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Perceptions of melanoma risk among Australian adolescents: barriers to sun protection and recommendations for improvement

Perceptions of melanoma risk among Australian adolescents: barriers to sun protection and... melanoma, with an annual incidence Objectives: To explore adolescents’ perceptions of melanoma risk, sun protection intervention Arate of 49.8 cases per 100,000 preferences and perceived barriers to sun protection recommendations. population, more than double the incidence reported in other predominantly Caucasian Methods: Semi-structured focus groups were held in school classes, stratified by location nations such as the US (14.2 per 100,000 (coastal, inland) and sector (public, private); discussions were transcribed verbatim and data population) and the UK (12.5 per 100,000 were analysed using NVivo8 software. population). Melanoma is also the most Results: 100 students (mean age=14.4 years, SD=0.5; range=14-16 years) from six high common cancer among Australians aged schools participated. Students demonstrated a high level of sun protection knowledge and between 12 and 24 years, disproportionately understanding of sun exposure as a primary risk factor for the development of melanoma. affecting Australia’s youth. The incidence of There was, however, an under-estimation of melanoma prevalence and mortality rates among melanoma among Australian 15-39 year olds youth, and poor understanding of the increased risk associated with sunburn during childhood/ (18.7 per 100,000 population) is more than adolescence. Adolescents’ preferences for intervention focused on first-person accounts of double that of the US and UK (8.1 and 8.3 receiving a melanoma diagnosis, communicated by young melanoma survivors. Interventions cases respectively per 100,000 population modelled on youth marketing campaigns or utilising social media were rated poorly. aged between 15 and 39 years). Conclusions: Despite young Australians’ adequate knowledge of melanoma and related health The primary preventable risk factor for recommendations, poor adherence continues to place young people at risk. Study findings developing melanoma is exposure to solar suggest that social media interventions developed to influence behaviour change, are not ultraviolet (UV) radiation. Excessive sun necessarily preferred by adolescents. exposure and sunburn during childhood Key words: melanoma, adolescents, perceived risk, intervention, attitudes and adolescence substantially increases risk 5,6 for the later development of melanoma. As such, over the past 30 years, sun safe sun protection guidelines. Almost half post intervention, yet few improvements in messages have been at the forefront of 10,11 of Australian adolescents (aged 12-17 behaviours. public health campaigns across Australia, years) continue to report a desire to tan Decision-making theories such as the Theory and sun exposure during childhood has been 12 (45%), almost one-third of adolescent girls of Planned Behaviour and health behaviour directly targeted through sun safe policies 13 deliberately tan (29%) and one-fifth (20%) models such as the Health Belief Model, implemented in primary schools around the of all adolescents are sunburned on an infer that individuals ‘compute’ whether or country, such as the ‘no hat, no play’ rule. average summer weekend, according to the not to engage in a particular behaviour (such These campaigns have continued to raise most recent National Sun Protection Survey as sun protection) by estimating risks and awareness; in 2012, 98% of Australians could 9 completed in 2011. Furthermore, only 24% rewards, with behavioural options considered correctly identify exposure to the sun as a risk of adolescents reported using two or more and acted on based on the balance factor for the development of melanoma. sun protection strategies (such as shade and between these competing factors. Greater However, despite this awareness, sun sunscreen use, or wearing a hat, clothing understanding of the issues adolescents protection behaviours remain suboptimal. or sunglasses) on summer weekends. weight as important in their decision-making Adolescents, more than any other group, Unfortunately, interventions targeting sun process is needed, including the influence of 14,15 continue to ignore health messages and protection behaviours within this age group appearance and adolescents’ tolerance report poor cooperation with recommended consistently show improved knowledge of risk as related to future events not related 1. Discipline of Paediatrics, School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales Australia 2. Psychosocial Research Group, Prince of Wales Clinical School, University of New South Wales Australia Correspondence to: Dr Jordana McLoone, Kids Cancer Centre, Level 1, Sydney Children’s Hospital, High St, Randwick, NSW 2031; e-mail: Jordana.Mcloone@unsw.edu.au Submitted: September 2013; Revision requested: October 2013; Accepted: January 2014 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38:321-5; doi: 10.1111/1753-6405.12209 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 321 © 2014 Public Health Association of Australia McLoone et al. Article to their current self-identity (e.g. a strong, explored adolescents’ preferences regarding desirable. Images ranged from no tan (image healthy, young person). intervention design, content and format. 1) to very darkly tanned (image 5). These images were created by New Knowledge This study aimed to develop a better A semi-structured discussion guide was understanding of Australian adolescents’ Directorate Ltd (www.nkd.org.uk) specifically developed, based on a review of the perceptions of melanoma risk and explore for GenoMEL, the Melanoma Genetics relevant literature and expert input from the whether perceptions affect adherence to sun Consortium (www.genomel.org), and were multidisciplinary research team. The focus protection guidelines and the maintenance used with permission from the creators. groups were facilitated by three, female post- of risky behaviours, such as unprotected doctoral researchers, experienced in focus or excessive sun exposure and intentional Analysis group delivery and qualitative methodology tanning, despite the relatively high risk of (JM, BM, EZ). Facilitators summarised focus Transcripts were analysed using the developing melanoma in Australia. The study group sessions and discussed emerging qualitative approach described by Miles also explored