Effective interventions

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Effective interventions

Skin cancer prevention programs delivered throughout Australia by state and territory Cancer Councils have been formed through needs analyses and formative research that has guided the development of effective and appropriately targeted strategies. The health belief model[1] guides strategies that might influence people’s perceived risk and ability to reduce this risk, within supportive environments, to motivate behavioural and attitudinal change.

Once skin cancer prevention programs are implemented, evaluation determines their effectiveness and possible areas for improvement. Site-specific interventions targeting childcare centres, pre-schools, primary and secondary schools, outdoor recreation settings, workplaces and health care settings have been shown to help reduce exposure to UV radiation[2]. Of all settings, the strongest evidence is for the effectiveness of school-based programs in improving knowledge and attitudes and in some cases improving short-term behaviours among primary school aged children.

For skin cancer prevention programs to be most effective, they should adopt a multi-strategic approach that enables a variety of priority groups to be targeted. Glanz, Saraiya and Briss (2004) recommend that programs use individual-directed strategies, environmental, policy and structural interventions, media campaigns and community-wide multi-component interventions[2].

Buller and Borland concluded that comprehensive, community-wide programs can increase sun protection behaviours and reduce UV radiation exposure[3]. These programs are more effective than smaller-scale interventions since they are delivered through multiple channels, creating repeated exposure to consistent sun protection messages. Though more expensive, community-wide interventions may prove the most efficient and cost-effective way to achieve behaviour change.

In addition, skin cancer prevention programs should embrace the recommendations of the Ottawa Charter[4] in relation to public policy development, advocacy strategies, developing personal skills, reorientating health services and strengthening community action.

In 2003, Cancer Council Australia and its members initiated the inaugural national sun survey to determine attitudes, knowledge and behaviours of the community with a specific focus on sun protection behaviours and sunburn incidence of Australian children, adolescents and adults[5]. The survey was replicated in the summer of 2006/2007. The results of this survey provide valuable evidence to guide the development of skin cancer prevention strategies and verification of the effectiveness of the program in the field of sun protection.

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Policy priorities

Need for a long-term national skin cancer awareness campaign

Funding a national multimedia skin cancer awareness and prevention campaign has been shown to be one of the most cost-effective public health investments available to government. A comprehensive cost-benefit analysis conducted in 2008 shows that government investment in such a campaign would returns $2.32 for every $1 invested over 20 years. It would also reduce the number of melanoma cases by 20,000 over that period and deliver $90 million in productivity gains each year[6].

In 2006–07 the Australian Government funded the first national mass media campaign for raising skin cancer awareness, with approximately $6 million. The campaign ran over the subsequent two summers, comprising television, print and radio advertisements aimed at educating young Australians about the importance of protecting themselves from the sun to reduce the risk of skin cancer[7].

In 2009-10 the campaign was stripped back with the removal of the free-to-air television component; funding ceased thereafter. It was, however, successful, with independent analysis indicating it had raised awareness and encouraged sun protection behaviour[5].

Currently there is no commitment to funding a national campaign, despite the body of evidence that points to its effectiveness[6][5].

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Perceptions of tanning

In Victoria, where surveys of summer sun protection attitudes and behaviour and sunburn have been conducted since 1987, sun protection behaviours and attitudes towards tanning began to improve with the launch of skin cancer prevention programs. In particular, improvements were seen in hat and sunscreen use up to the mid-to-late 1990s. However, these and other key indicators have since regressed towards baseline, which coincided with a decrease in funds to support the public health programs, particularly mass media campaigns.

More recently, attitudes and behaviour among both adults and adolescents have improved, coinciding with the introduction from 2006 of a national skin cancer prevention media campaign funded by the Australian Government (Cancer Council Australia, unpublished data). Given the association between sun protection campaigns and community attitudes and behaviours, a long-term government investment in mass media campaigns is essential to reducing skin cancer incidence and mortality. To reinforce the decreasing trend of adolescents seeking a tan in particular, innovative social marketing and new technology should be utilised.

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Changing adolescents’ sun exposure patterns

Adolescents generally adopt sun protection behaviours less frequently than adults; it is more challenging to achieve attitude and behaviour changes among teenagers[8][9][10].

Adolescents spend more time in the sun than any other population group[11]. While they have been shown to understand the dangers of sun exposure, they do relatively few of the behaviours necessary to reduce risk. As well as effective interventions to counter adolescents’ perception of a tan as desirable, it is necessary to reduce the higher rates of sunburn among adolescents compared with the adult population. Supportive environments are also critical, as it has been shown that secondary school students will use rather than avoid shaded areas provided by purpose built shade sails[12].

