 1992 to 2002: Serial Cross-sectional Observation Survey

Previous population-based surveys to monitor sun protection behavior over time have relied on self-report, which can be subject to recall and misclassification bias and social desirability bias. The present study aimed to describe the prevalence and determinants of teenagers' and adults' observed sun protection behavior while engaged in outdoor leisure activities on summer weekends, over a decade of the SunSmart skin cancer prevention program, which involved public education and advocacy. Serial cross-sectional observational field surveys of teenagers and adults at leisure were undertaken during summer weekends between 11 a.m. and 3 p.m., from 1992 to 2002 (N = 46,810). The four types of setting for observation were parks and gardens, golf courses, tennis courts, and pools and beaches, located within a 25-km radius of Melbourne city center, Australia. The main outcome measure was a binary clothes cover index representing persons above or below the median level of body cover for each type of leisure setting. The index was based on the proportion of body surface covered by the type of hat, shirt, and leg cover garments worn. Body cover varied by environmental factors and the activity demands and demographic characteristics of individuals. After adjusting for covariates, significant improvements in the extent of body cover occurred over the decade, such that the odds of the proportion of people wearing clothes cover above the median level increased by 3% per year (95% confidence interval, 2-4%). Results suggest that significant gains in sun-protective behavior have occurred, coincident with the conduct of an ongoing comprehensive skin cancer prevention program.

Weekend Sun Protection and Sunburn in Australia: Trends (1987–2002) and Association with SunSmart Television Advertising

The Australian state of Victoria has run a population-based skin cancer prevention program called SunSmart since 1988, incorporating substantial public education efforts and environmental change strategies. Trends over 15 years in behavioral risk factors for skin cancer were examined in a population exposed to the SunSmart program. Whether outcomes were associated with extent of SunSmart television advertising was then assessed. In nine cross-sectional surveys from 1987 to 2002, 11,589 adults were interviewed by telephone about their sun exposure and sun protection during outdoor activities on summer weekends. Analyses completed in 2007 adjusted for ambient temperature and ultraviolet radiation. Sun protection and sunburn show substantial general improvement over time, but have stalled in recent years. Use of hats and sunscreens significantly increased over time and peaked during the mid to late 1990s, compared with the pre-SunSmart baseline. The mean proportion of unprotected skin was reduced and was lowest in the summer of 1997-1998. Summer sunburn incidence declined over time and was 9.1% in 2002, almost half baseline (OR=0.53; 95% CI=0.39-0.73). Higher exposure to SunSmart advertising in the 4 weeks before the interview increased: (1) preference for no tan, (2) hat and sunscreen use, and (3) proportion of body surface protected from the sun. The general improvement in sun-protective behaviors over time highlight that a population's sun-protective behaviors are amenable to change. Population-based prevention programs incorporating substantial television advertising campaigns into the mix of strategies may be highly effective in improving a population's sun-protective behaviors.

Photoprotection by clothing

Photodermatology, Photoimmunology & PhotomedicineVolume 23, Issue 6 p. 264-274 Photoprotection by clothing Peter Gies, Peter Gies Ultraviolet Radiation Section, Non Ionizing Radiation Branch, Australian Radiation Protection and Nuclear Safety Agency, Yallambie, Vic., AustraliaSearch for more papers by this author Peter Gies, Peter Gies Ultraviolet Radiation Section, Non Ionizing Radiation Branch, Australian Radiation Protection and Nuclear Safety Agency, Yallambie, Vic., AustraliaSearch for more papers by this author First published: 01 November 2007 https://doi.org/10.1111/j.1600-0781.2007.00309.xCitations: 52 Corresponding author: Peter Gies, PhDUltraviolet Radiation SectionNon Ionizing Radiation BranchAustralian Radiation Protection and Nuclear Safety Agency619 Lower Plenty RoadYallambie VIC 3085AustraliaTel: +61 3 9433 2211Fax: +61 3 9432 1835e-mail: Peter.Gies@arpansa.gov.au Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume23, Issue6December 2007Pages 264-274 RelatedInformation

Process evaluation of the Pool Cool Diffusion Trial for skin cancer prevention across 2 years

Though process evaluation of health programs has received growing attention, few interventions have reported process evaluation over multiple years. This article describes 2 years of process evaluation (2003-04) for the Pool Cool Diffusion Trial. Pool Cool is a skin cancer prevention program designed to increase sun protection habits among children and improve organizational and environmental supports for sun protection at swimming pools. Each year, 80 telephone interviews and 40 site visits at pools across the United States were completed, to examine how fully the program was implemented and the extent of use of program components between the two study conditions. Major components of the Pool Cool program, including sun safety lessons, sun safety signs and sunscreen use, had high implementation. Between the 2 years, most of the core elements were either maintained or increased in use. There were no significant differences between the basic and enhanced conditions on implementation. Reasons given for successful implementation were the provision of a toolkit, ease of implementing the program, pool staff and children enjoying the program and the field coordinators' support. These data provide information on programmatic factors that contribute to successful program diffusion.