adolescents’ perspectives on themes concurrent with the collection of and Huberman. Themes were derived how researchers, health professionals and data to establish additional lines of enquiry in inductively from the data by a member of educators may be able to improve health 20-22 subsequent focus groups and to discontinue the research team (MS) and organised behaviours amongst adolescents, through a sampling once saturation of information into meaningful hierarchical clusters using qualitative exploration of their preferences and themes was achieved, as is standard in QSR NVivo 8 software. A manual of coding and perspectives on various modes of 17,18 qualitative methodology. Focus group definitions was developed by the research intervention dissemination. interviews lasting an average of 35 minutes team and an audit log was maintained to (range 25-50 minutes) were conducted record the development of the coding tree. between July and November 2010. They were A random 10% sample of the transcribed Method transcribed verbatim for further coding and data was re-coded by a different member of Participants and procedure analysis using QSR software, NVivo 8. the research team (BM), experienced in the Approval was obtained from the use of QSR NVivo, to ensure coding accuracy Immediately following the focus group 23-25 relevant research ethics committees. and reliability. Any discrepancies in discussion, participants completed a brief, coding were discussed with the team until a The principals of 23 schools in Sydney, self-administered questionnaire that included consensus was reached. Descriptive statistics Australia, were mailed a study invitation letter. the following measures: were used to explore quantitative data, using Purposive sampling of schools was used Demographics: Age, sex, country of birth, the Prediction Application Software (PASW) to maximise heterogeneity of the sample, ancestry and language most commonly Statistics 17.0. to provide as diverse a range of views and spoken at home were assessed, as well as beliefs as possible. Grade nine students from participants’ self-rated skin tone using a participating schools were given a participant Table 1. Preferences for the format of sun protection 4-point scale ranging from ‘very fair’ to ‘dark’. information letter and consent form requiring interventions. Information dissemination preferences: A parental consent prior to focus group Format Preference Rating brief written description of nine modes of participation. Movie tickets and sunscreen Mean SD information dissemination was provided products were given to acknowledge Talk by an expert 3.37 2.40 (Table 1). Participants ranked the order of students’ time participating in the study. Facebook group 4.12 2.57 each medium in order of preference (1=most Informative DVD 4.39 2.78 Focus groups were used to explore preferred to 9=least preferred) for receiving Information Website 4.70 2.27 participants’ beliefs about, and understanding information about melanoma risk and related Pamphlet 5.37 2.47 of, sun exposure as a risk factor for the health behaviours. Email 5.74 2.34 development of melanoma; personal Appearance-based preferences: Five photos Twitter 5.85 2.32 perceptions of risk of developing skin of a young man and woman in swimwear CDROM 6.04 2.32 cancer; perceived benefits of, and barriers were presented to participants, with each SMS 6.58 2.49 to, co-operation with recommended photo manipulated to incrementally increase Note: Participants were asked to rate the intervention formats from sun protection guidelines; and current most to least preferred format. A score of “1” was used to indicate a the depth of the models’ tan (Figure 1). patterns of sun exposure, sun protection participant’s first preference, continuing through to a score of “9” to Participants were asked to indicate which indicate their last preference (that is, a lower score indicates a higher and skin examination. The focus group also shade of tan they believed was the most preference). Figure 1: Images of adolescents with an increasingly tanned appearance. * Image provided courtesy of GenoMEL; photographer Vasko (iStockphoto). 322 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Perceptions of melanoma risk among Australian adolescents of the physical education curriculum, or that, girls reported using sun protection to limit Results “In science we studied skin cancers” (female, the development of freckles and wrinkles, In total, 11 focus groups were conducted; coastal, private). Students reported that and used a sunscreen in their moisturiser or students were recruited from six high schools melanoma was “quite prevalent in Australia” foundation. (from 23 invited schools), which represented (female, inland, public), though low among a combination of both public and private young people; that it could potentially “… Adolescents’ barriers to sunscreen use schools, inland and coastal schools (three spread to other parts of the body” (female, There was consistent negative appraisal schools were included from each sector coastal, private); and it was a potentially about the properties of sunscreen, with and each location), as well as single sex terminal disease, “It can kill you” (male, inland, participants reporting that it looked too and co-educational schools (see Table 2). private). They were aware of the importance shiny, felt too oily or had an undesirable One hundred grade nine students (mean of clinical skin examinations, and believed smell. Other complaints reported were that age=14.4 years, SD=0.5; age range=14-16 that these should be undertaken regularly sunscreen washed off too easily, stung one’s years), participated in a semi-structured from late adolescence and throughout eyes, or caused sand to stick to one’s body. focus group discussion (average focus group adulthood, though many students over- Females were more likely to use sunscreen n=10 students). Thirty-seven per cent of estimated the age at which melanoma could if their sunscreen was incorporated in their participants were male and 79% were born first develop. moisturiser or make-up foundation. No in Australia. The majority were of British, Irish accounts of stigma associated with sunscreen However, the majority of students reported and Scottish (41%); Chinese (15%); southern application were reported, rather peer using sunscreen infrequently, “Most people European (8%); and Arabic (4%) ancestry. application was viewed as a cue to action, wouldn’t care anyway, like if it says the UV