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Trends in Australian adolescents' sun‐protection behaviours: implications for health campaigns

Trends in Australian adolescents' sun‐protection behaviours: implications for health campaigns ultraviolet (UV) radiation is a major 1,2 Ecause of skin cancer. Worldwide, skin Objective: Protecting the skin from ultraviolet (UV) radiation is critical during adolescence to cancer is the most commonly diagnosed reduce the risk of developing skin cancer later in life, but adolescents tend to be less likely to 3,4 cancer among Caucasians. In Australia, engage in sun-protective behaviours than adults. The present study examined changes and skin cancer rates are high and rising. There trends (2001/02-2011/12) in sun-protection behaviours among adolescents living in Western was an 86% increase in treatments for non- Australia – a region with high levels of UV radiation. melanoma skin cancer (NMSC) between 1997 Methods: A cross-sectional survey was conducted during 10 summers between 2001/02 and and 2010, which is only partially accounted 2011/12 to investigate how often adolescents engaged in various sun-protection behaviours, for by the population growth of 19% during including outdoor protective measures (wearing a hat, wearing protective clothing, using this period. Due to the high levels of UV sunscreen, wearing sunglasses, seeking shade) and avoidance of UV radiation by staying inside. radiation commonly found in this part of Results: Hat use significantly decreased between 2001/02 and 2011/12, whereas use of the world, combined with a failure to use sunscreen and wearing covering clothes were unchanged in most survey years relative to adequate protection measures while in the 2001/02. Use of sunglasses peaked in 2006/07 and 2007/08, but returned to first survey year sun, at least two in three Australians will be levels in 2011/12, while staying inside was more frequently reported from 2006/07 onwards. diagnosed with skin cancer before the age of Conclusions: New approaches are needed to minimise reactance responses in adolescents 70. Overall, skin cancer has high prevalence while fostering favourable attitudes to sun protection. Implications and opportunities for and is an ever-growing burden on the interventions to promote better sun-protection practices among adolescents are provided. Australian health care system. Key words: skin cancer, adolescents, prevention, protection, trends Skin cancer is largely preventable by adhering to a number of simple behavioural guidelines to minimise exposure to the sun. and their specific focus). Along with mass addition, parents tend to have less influence It is recommended that when the UV index media campaigns, policies and educational on older children, including in relation is 3 or above, individuals spending time programmes play an important role in skin to behaviours that affect sun exposure 18,19 outdoors should wear a hat, wear sunscreen cancer prevention, although the reach of such as clothing practices. This greater with a sun-protection factor of 30 or higher, these approaches varies for different age independence during adolescence comes wear clothing that covers most of the body, groups. For example, primary school children at a risk, with qualitative research indicating and stay in the shade. Protecting the skin have been protected to some extent by that sun protection is a low-priority issue for from the sun is particularly critical during parental precautions, school policies such adolescents and an unwelcome interruption childhood and adolescence to reduce the risk as “no hat, no play” (i.e. a requirement for to their preferably spontaneous and care-free 9,10 of developing skin cancer later in life. students to wear hats when playing outdoors lifestyles. These findings are reflected in 12-14 during times of high UV radiation levels), quantitative studies showing that adolescents Since the early 1980s, numerous mass and a strong emphasis on teaching children in Australia and elsewhere are significantly media campaigns have been run in Australia sun-protection skills at schools in high UV less likely than adults to engage in sun- to raise skin cancer awareness among 15 21-26 regions. However, these strategies often protection practices. the community in general and specific do not apply to adolescents, who as a result vulnerable groups such as adolescents (see Longitudinal