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Vitamin D: a balanced approach to UV risks and benefits

The sun's UV radiation is the major cause of skin cancer and also the best natural source of vitamin D. Low vitamin D levels have been reported to be associated with an increased risk of bowel cancer, heart disease, multiple sclerosis, falls and bone fractures, infections, diabetes and rheumatoid arthritis; more research is needed for any conclusive evidence to be derived.

Some population groups are more likely to be at risk of low vitamin D or deficiency. Importantly, however, sensible sun protection does not put people at risk of vitamin D deficiency.

Contention continues to emerge about the health risks and benefits of UV radiation exposure in terms of vitamin D, causing potential confusion in the community at a time when reducing skin cancer mortality and incidence remains a major public health challenge for Australia[13]. More work needs to be done to ensure that people are getting enough sun exposure to maintain vitamin D levels, without increasing their risk of skin cancer. People at risk of vitamin D deficiency should seek medical advice (e.g. supplementation may be an option).

The SunSmart UV Alert can be used as a personal tool for people to know when they need to protect themselves from UV radiation caused by the sun and when protection is not generally recommended.

Solariums should never be used to boost vitamin D levels. See the Cancer Council position statements on Risks and benefits of sun exposure and Solariums for more information.

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Promoting the SunSmart UV Alert

The UV Index was developed as an internationally standardised scale to communicate the degree of risk associated with different levels of UV radiation. The World Health Organization (WHO) recommends the use of sun protection when the UV Index reaches 3 or above, to prevent skin damage and particularly sunburn[14].

In 2005, Cancer Council Australia, the Bureau of Meteorology and the Australian Radiation Protection and Nuclear Safety Agency launched the SunSmart UV Alert in Australia[15].

The alert currently appears in various forms (depending on the media) and aims to communicate the maximum UV for each day and forecast times when sun protection is recommended. Qualitative research in 2008 showed the current bell-curve was, in general, poorly understood, and some doubt was expressed regarding its appropriateness for display and use as a daily reminder[16]. Work has since commenced on using the key elements of the alert, rather than the bell curve alone, to improve understanding and action by consumers and key settings groups. Additional work is required to implement effective presentations across a range of media, including TV, radio, print, organisational settings and the emerging area of digital media and smart phones.

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Climate change

Much research to date on health and climate change, specifically increased temperature, has focused on cardiovascular and respiratory illnesses, thermal stress and increased frequency of infectious vector-borne diseases. Little research has investigated the effects of climate change, UV radiation and skin cancer.

However, it is known that temperature is a strong determinant of sunburn for adults and adolescents[5] and next century global warming of 1.1–6.4°C is predicted[17]. Furthermore, early data shows that for each 1°C increase there are estimated increases in the incidence of basal cell carcinoma and squamous cell carcinoma of 3% and 6%, respectively[18].

A Western Australian Health Impact Assessment[19] recognised that climate change would continue to expose most of the population to high levels of UV radiation, with significant health consequences. UV exposure was classified as an extreme risk, i.e. a risk that requires urgent attention at the most senior level and cannot be simply accepted by the community. Advocating for the UV-related health effects of climate change to be on the agenda and contributing to the policy environment will be increasingly important.

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Eradication of solariums

The number of solariums and their commercial profile increased significantly over the decade to 2006[20]. Industry competition thus led to substantial publicity and marketing campaigns waged by solarium operators. However, triggered by the death of Clare Oliver in 2007, and supported by more than 10 years of advocacy by state Cancer Councils, state and territory governments began to consider or introduce legislation governing the solarium industry in 2007[21]. Legislation supported by most jurisdictions restricts access by minors and those with fair skin, among other provisions[22].

The publicity around Clare Oliver’s death raised awareness of the dangers associated with solariums[23]. Following the resulting drop in demand, and the introduction of legislation in several states, a 32% reduction in solarium listings for Australia’s capital cities was recorded between 2006 and 2009. In most cases, larger decreases in solarium numbers have been observed in states where legislation has been introduced[22].

On 1 January 2015, the New South Wales, South Australian, Victorian, Australian Capital Territory, Tasmania and Queensland Governments introduced a complete ban of commercial sunbeds. Western Australia has announced that they will also be banning sunbeds, effective 1 January 2016. There are no commercial solariums currently operating in the Northern Territory.

For an overview of state regulations in this space and for more information about Cancer Council Australia's recommendations, see the Solariums position statement.

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Supporting GPs in skin cancer control

Australia needs to ensure that GP knowledge and skill keeps pace with scientific developments in the detection and treatment of skin cancer. As SunSmart messages advise the general population to seek GP advice about any suspicious spot or lesion, it is critical that GPs are supported in responding to such requests. It is also essential that GPs have the skills and knowledge regarding vitamin D deficiency and appropriate recommendations and treatment options.

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Screening for melanoma

There is insufficient Australian research to support a population-based screening program for melanoma.

More information on melanoma screening tools is available in the Melanoma screening chapter.

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