The participant group described their skin “When we go down the beach we all get rays are up, it’s just like ‘Ah well, the UV rays’… tone as ‘very fair’ (10%), ‘fair’ (39%), ‘medium’ together and do it before we swim and stuff, we’re all not going to get sunburned” (male, (39%), and ‘dark’ (12%), with 25% stating that so it’s sort of like a tradition that we do it now” coastal, public). And if participants did report after one hour of sun exposure at midday, (female, coastal, private). using sunscreen, they would not reapply their skin would ‘burn easily/tan minimally adequately, “I always forget to reapply” (male, In addition to sunscreen characteristics, or never’, 29% would ‘burn modestly/tan coastal, public). Reported barriers for lack an important barrier competing against moderately’ and 46% would ‘burn rarely or of sun protection included not planning the adoption of protective behaviours was never/tan easily’. ahead, forgetfulness, lack of availability, adolescents’ discounting of the severity of impatience should sunscreen application developing melanoma and the importance Adolescents’ sun exposure awareness delay play or socialisation, and a dislike of the of quality of life in older age, “I’d rather live my and related behaviours product’s texture or odour. These findings are life when I’m young. Like when you’re old, who supported by past research which has also Students demonstrated a high level of sun cares?” (female, coastal, private). Adolescents reported that sunscreen properties, cost and were also aware of their peers’ lack of protection knowledge, including awareness forgetting were commonly expressed barriers perceived susceptibility and their disconnect of the need to wear sunscreen when to adolescent sunscreen use. between their knowledge of the risks of outdoors, the importance of reapplication excessive sun exposure and their belief that and the benefits of shade, clothing, hats and Adolescents’ motivations for they may experience the repercussions eye wear. Additionally, adolescents were personally at a later date, “They all know aware of peak UV periods and reported that sunscreen use about skin cancer, they know it can happen, one should avoid sun exposure at “midday, Adolescents’ use of sunscreen was most but they don’t actually think ‘Oh it’s going to [you should go out] before 10am and after commonly motivated by their desire to happen to me if I don’t stop going in the sun’” 3pm” (female, inland, public), and that this avoid the immediate discomfort and pain (male, coastal, public). A sense of youth as differed in winter months. Participants also of sunburn. The short-term experience of immunity was present among participants, “I understood the importance of UV levels and being sunburned was seen as a compelling think everyone this age has it in their mind that the risk of becoming sunburned even on reason to apply sunscreen when in the sun, it’s just too far away from them, it’s not going to cloudy days. Many reported that they had “I got so sunburned and it was so painful… all reach them as they are” (male, coastal, public). studied ‘sun safe’ modules in school as part on my shoulders I have all these marks from Participants lacked understanding of future the sun now. And so after that I always put on Table 2: Summary of focus group characteristics . consequences due to a disconnect between sun cream and wear hats because I don’t want Public school Private school knowledge and emotional cues to action, to get sunburned again because it was really Coastal Male group (n=10) Female group (n=11) “I think it’s one thing for them to be aware of painful” (female, inland, private). The negative Male group (n=9) Female group (n=11) the danger and another thing for them to be deterrent of sunburned skin is supported by Coed group (n=9; 4F, 5M) actually fearful of getting skin cancer” (male, the literature. Similarly, parental reprimand Coed group (n=8; 4F, 4M) coastal, public). for being sunburned was a motivator to Inland Female group (n=10) Coed group (n=7; 3F, 4M) apply sunscreen, “I get burnt and then I get Female group (n=10) Coed group (n=7; 4F, 3M) Appearance-related in trouble” (female, coastal, private). Some Coed group (n=8; 6F, 2M) motivations to tan Legend: F = Female, M = Male, Coed = Co-education. Students from participating private schools In Australia, public schools are government funded and private schools a. Participant details indicated as (sex, in attendance incur fees, paid for by the individual. (n=50) were asked to rate images of a young at a coastal/inland school, in attendance at a public/ male and female dressed in bathing suits private school). 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 323 © 2014 Public Health Association of Australia McLoone et al. Article (state school students did not take part in as communicated by young melanoma in direct contrast to the findings of Potente this section of the study as ethics approval survivors. Interventions modelled on youth et al, who reported fear of peer judgement as was not granted for the use of images). The marketing campaigns or utilising social a barrier to sun protection. five images were manipulated to show the media tools, such as SMS were rated poorly Though Australia as a nation is challenged young people with increasing shades of sun during the focus group interviews: “I don’t like by comparatively high rates of melanoma in tan colour. Significant differences in sun tan spam on my mobile, it’s so annoying.” (male, adolescents and young people, participants’ colour preference were reported. Of the 50 coastal, public); “People would just delete it were correct in believing that the likelihood participants who answered this question straight away.” (female, coastal, private), the of developing melanoma in adolescence (72% female), the majority chose the image Internet “I couldn’t be bothered to search skin is relatively low. As such, participants depicting the second darkest tan image cancer.” (male, coastal, private), and Facebook viewed their current behaviours in terms of (68%), followed by the mid-depth tan image “They’d have to change [the content] every few future risk, “when we’re old”, and generally (24%). A light tan was much less preferred weeks... [otherwise] it’s so annoying.” (female, expressed little concern for consequences (6%) as was no tan (2%). However, not a single coastal, private). By contrast, interventions that may never eventuate, a finding similar to student selected the most deeply tanned that