studies have been undertaken of their growing maturity are expected to Iannacone and Green for an overview of in the US and Australia to document changes 16,17 be more self-reliant and responsible. In Australian skin cancer awareness campaigns 1. Curtin University, Western Australia 2. Cancer Council Western Australia 3. La Trobe University, Victoria Correspondence to: Professor Simone Pettigrew, Western Australian Cancer Prevention Research Unit (WACPRU), School of Psychology and Speech Pathology, Curtin University, Kent Street, Bentley, WA 6102; e-mail: simone.pettigrew@curtin.edu.au Submitted: November 2015; Revision requested: January 2016; Accepted: April 2016 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2016; 40:468-73; doi: 10.1111/1753-6405.12561 468 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 5 © 2016 Public Health Association of Australia Youth Trends in sun-protection behaviour in adolescent sun-protection behaviours premises, it was predicted that in recent (wearing a hat, wearing protective clothing, over time. In terms of sunscreen use, US data years there would be less time spent outdoors using sunscreen, wearing sunglasses, indicate that usage rates increased between and greater use of shade among Western and seeking shade). One item measured 1998 and 2004, followed by a substantial Australian adolescents. the complete avoidance of UV radiation decrease between 2004 and 2007, while by staying inside. With regard to the five no changes were observed in other sun- outdoor protection behaviours, respondents Method protection behaviours. Data are available were asked to indicate on a 5-point Likert for a longer period in Australia, with results The study received approval from the scale how often they would engage in the indicating a steep increase in sun-protection Curtin University Human Research Ethics behaviour during a sunny day in summer behaviours between 1987 and the mid-1990s, Committee. A cross-sectional survey was between 10am and 2pm when being in the with smaller fluctuations and greater stability conducted via Computer Assisted Telephone sun for an hour or more. The item measuring in the following decade. The use of hats Interviewing (CATI) during 10 summers how frequently respondents avoided the sun and protective clothing among Australian between 2001/02 and 2011/12 as part of a completely by staying inside was modified adolescents marginally decreased from 1993 long-running survey that tracked Western by omitting the phrase ‘when being in the 30,31 onwards, while sunscreen use decreased Australians’ knowledge and behaviours sun for an hour or more’. Response categories between 1993 and 2002, and then remained relating to sun exposure. No data collection were never (1), rarely (2), sometimes (3), constant between 2003 and 2010. The occurred in 2004/05 due to a lack of funding. usually (4), and always (5). only increase in recent years was for staying The respondents were residents of Western indoors during peak UV times, with a slight Australia, where the risk of developing skin Statistical analysis rise in the frequency of this behaviour from cancer is – together with Queensland – the Due to the ordinal nature of the response 31 40 2006 to 2010. It appears that the smaller highest in Australia. Average UV radiation categories, separate ordinal regression changes observed in more recent years may levels in Western Australia are 11 or higher at analyses were conducted with each of the be indicative of a plateau effect following noon during the summer months. six sun-protection behaviours as dependent the large improvements in sun-protection Respondents were recruited over a period measures, controlling for the effects of behaviours observed in prior decades. of approximately 6 weeks each summer via age, gender, and skin colour. In addition, random digit dialling. The total usable sample Monitoring sun-protection behaviours the remaining protection behaviours were consisted of 5,053 14–17 year olds, with an among adolescents is crucial to identify entered as covariates to control for influences equal representation of males and females. trends that can inform interventions to that arise from the likelihood of engaging in Table 1 reports the number of respondents promote better sun-protection practices in other forms of sun-protection. Year of survey by age, gender, and skin colour. The seven this vulnerable age group. New