Solar UVR Exposure, Concurrent Activities and Sun-Protective Practices Among Primary Schoolchildren

Comprehensive measures of ultraviolet radiation (UVR) exposure, concurrent activities and sun-protective practices are needed to develop and evaluate skin cancer prevention and sun protection interventions. The UVR exposures of 345 primary schoolchildren at 23 schools around New Zealand were measured using electronic UVR monitors for 1-week periods over 12 weeks in 2004 and 2005. In addition, ambient UVR levels on a horizontal surface were measured on-site at each school. Children completed activity diaries during the period UVR measurements were made and provided information on their indoor and outdoor status and clothing and sun protection worn. Mean total daily UVR exposure (7:00-20:00 h NZST + 1) at the body location where the UVR monitors were worn was 0.9 SED (standard erythemal dose, 1 SED = 100 J m(-2)). This was 4.9% of the ambient UVR on a horizontal surface. Mean time spent outdoors was 2.3 h day(-1). Differences in children's UVR exposure could be explained in part by activity, where outdoor passive pursuits were associated with higher UVR exposure rates than outdoor active and outdoor travel pursuits. Compared with older children, the activities of younger children, although labeled the same, resulted in different UVR exposures, either as a result of reporting differences or a real difference in UVR exposure patterns. UVR exposure rates were generally higher on weekdays compared with the weekend, confirming the important role of school sun protection and skin cancer prevention programs. High UVR exposure activities included physical education, athletics and lunch break.

Sunlight, skin cancer and vitamin D: What are the conclusions of recent findings that protection against solar ultraviolet (UV) radiation causes 25-hydroxyvitamin D deficiency in solid organ-transplant recipients, xeroderma pigmentosum, and other risk groups?

A connection between vitamin D deficiency and severe health problems including various types of cancer has been demonstrated. We have shown that patients that have to protect themselves against solar UV radiation for medical reasons, including patients with xeroderma pigmentosum (XP), basal cell nevus syndrome (BCNS), lupus erythematodes (LE) or transplant recipients, are at risk to develop vitamin D deficiency. We conclude that 25-hydroxyvitamin D serum levels as a measure of vitamin D status have to be analyzed in patients that have to protect themselves against solar UV radiation for medical reasons. Suboptimal vitamin D status has to be substituted (e.g. via oral treatment) to protect against serious vitamin D deficiency-related health problems without increasing the risk to develop solar UV-induced skin cancer. Our finding that protection against solar UV radiation causes vitamin D deficiency underlines the need for re-defining dermatological recommendations for solar UV protection in skin cancer prevention programs.

Motives of Belgian Adolescents for Using Sunscreen: The Role of Action Plans

The first objective of this study was to analyze the differences between adolescents who use sunscreen frequently and those who do not. The second objective was to explore the importance of specific action plans when planning sunscreen use. Data was gathered among 602 Belgian secondary school students. Frequent and infrequent users of sunscreen were compared on several determinants related with sunscreen use, and a regression analysis on sunscreen use was done. Frequent users of sunscreen measures had significantly higher scores on attitudes, social influence, self-efficacy, some awareness factors, intention, and action plans. The integrated model for exploring motivational and behavioral change (I-Change model) explained 57% of the total variance of using sunscreen every 2 hours. Frequent sunscreen use was most strongly predicted by action plans, followed by positive intentions to use sunscreen, wearing protective clothing, seeking shade, attitude toward sunscreen use, education, social influence, and exposure to the sun. Our results suggest that skin cancer prevention programs aimed at promoting sunscreen use need to emphasize the advantages of sunscreen to infrequent users and to increase feelings of self-efficacy. Moreover, support by friends and parents should be stimulated. Finally, developing specific action plans for the use of sunscreen should be promoted to more effectively translate general intentions into actual sunscreen use.