portrayed a similarly aged peer, who 28 the past research of Heckman et al. This also image as a preferred sun tan shade. had experienced melanoma first hand, were supports recent research which demonstrates seen as relevant, “Someone who actually had During focus group discussions participants adolescents’ risk–related decision-making is skin cancer and we could talk to them, then 16 did comment on the attractiveness of a tan, affected by their tolerance to ambiguity. that would be good” (female, inland, private) “I also get a tan … because it looks better” In situations representing risk, where the and potentially capable of changing beliefs (female, inland, public); “You look skinnier with outcome is unknown, adolescents show a and behaviours; “Something based on a true a tan” (female, coastal, private); “I think pale much higher willingness to accept and adapt story that actually did happen to someone, 16 just makes them look really drained and worn to ambiguous conditions. Tymula et al. that would change my mind” (female, inland, out” (female, coastal, private); “It’s sexy” (male, suggest that acceptance of the unknown public); “If there was a kid my age and he had coastal, public). Also commented on was the and the associated willingness to take risks skin cancer and he made a speech himself that social prestige of a tan, “Some people compare may allow young individuals to take greater would probably be touching” (male, coastal, their tans to others and they judge you by advantage of learning opportunities. In private). your tan” (female, coastal, private). However, regards to sun protection and melanoma risk, many adolescents were open to other Traditional approaches such as the adolescents may be much less motivated to ways of gaining a tan that did not expose distribution of written materials including engage in protective behaviours directed them to the health risks associated with UV booklets and pamphlets, and announcements towards an uncertain event (i.e. development exposure, namely the use of fake tans. “A over the school public address system were of skin cancer), should they feel comfortable while ago everyone wanted to tan but then regarded as “boring” and likely to be “ignored”. believing it may or may not ever eventuate. If now everyone’s all cancer conscious and …. I In addition to discussion, students were so, benefits such as a preference for a mid- to still think it’s nice to look tanned but you can asked to rank nine modes of information deep-tan (which was endorsed by 92% of still do it in other ways, like everyone has a fake dissemination. The results indicate that a talk private school participants) may outweigh tan now” (female, coastal, private). They were by an expert in the field of sun protection any associated future risks. This is unlike satisfied that they could achieve the same is the most preferred way of receiving adult perspectives of risk-taking, which view outcomes, “You look thinner with a tan, even education about sun protection issues, above benefits within the context of a risk event if it’s fake” (female, coastal, private) and that Facebook, DVDs, and a website. Twitter, CD occurring (e.g. the benefit of a tan is viewed current products were not only real looking, ROM and SMS received the lowest preference within the context of its uselessness should but that you could use gradual tanners in rankings (Table 1). one receive a diagnosis of melanoma), which winter so that “you’re obviously not tanned, potentially minimises the value of possible but it’s just a bit more colour and it looks good” future benefits. The adolescents’ perspective, Discussion (female, coastal, private). It should be pointed with their differential responses to immediate out that these findings were not unanimous and future risk, should be considered Overall, adolescents were aware of UV and many adolescents also reported that foremost when developing interventions, exposure as a risk factor for the development they had no desire to intentionally tan for the with emphasis placed on immediate risk/ of melanoma and the benefits of sunscreen sake of appearance, “I don’t really care” (male, consequences, such as freckle development use and other sun protection methods, coastal, public) and that some adolescents and painful sunburn and the potential impact such as the use of hats, protective clothing, who belonged to immigrant Asian and Arabic of immediate events (such as perceptions of sunglasses and shade. In addition, cultures viewed pale skin as more attractive, appearance-related popularity). This focus on participants were aware of the potential “I don’t like having dark skin” (female, inland, what adolescents perceive as immediately severity of melanoma and associated private). relevant to them, as well as the removal mortality, its high prevalence in Australia of other barriers to sunscreen use (e.g. and the importance of participation in skin Intervention methods to improve sun forgetfulness, inconvenience, oily product screening programs to identify changes in the consistency), should drive the development protection behaviours appearance of moles which may indicate the of adolescent sun protection interventions. occurrence of melanoma. The application of Adolescents reported a strong preferences sunscreen was viewed positively and was not Findings from this study highlight the for interventions that used first person felt to create stigma among one’s peers, this is potential importance of risk perceptions accounts of being diagnosed with melanoma, 324 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Perceptions of melanoma risk among Australian adolescents 8. Coote A. About half of Australians have never had when developing skin cancer-related and sunglasses were often inferred, these skin checked new research reveals. Daily Telegraph. interventions for adolescents. Moreover, were not specifically assessed. Furthermore, 2012:Nov 1. it seems important to frame risks in focus group methodology greatly prohibits 9. Volkov A, Dobbinson S, Wakefield M, Slevin T. 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Health Educ Behav. employed, the results have been limited to 2001;28(3):290-305. participant use of sunscreen, though other forms of sun protection such as hats, shade 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 325 © 2014 Public Health Association of Australia http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Perceptions of melanoma risk among Australian adolescents: barriers to sun protection and recommendations for improvement