approaches was the predictor variable of interest. The first skin colour categories were ‘very fair’, ‘fair’, are needed because although adolescents survey year (2001/02) served as the baseline ‘medium’ , ‘olive’ , ‘dark’ , ‘very dark’ , and ‘black’ tend to be knowledgeable about sun- year to which all other years were compared. and referred to self-reported skin colour related health risks, this knowledge has not For ease of interpretation, the regression without a tan. generally translated into appropriate changes coefficients were transformed into odds 33-37 in sun-protection behaviour. The present ratios. P-values of 0.05 or less were considered Measures of sun-protection study aimed to provide more comprehensive statistically significant for all reported behaviours and updated information relating to changes analyses. in Australian adolescents’ sun-protection The frequency of engaging in six sun- To evaluate the overall trend in adolescent behaviours by analysing a decade of protection behaviours was measured, five of outdoor sun protection during the survey sun-protection data (2001/02 to 2011/12) which related to protection when outdoors period, the outdoor protection behaviours involving more time points and more recent were combined into a composite score by Table 1: Gender, age and skin colour of adolescents years than reported in previous research. In computing the mean of the five behaviours surveyed (N = 5,053). addition, a larger number of sun-protection pertaining to outdoor protection (wearing n % behaviours were tracked over time. Extending a hat, wearing protective clothing, using Gender previous research, the focus was on various sunscreen, wearing sunglasses, and seeking Male 2,532 50.1 behaviours that reduce the risk of UV Female 2,521 49.9 shade) for each respondent. A hierarchical radiation when outdoors and the complete Age linear regression analysis was conducted avoidance of UV radiation by staying inside. 14 years 1,135 22.5 with the composite score as the dependent 15 years 1,444 28.6 Based on previously identified trends among variable and survey year as a continuous 16 years 1,423 28.2 30,31 Australian adolescents, it was predicted predictor variable, controlling for the effects 17 years 1,051 20.8 that outdoor protection behaviours would of age, gender, and skin colour. Skin colour either stabilise or continue to decrease. Very fair 522 10.3 In addition, in accordance with research Fair 1,615 32.0 Results indicating greater engagement in screen- Medium 1,608 31.8 based activities among adolescents and Sun-protection behaviours Olive 1,096 21.7 the results of a cluster randomised controlled Dark 189 3.7 Means, standard errors, proportions of trial indicating that students used rather Very dark 18 0.4 respondents in each response category, than avoided newly shaded areas on school Black 5 0.1 adjusted odds ratios (AORs) with 95% 2016 vol . 40 no . 5 Australian and New Zealand Journal of Public Health 469 © 2016 Public Health Association of Australia Koch et al. Article confidence intervals, and p -values for all protection behaviour that was practised least and ‘usually’ , which means that the sun-protective behaviours are presented for frequently across all survey years (in 2001/02 measure may lack sensitivity to detect small each survey year separately in Table 2. Trends 31% usually or always, M = 2.70; in 2011/12 improvements in this frequency range. were examined for each of the six behaviours 26% usually or always, M = 2.65). Adolescents While the frequency of staying in the under investigation. most frequently reported wearing covering shade and staying inside significantly clothes ‘rarely’ or ‘sometimes’ (53% across all Protection From Sun when Outdoors. In all increased between 2001/02 and 2011/12, survey years). survey years from 2005/06, respondents both behaviours dropped significantly in reported less frequent hat use compared to Composite scores for outdoor protection survey year 2005/06. Although summers 2001/02. This finding was replicated when behaviours. Over the study period, a small in the highly populated areas of Western excluding respondents from the analysis but significant decrease in outdoor sun- Australia tend to be hot and dry with who indicated they usually or always stay protection behaviour was found (β = -0.063, generally low variability, weather statistics inside. The frequency of wearing covering t (5051) = - 4.504, p < 0.001). The composite from the Australian Government Bureau of clothes was unchanged in most survey score was highest in the first two survey years Meteorology for the summer of 2005/06 years, including the most recent survey year (M = 3.17 in 2001/02 and M = 3.20 in 2002/03) show somewhat cooler conditions and 2011/12. The frequency of wearing sunscreen and lowest in 2009/10 (M = 3.05). Averaged more rainfall, which could explain the lower also remained relatively stable across the across all survey years, the composite score frequency of these two sun-protection survey years, although a significant drop in was M = 3.12. strategies. the frequency of this behaviour was noted for Use of sunscreen was the most frequently 2006/07 (AOR = 0.69). practiced sun-protection behaviour in all Discussion Compared to 2001/02, respondents reported 10 survey years, which is consistent with The present study investigated trends in more frequent use of sunglasses in most previous findings in samples of US and 27,44 sun-protection behaviours in adolescents of the following years. Use of sunglasses European adolescents. In the present living in a high-UV region over a 10-year peaked in 2006/07 (AOR = 1.65) and 2007/08 study, 64% of all adolescents reported using time period. The observed sun-protection (AOR = 1.62), but returned to baseline levels sunscreen either ‘usually’ or ‘always’ on sunny behaviours pertained to outdoor protection in the most recent survey year. An increase days in summer between 10am and 2pm (wearing a hat, wearing protective clothing, in the reported frequency of staying in when outdoors for an hour or more. However, using sunscreen, wearing sunglasses, the shade was observed in recent survey the composite score of all outdoor protection and seeking shade) and avoidance of sun years. In 2011/12, the reported frequency of behaviours averaged across survey years (M exposure by staying inside. Over the study staying in the shade was significantly higher = 3.12) speaks to the generally poor routine period, varying trends were observed for the compared to baseline (AOR = 1.36), however use of sun-protection measures among this behaviours under investigation. The reported the increase for 2010/11 was marginal (AOR group. frequency of wearing a hat when outdoors = 1.23, p = 0.095). There was only one year The observed increase in adolescent during peak UV hours decreased significantly (2005/06) in which respondents reported sun avoidance during peak UV times from 2001/02 to 2011/12, whereas use of staying in the shade less frequently compared is a favourable trend in terms of skin sunscreen and wearing covering clothes to baseline (AOR = 0.79). cancer prevention, but potential adverse were unchanged in most survey years relative Avoiding Sun by Staying Inside. Respondents consequences may be the development to 2001/02. In the first half of the survey reported staying inside more frequently since of vitamin D deficiency and decreases in period, the frequency of using sunglasses 2006/07 (average AOR = 1.48). Similar to the physical activity levels. The human body increased, peaking in 2006/07 and 2007/08. frequency of staying in the shade, adolescents depends on moderate levels of sunlight to However, in the most recent survey year, use 47-49 reported staying inside significantly less produce sufficient amounts of vitamin D, of sunglasses returned to the first survey year frequently only in 2005/06 (AOR = 0.66). and high rates of vitamin D deficiency have level. Combining the five outdoor protection been linked to avoidance of sun exposure in Differences in Compliance. In every survey behaviours into a composite score revealed high-UV countries due to excessive outside year, sunscreen use was the most frequently a slight but significant decline over time in heat and cultural dress codes. Although practiced sun-protection behaviour on sunny the frequency of practicing outdoor sun clinically significant vitamin D deficiencies days in summer between 10am and 2pm protection. (<30 nmol/L) are currently rare in Australia when being outdoors for an hour or more Avoiding sun exposure by staying inside and less common among adolescents than (in 2001/02 68% usually or always, M = 3.76; 51,52 consistently improved over time, and adults, attaining sufficient levels of natural in 2011/12 66% usually or always, M = 3.81 staying in the shade showed a trend towards