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References (34)

Publisher
Wiley
Copyright
© 2014 Public Health Association of Australia
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/1753-6405.12209
pmid
24962426
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Abstract

melanoma, with an annual incidence Objectives: To explore adolescents’ perceptions of melanoma risk, sun protection intervention Arate of 49.8 cases per 100,000 preferences and perceived barriers to sun protection recommendations. population, more than double the incidence reported in other predominantly Caucasian Methods: Semi-structured focus groups were held in school classes, stratified by location nations such as the US (14.2 per 100,000 (coastal, inland) and sector (public, private); discussions were transcribed verbatim and data population) and the UK (12.5 per 100,000 were analysed using NVivo8 software. population). Melanoma is also the most Results: 100 students (mean age=14.4 years, SD=0.5; range=14-16 years) from six high common cancer among Australians aged schools participated. Students demonstrated a high level of sun protection knowledge and between 12 and 24 years, disproportionately understanding of sun exposure as a primary risk factor for the development of melanoma. affecting Australia’s youth. The incidence of There was, however, an under-estimation of melanoma prevalence and mortality rates among melanoma among Australian 15-39 year olds youth, and poor understanding of the increased risk associated with sunburn during childhood/ (18.7 per 100,000 population) is more than adolescence. Adolescents’ preferences for intervention focused on first-person accounts of double that of the US and UK (8.1 and 8.3 receiving a melanoma diagnosis, communicated by young melanoma survivors. Interventions cases respectively per 100,000 population modelled on youth marketing campaigns or utilising social media were rated poorly. aged between 15 and 39 years). Conclusions: Despite young Australians’ adequate knowledge of melanoma and related health The primary preventable risk factor for recommendations, poor adherence continues to place young people at risk. Study findings developing melanoma is exposure to solar suggest that social media interventions developed to influence behaviour change, are not ultraviolet (UV) radiation. Excessive sun necessarily preferred by adolescents. exposure and sunburn during childhood Key words: melanoma, adolescents, perceived risk, intervention, attitudes and adolescence substantially increases risk 5,6 for the later development of melanoma. As such, over the past 30 years, sun safe sun protection guidelines. Almost half post intervention, yet few improvements in messages have been at the forefront of 10,11 of Australian adolescents (aged 12-17 behaviours. public health campaigns across Australia, years) continue to report a desire to tan Decision-making theories such as the Theory and sun exposure during childhood has been 12 (45%), almost one-third of adolescent girls of Planned Behaviour and health behaviour directly targeted through sun safe policies 13 deliberately tan (29%) and one-fifth (20%) models such as the Health Belief Model, implemented in primary schools around the of all adolescents are sunburned on an infer that individuals ‘compute’ whether or country, such as the ‘no hat, no play’ rule. average summer weekend, according to the not to engage in a particular behaviour (such These campaigns have continued to raise most recent National Sun Protection Survey as sun protection) by estimating risks and awareness; in 2012, 98% of Australians could 9 completed in 2011. Furthermore, only 24% rewards, with behavioural options considered correctly identify exposure to the sun as a risk of adolescents reported using two or more and acted on based on the balance factor for the development of melanoma. sun protection strategies (such as shade and between these competing factors. Greater However, despite this awareness, sun sunscreen use, or wearing a hat, clothing understanding of the issues adolescents protection behaviours remain suboptimal. or sunglasses) on summer weekends. weight as important in their decision-making Adolescents, more than any other group, Unfortunately, interventions targeting sun process is needed, including the influence of 14,15 continue to ignore health messages and protection behaviours within this age group appearance and adolescents’ tolerance report poor cooperation with recommended consistently show improved knowledge of risk as related to future events not related 1. Discipline of Paediatrics, School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales Australia 2. Psychosocial Research Group, Prince of Wales Clinical School, University of New South Wales Australia Correspondence to: Dr Jordana McLoone, Kids Cancer Centre, Level 1, Sydney Children’s Hospital, High St, Randwick, NSW 2031; e-mail: Jordana.Mcloone@unsw.edu.au Submitted: September 2013; Revision requested: October 2013; Accepted: January 2014 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38:321-5; doi: 10.1111/1753-6405.12209 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 321 © 2014 Public Health Association of Australia McLoone et al. Article to their current self-identity (e.g. a strong, explored adolescents’ preferences regarding desirable. Images ranged from no tan (image healthy, young person). intervention design, content and format. 1) to very darkly tanned (image 5). These images were created by New Knowledge This study aimed to develop a better A semi-structured discussion guide was understanding of Australian adolescents’ Directorate Ltd (www.nkd.org.uk) specifically developed, based on a review of the perceptions of melanoma risk and explore for GenoMEL, the Melanoma Genetics relevant literature and expert input from the whether perceptions affect adherence to sun Consortium (www.genomel.org), and were multidisciplinary research team. The focus protection guidelines and the maintenance used with permission from the creators. groups were facilitated by three, female post- of risky behaviours, such as unprotected doctoral researchers, experienced in focus or excessive sun exposure and intentional Analysis group delivery and qualitative methodology tanning, despite the relatively high risk of (JM, BM, EZ). Facilitators summarised focus Transcripts were analysed using the developing melanoma in Australia. The study group sessions and