vitamin D will become more difficult if time in 2011/12). In terms of response categories increased frequency in recent survey years. spent indoors keeps increasing. for this sun-protection behaviour, ‘usually’ However, favourable trends in these two was the most frequently reported behaviour sun-protection behaviours may be more Intervention implications frequency for sunscreen in all survey years, difficult to capture with the rating scales used with between 33 and 40% of respondents Considering the low compliance with because the majority of adolescents rated reporting this frequency. recommended sun-protection guidelines their enactment frequencies as ‘sometimes’ among adolescents found in this and Wearing covering clothes on sunny days for both sun-protection behaviours. Previous 24-26 previous studies, tailoring sun-protection in summer between 10am and 2pm when research has found particularly large intervals messages and interventions to the distinctive outdoors for an hour or more was the sun- between the response categories ‘sometimes’ 470 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 5 © 2016 Public Health Association of Australia Youth Trends in sun-protection behaviour Table 2: Trends in likelihood of different sun-protection behaviours in Western Australian adolescents from 2001/02 to 2011/12. Behaviour 2001/02 2002/03 2003/04 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 N = 609 N = 602 N = 600 N = 611 N = 502 N = 559 N = 455 N = 399 N = 415 N = 301 Wear a hat Mean (SE ) 3.22 (0.05) 3.14 (0.05) 3.27 (0.05) 3.04 (0.05) 2.85 (0.05) 2.79 (0.05) 2.74 (0.06) 2.61 (0.06) 2.61 (0.06) 2.72 (0.07) % never 14 14 13 16 21 20 24 26 26 23 % rarely 16 15 14 20 21 22 22 24 21 21 % sometimes 23 27 25 25 23 26 22 27 26 26 % usually 29 30 30 26 22 21 21 15 19 21 11 11 9 8 10 % always 19 15 18 14 13 Adjusted odds ra tio 1 0.90 1.08 0.75 0.58 0.53 0.47 0.39 0.40 0.47 95%CI 0.74–1.11 0.88–1.32 0.62–0.92 0.47–0.72 0.43–0.65 0.38–0.59 0.31–0.49 0.32–0.50 0.37–0.60 p-value 0.323 0.482 0.006 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 Wear covering clothes Mean (SE ) 2.70 (0.05) 2.70 (0.05) 2.64 (0.05) 2.77 (0.05) 2.85 (0.05) 2.64 (0.05) 2.68 (0.05) 2.53 (0.06) 2.60 (0.06) 2.65 (0.07) 18 18 21 16 19 19 25 23 17 % never 16 % rarely 29 27 28 25 26 28 30 27 27 30 % sometimes 25 27 27 23 25 28 26 25 25 26 % usually 25 24 24 25 24 20 21 19 20 19 % always 6 5 3 6 9 5 5 4 6 7 Adjusted odds ra tio 1 1.01 0.93 1.12 1.27 0.90 0.95 0.76 0.83 0.92 95%CI 0.83–1.24 0.76–1.14 0.92–1.37 1.03–1.58 0.73–1.10 0.76–1.18 0.61–0.96 0.66–1.04 0.72–1.19 0.538 p-value 0.899 0.499 0.268 0.026 0.304 0.627 0.021 0.104 Wear sunscreen Mean (SE ) 3.76 (0.04) 3.77 (0.4) 3.73 (0.4) 3.70 (0.04) 3.57 (0.05) 3.74 (0.04) 3.72 (0.05) 3.74 (0.05) 3.79 (0.05) 3.81 (0.06) % never 4 3 5 6 5 3 4 7 5 5 % rarely 10 7 8 8 11 11 11 9 8 9 % sometimes 18 23 19 21 29 24 22 22 25 21 35 39 36 35 37 % usually 36 37 40 37 33 % always 32 30 28 28 22 27 24 27 27 29 Adjusted odds ra tio 1 0.99 0.95 0.92 0.69 0.96 0.92 1.02 1.07 1.11 95%CI 0.80–1.21 0.77–1.17 0.75–1.14 0.56–0.86 0.78–1.19 0.74–1.15 0.81–1.29 0.85–1.34 0.86–1.43 p-value 0.898 0.632 0.457 0.001 0.715 0.469 0.856 0.581 0.438 Wear sunglasses Mean (SE 3.01 (0.06) 2.80 (0.06) 2.96 (0.06) 3.23 (0.07) 3.21(0.06) 3.19 (0.07) 3.12 (0.07) 2.98 (0.8) ) 2.79 (0.06) 2.98 (0.07) % never 34 29 32 29 25 25 30 25 24 33 % rarely 13 11 14 13 11 12 10 11 15 10 % sometimes 16 13 16 12 14 14 20 16 15 13 % usually 13 20 18 16 24 21 17 21 21 19 % always 24 27 21 29 27 28 24 28 25 26 Adjusted odds ra tio 1 1.30 0.98 1.23 1.65 1.62 1.24 1.56 1.45 1.19 95%CI 1.06–1.60 0.80–1.21 1.01–1.51 1.33–2.04 1.31–2.00 0.99–1.54 1.23–1.96 1.16–1.83 0.92–1.53 p-value 0.011 0.862 0.045 <0.001 <0.001 0.060 <0.001 0.001 0.187 Stay in shade Mean (SE ) 3.23 (0.03) 3.24 (0.03) 3.19 (0.03) 3.15 (0.03) 3.19 (0.03) 3.22 (0.03) 3.31 (0.03) 3.32 (0.04) 3.31 (0.04) 3.34 (0.04) % never 2 2 3 3 1 2 1 2 2 1 % rarely 14 16 16 17 13 13 12 9 10 10 45 47 47 45 45 % sometimes 47 46 46 54 49 % usually 35 33 35 23 34 35 37 40 37 39 % always 3 4 2 3 3 4 4 3 6 6 Adjusted odds ra tio 1 1.02 0.91 0.79 0.89 0.96 1.21 1.29 1.23 1.36 95%CI 0.82–1.26 0.73–1.14 0.63–0.98 0.70–1.12 0.77–1.20 0.96–1.53 1.01–1.65 0.96–1.57 1.04–1.77 p-value 0.871 0.414 0.029 0.302 0.745 0.112 0.045 0.095 0.027 Stay inside Mean (SE ) 3.12 (0.03) 3.06 (0.03) 3.15 (0.03) 2.97 (0.03) 3.28 (0.03) 3.30 (0.03) 3.21 (0.04) 3.27 (0.04) 3.31 (0.04) 3.27 (0.04) % never 3 5 1 4 1 2 2 2 1 1 % rarely 17 18 19 26 15 14 13 13 11 12 % sometimes 47 46 49 49 41 40 47 43 43 44 % usually 32 30 30 21 38 38 35 40 41 39 % always 2 1 1 1 4 5 3 3 4 5 1.47 Adjusted odds ra tio 1 0.89 1.04 0.66 1.46 1.58 1.26 1.47 1.62 95%CI 0.71–1.10 0.84–1.29 0.53–0.81 1.16–1.83 1.27–1.97 1.00–1.60 1.15–1.88 1.27–2.07 1.12–1.91 <0.001 0.001 <0.001 0.050 0.002 <0.001 0.005 p-value 0.264 0.724 Note. The results of ordinal regression models are presented, adjusting for the effects of age, gender, skin colour, and other protection behaviours. Survey year 2001/02 is the referent year. Means are estimated marginal means with covariates held constant. Frequency of behaviour was classified into the ordinal response categories never (1), rarely (2), sometimes (3), usually (4), and always (5). No data were collected in year 2004/05. a: SE = standard error ; b: CI = confidence interval 2016 vol . 40 no . 5 Australian and New Zealand Journal of Public Health 471 © 2016 Public Health Association of Australia Koch et al. Article characteristics of this age group is an and more time spent in front of screens has References important step to encourage behaviour been associated with lower levels of physical 1. Armstrong BK, Kricker A. The epidemiology of change. However, health education activity, which in turn are associated with UV induced skin cancer. 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Livingston PM, White V, Hayman J, Dobbinson S. Sun 4363.0.55.001. Canberra: ABS; 2014. exposure and sun protection behaviours among Australian adolescents: trends over time. Preventive Medicine. 2003;37(6):577-84. 2016 vol . 40 no . 5 Australian and New Zealand Journal of Public Health 473 © 2016 Public Health Association of Australia http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Trends in Australian adolescents' sun‐protection behaviours: implications for health campaigns

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Wiley
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© 2016 Public Health Association of Australia
ISSN
1326-0200
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1753-6405
DOI
10.1111/1753-6405.12561
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27523880
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Abstract

ultraviolet (UV) radiation is a major 1,2 Ecause of skin cancer. Worldwide, skin Objective: Protecting the skin from ultraviolet (UV) radiation is critical during adolescence to cancer is the most commonly diagnosed reduce the risk of developing skin cancer later in life, but adolescents tend to be less likely to 3,4 cancer among Caucasians. In Australia, engage in sun-protective behaviours than adults. The present study examined changes and skin cancer rates are high and rising. There trends (2001/02-2011/12) in sun-protection behaviours among adolescents living in Western was an 86% increase in treatments for non- Australia – a region with high levels of UV radiation. melanoma skin cancer (NMSC) between 1997 Methods: A cross-sectional survey was conducted during 10 summers between 2001/02 and and 2010, which is only partially accounted 2011/12 to investigate how often adolescents engaged in various sun-protection behaviours, for by the population growth of 19% during including outdoor protective measures (wearing a hat, wearing protective clothing, using this period. Due to the high levels of UV sunscreen, wearing sunglasses, seeking shade) and avoidance of UV radiation by staying inside. radiation commonly found in this part of Results: Hat use significantly decreased between 2001/02 and 2011/12, whereas use of the world, combined with a failure to use sunscreen and wearing covering clothes were unchanged in most survey years relative to adequate protection measures while in the 2001/02. Use of sunglasses peaked in 2006/07 and 2007/08, but returned to first survey year sun, at least two in three Australians will be levels in 2011/12, while staying inside was more frequently reported from 2006/07 onwards. diagnosed with skin cancer before the age of Conclusions: New approaches are needed to minimise reactance responses in adolescents 70. Overall, skin cancer has high prevalence while fostering favourable attitudes to sun protection. Implications and opportunities for and is an ever-growing burden on the interventions to promote better sun-protection practices among adolescents are