discussed emerging qualitative approach described by Miles also explored adolescents’ perspectives on themes concurrent with the collection of and Huberman. Themes were derived how researchers, health professionals and data to establish additional lines of enquiry in inductively from the data by a member of educators may be able to improve health 20-22 subsequent focus groups and to discontinue the research team (MS) and organised behaviours amongst adolescents, through a sampling once saturation of information into meaningful hierarchical clusters using qualitative exploration of their preferences and themes was achieved, as is standard in QSR NVivo 8 software. A manual of coding and perspectives on various modes of 17,18 qualitative methodology. Focus group definitions was developed by the research intervention dissemination. interviews lasting an average of 35 minutes team and an audit log was maintained to (range 25-50 minutes) were conducted record the development of the coding tree. between July and November 2010. They were A random 10% sample of the transcribed Method transcribed verbatim for further coding and data was re-coded by a different member of Participants and procedure analysis using QSR software, NVivo 8. the research team (BM), experienced in the Approval was obtained from the use of QSR NVivo, to ensure coding accuracy Immediately following the focus group 23-25 relevant research ethics committees. and reliability. Any discrepancies in discussion, participants completed a brief, coding were discussed with the team until a The principals of 23 schools in Sydney, self-administered questionnaire that included consensus was reached. Descriptive statistics Australia, were mailed a study invitation letter. the following measures: were used to explore quantitative data, using Purposive sampling of schools was used Demographics: Age, sex, country of birth, the Prediction Application Software (PASW) to maximise heterogeneity of the sample, ancestry and language most commonly Statistics 17.0. to provide as diverse a range of views and spoken at home were assessed, as well as beliefs as possible. Grade nine students from participants’ self-rated skin tone using a participating schools were given a participant Table 1. Preferences for the format of sun protection 4-point scale ranging from ‘very fair’ to ‘dark’. information letter and consent form requiring interventions. Information dissemination preferences: A parental consent prior to focus group Format Preference Rating brief written description of nine modes of participation. Movie tickets and sunscreen Mean SD information dissemination was provided products were given to acknowledge Talk by an expert 3.37 2.40 (Table 1). Participants ranked the order of students’ time participating in the study. Facebook group 4.12 2.57 each medium in order of preference (1=most Informative DVD 4.39 2.78 Focus groups were used to explore preferred to 9=least preferred) for receiving Information Website 4.70 2.27 participants’ beliefs about, and understanding information about melanoma risk and related Pamphlet 5.37 2.47 of, sun exposure as a risk factor for the health behaviours. Email 5.74 2.34 development of melanoma; personal Appearance-based preferences: Five photos Twitter 5.85 2.32 perceptions of risk of developing skin of a young man and woman in swimwear CDROM 6.04 2.32 cancer; perceived benefits of, and barriers were presented to participants, with each SMS 6.58 2.49 to, co-operation with recommended photo manipulated to incrementally increase Note: Participants were asked to rate the intervention formats from sun protection guidelines; and current most to least preferred format. A score of “1” was used to indicate a the depth of the models’ tan (Figure 1). patterns of sun exposure, sun protection participant’s first preference, continuing through to a score of “9” to Participants were asked to indicate which indicate their last preference (that is, a lower score indicates a higher and skin examination. The focus group also shade of tan they believed was the most preference). Figure 1: Images of adolescents with an increasingly tanned appearance. * Image provided courtesy of GenoMEL; photographer Vasko (iStockphoto). 322 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Perceptions of melanoma risk among Australian adolescents of the physical education curriculum, or that, girls reported using sun protection to limit Results “In science we studied skin cancers” (female, the development of freckles and wrinkles, In total, 11 focus groups were conducted; coastal, private). Students reported that and used a sunscreen in their moisturiser or students were recruited from six high schools melanoma was “quite prevalent in Australia” foundation. (from 23 invited schools), which represented (female, inland, public), though low among a combination of both public and private young people; that it could potentially “… Adolescents’ barriers to sunscreen use schools, inland and coastal schools (three spread to other parts of the body” (female, There was consistent negative appraisal schools were included from each sector coastal, private); and it was a potentially about the properties of sunscreen, with and each location), as well as single sex terminal disease, “It can kill you” (male, inland, participants reporting that it looked too and co-educational schools (see Table 2). private). They were aware of the importance shiny, felt too oily or had an undesirable One hundred grade nine students (mean of clinical skin examinations, and believed smell. Other complaints reported were that age=14.4 years, SD=0.5; age range=14-16 that these should be undertaken regularly sunscreen washed off too easily, stung one’s years), participated in a semi-structured from late adolescence and throughout eyes, or caused sand to stick to one’s body. focus group discussion (average focus group adulthood, though many students over- Females were more likely to use sunscreen n=10 students). Thirty-seven per cent of estimated the age at which melanoma could if their sunscreen was incorporated in their participants were male and 79% were born first develop. moisturiser or make-up foundation. No in Australia. The majority were of British, Irish accounts of stigma associated with sunscreen However, the majority of students reported and Scottish (41%); Chinese (15%); southern application were reported, rather peer using sunscreen infrequently, “Most people European (8%); and Arabic (4%) ancestry. application was viewed as a cue to action, wouldn’t care anyway, like if it says the UV The participant group described their skin “When we go down the beach we all get rays are up, it’s just like ‘Ah well, the UV rays’… tone as ‘very fair’ (10%), ‘fair’ (39%), ‘medium’ together and do it before we swim and stuff, we’re all not going to get sunburned” (male, (39%), and ‘dark’ (12%), with 25% stating that so it’s sort of like a tradition that we do it now” coastal, public). And if participants did report after one hour of sun exposure at midday, (female, coastal, private). using sunscreen, they would not reapply their skin would ‘burn easily/tan minimally adequately, “I always forget to reapply” (male, In addition to sunscreen characteristics, or never’, 29% would ‘burn modestly/tan coastal, public). Reported barriers for lack an important barrier competing against moderately’ and 46% would ‘burn rarely or of sun protection included not planning the adoption of protective behaviours was never/tan easily’. ahead, forgetfulness, lack of availability, adolescents’ discounting of the severity of impatience should sunscreen application developing melanoma and the importance Adolescents’ sun exposure awareness delay play or socialisation, and a dislike of the of quality of life in older age, “I’d rather live my and related behaviours product’s texture or odour. These findings are life when I’m young. Like when you’re old, who supported by past research which has also Students demonstrated a high level of sun cares?” (female, coastal, private). Adolescents reported that sunscreen properties, cost and were also aware of their peers’ lack of protection knowledge, including awareness forgetting were commonly expressed barriers perceived susceptibility and their disconnect of the need to wear sunscreen when to adolescent sunscreen use. between their knowledge of the risks of outdoors, the importance of reapplication excessive sun exposure and their belief that and the benefits of shade, clothing, hats and Adolescents’ motivations for they may experience the repercussions eye wear. Additionally, adolescents were personally at a later date, “They all know aware of peak UV periods and reported that sunscreen use about skin cancer, they know it can happen, one should avoid sun exposure at “midday, Adolescents’ use of sunscreen was most but they don’t actually think ‘Oh it’s going to [you should go out] before 10am and after commonly motivated by their desire to happen to me if I don’t stop going in the sun’” 3pm” (female, inland, public), and that this avoid the immediate discomfort and pain (male, coastal, public). A sense of youth as differed in winter months. Participants also of sunburn. The short-term experience of immunity was present among participants, “I understood the importance of UV levels and being sunburned was seen as a compelling think everyone this age has it in their mind that the risk of becoming sunburned even on reason to apply sunscreen when in the sun, it’s just too far away from them, it’s not going to cloudy days. Many reported that they had “I got so sunburned and it was so painful… all reach them as they are” (male, coastal, public). studied ‘sun safe’ modules in school as part on my shoulders I have all these marks from Participants lacked understanding of future the sun now. And so after that I always put on Table 2: Summary of focus group characteristics . consequences due to a disconnect between sun cream and wear hats because I don’t want Public school Private school knowledge and emotional cues to action, to get sunburned again because it was really Coastal Male group (n=10) Female group (n=11) “I think it’s one thing for them to be aware of painful” (female, inland, private). The negative Male group (n=9) Female group (n=11) the danger and another thing for them to be deterrent of sunburned skin is supported by Coed group (n=9; 4F, 5M) actually fearful of getting skin cancer” (male, the literature. Similarly, parental reprimand Coed group (n=8; 4F, 4M) coastal, public). for being sunburned was a motivator to Inland Female group (n=10) Coed group (n=7; 3F, 4M) apply sunscreen, “I get burnt and then I get Female group (n=10) Coed group (n=7; 4F, 3M) Appearance-related in trouble” (female, coastal, private). Some Coed group (n=8; 6F, 2M) motivations to tan Legend: F = Female, M = Male, Coed = Co-education. Students from participating private schools In Australia, public schools are government funded and private schools a. Participant details indicated as (sex, in attendance incur fees, paid for by the individual. (n=50) were asked to rate images of a young at a coastal/inland school, in attendance at a public/ male and female dressed in bathing suits private school). 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 323 © 2014 Public Health Association of Australia McLoone et al. Article (state school students did not take part in as communicated by young melanoma in direct contrast to the findings of Potente this section of the study as ethics approval survivors. Interventions modelled on youth et al, who reported fear of peer judgement as was not granted for the use of images). The marketing campaigns or utilising social a barrier to sun protection. five images were manipulated to show the media tools, such as SMS were rated poorly Though Australia as a nation is challenged young people with increasing shades of sun during the focus group interviews: “I don’t like by comparatively high rates of melanoma in tan colour. Significant differences in sun tan spam on my mobile, it’s so annoying.” (male, adolescents and young people, participants’ colour preference were reported. Of the 50 coastal, public); “People would just delete it were correct in believing that the likelihood participants who answered this question straight away.” (female, coastal, private), the of developing melanoma in adolescence (72% female), the majority chose the image Internet “I couldn’t be bothered to search skin is relatively low. As such, participants depicting the second darkest tan image cancer.” (male, coastal, private), and Facebook viewed their current behaviours in terms of (68%), followed by the mid-depth tan image “They’d have to change [the content] every few future risk, “when we’re old”, and generally (24%). A light tan was much less preferred weeks... [otherwise] it’s so annoying.” (female, expressed little concern for consequences (6%) as was no tan (2%). However, not a single coastal, private). By contrast, interventions that may never eventuate, a finding similar to student selected the most deeply tanned that portrayed a similarly aged peer, who 28 the past research of Heckman et al. This also image as a preferred sun tan shade. had experienced melanoma first hand, were supports recent research which demonstrates seen as relevant, “Someone who actually had During focus group discussions participants adolescents’ risk–related decision-making is skin cancer and we could talk to them, then 16 did comment on the attractiveness of a tan, affected by their tolerance to ambiguity. that would be good” (female, inland, private) “I also get a tan … because it looks better” In situations representing risk, where the and potentially capable of changing beliefs (female, inland, public); “You look skinnier with outcome is unknown, adolescents show a and behaviours; “Something based on a true a tan” (female, coastal, private); “I think pale much higher willingness to accept and adapt story that actually did happen to someone, 16 just makes them look really drained and worn to ambiguous conditions. Tymula et al. that would change my mind” (female, inland, out” (female, coastal, private); “It’s sexy” (male, suggest that acceptance of the unknown public); “If there was a kid my age and he had coastal, public). Also commented on was the and the associated willingness to take risks skin cancer and he made a speech himself that social prestige of a tan, “Some people compare may allow young individuals to take greater would probably be touching” (male, coastal, their tans to others and they judge you by advantage of learning opportunities. In private). your tan” (female, coastal, private). However, regards to sun protection and melanoma risk, many adolescents were open to other Traditional approaches such as the adolescents may be much less motivated to ways of gaining a tan that did not expose distribution of written materials including engage in protective behaviours directed them to the health risks associated with UV booklets and pamphlets, and announcements towards an uncertain event (i.e. development exposure, namely the use of fake tans. “A over the school public address system were of skin cancer), should they feel comfortable while ago everyone wanted to tan but then regarded as “boring” and likely to be “ignored”. believing it may or may not ever eventuate. If now everyone’s all cancer conscious and …. I In addition to discussion, students were so, benefits such as a preference for a mid- to still think it’s nice to look tanned but you can asked to rank nine modes of information deep-tan (which was endorsed by 92% of still do it in other ways, like everyone has a fake dissemination. The results indicate that a talk private school participants) may outweigh tan now” (female, coastal, private). They were by an expert in the field of sun protection any associated future risks. This is unlike satisfied that they could achieve the same is the most preferred way of receiving adult perspectives of risk-taking, which view outcomes, “You look thinner with a tan, even education about sun protection issues, above benefits within the context of a risk event if it’s fake” (female, coastal, private) and that Facebook, DVDs, and a website. Twitter, CD occurring (e.g. the benefit of a tan is viewed current products were not only real looking, ROM and SMS received the lowest preference within the context of its uselessness should but that you could use gradual tanners in rankings (Table 1). one receive a diagnosis of melanoma), which winter so that “you’re obviously not tanned, potentially minimises the value of possible but it’s just a bit more colour and it looks good” future benefits. The adolescents’ perspective, Discussion (female, coastal, private). It should be pointed with their differential responses to immediate out that these findings were not unanimous and future risk, should be considered Overall, adolescents were aware of UV and many adolescents also reported that foremost when developing interventions, exposure as a risk factor for the development they had no desire to intentionally tan for the with emphasis placed on immediate risk/ of melanoma and the benefits of sunscreen sake of appearance, “I don’t really care” (male, consequences, such as freckle development use and other sun protection methods, coastal, public) and that some adolescents and painful sunburn and the potential impact such as the use of hats, protective clothing, who belonged to immigrant Asian and Arabic of immediate events (such as perceptions of sunglasses and shade. In addition, cultures viewed pale skin as more attractive, appearance-related popularity). This focus on participants were aware of the potential “I don’t like having dark skin” (female, inland, what adolescents perceive as immediately severity of melanoma and associated private). relevant to them, as well as the removal mortality, its high prevalence in Australia of other barriers to sunscreen use (e.g. and the importance of participation in skin Intervention methods to improve sun forgetfulness, inconvenience, oily product screening programs to identify changes in the consistency), should drive the development protection behaviours appearance of moles which may indicate the of adolescent sun protection interventions. occurrence of melanoma. The application of Adolescents reported a strong preferences sunscreen was viewed positively and was not Findings from this study highlight the for interventions that used first person felt to create stigma among one’s peers, this is potential importance of risk perceptions accounts of being diagnosed with melanoma, 324 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Perceptions of melanoma risk among Australian adolescents 8. Coote A. About half of Australians have never had when developing skin cancer-related and sunglasses were often inferred, these skin checked new research reveals. Daily Telegraph. interventions for adolescents. Moreover, were not specifically assessed. Furthermore, 2012:Nov 1. it seems important to frame risks in focus group methodology greatly prohibits 9. Volkov A, Dobbinson S, Wakefield M, Slevin T. 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Health Educ Behav. employed, the results have been limited to 2001;28(3):290-305. participant use of sunscreen, though other forms of sun protection such as hats, shade 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 325 © 2014 Public Health Association of Australia

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