provided. Australian health care system. Key words: skin cancer, adolescents, prevention, protection, trends Skin cancer is largely preventable by adhering to a number of simple behavioural guidelines to minimise exposure to the sun. and their specific focus). Along with mass addition, parents tend to have less influence It is recommended that when the UV index media campaigns, policies and educational on older children, including in relation is 3 or above, individuals spending time programmes play an important role in skin to behaviours that affect sun exposure 18,19 outdoors should wear a hat, wear sunscreen cancer prevention, although the reach of such as clothing practices. This greater with a sun-protection factor of 30 or higher, these approaches varies for different age independence during adolescence comes wear clothing that covers most of the body, groups. For example, primary school children at a risk, with qualitative research indicating and stay in the shade. Protecting the skin have been protected to some extent by that sun protection is a low-priority issue for from the sun is particularly critical during parental precautions, school policies such adolescents and an unwelcome interruption childhood and adolescence to reduce the risk as “no hat, no play” (i.e. a requirement for to their preferably spontaneous and care-free 9,10 of developing skin cancer later in life. students to wear hats when playing outdoors lifestyles. These findings are reflected in 12-14 during times of high UV radiation levels), quantitative studies showing that adolescents Since the early 1980s, numerous mass and a strong emphasis on teaching children in Australia and elsewhere are significantly media campaigns have been run in Australia sun-protection skills at schools in high UV less likely than adults to engage in sun- to raise skin cancer awareness among 15 21-26 regions. However, these strategies often protection practices. the community in general and specific do not apply to adolescents, who as a result vulnerable groups such as adolescents (see Longitudinal studies have been undertaken of their growing maturity are expected to Iannacone and Green for an overview of in the US and Australia to document changes 16,17 be more self-reliant and responsible. In Australian skin cancer awareness campaigns 1. Curtin University, Western Australia 2. Cancer Council Western Australia 3. La Trobe University, Victoria Correspondence to: Professor Simone Pettigrew, Western Australian Cancer Prevention Research Unit (WACPRU), School of Psychology and Speech Pathology, Curtin University, Kent Street, Bentley, WA 6102; e-mail: simone.pettigrew@curtin.edu.au Submitted: November 2015; Revision requested: January 2016; Accepted: April 2016 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2016; 40:468-73; doi: 10.1111/1753-6405.12561 468 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 5 © 2016 Public Health Association of Australia Youth Trends in sun-protection behaviour in adolescent sun-protection behaviours premises, it was predicted that in recent (wearing a hat, wearing protective clothing, over time. In terms of sunscreen use, US data years there would be less time spent outdoors using sunscreen, wearing sunglasses, indicate that usage rates increased between and greater use of shade among Western and seeking shade). One item measured 1998 and 2004, followed by a substantial Australian adolescents. the complete avoidance of UV radiation decrease between 2004 and 2007, while by staying inside. With regard to the five no changes were observed in other sun- outdoor protection behaviours, respondents Method protection behaviours. Data are available were asked to indicate on a 5-point Likert for a longer period in Australia, with results The study received approval from the scale how often they would engage in the indicating a steep increase in sun-protection Curtin University Human Research Ethics behaviour during a sunny day in summer behaviours between 1987 and the mid-1990s, Committee. A cross-sectional survey was between 10am and 2pm when being in the with smaller fluctuations and greater stability conducted via Computer Assisted Telephone sun for an hour or more. The item measuring in the following decade. The use of hats Interviewing (CATI) during 10 summers how frequently respondents avoided the sun and protective clothing among Australian between 2001/02 and 2011/12 as part of a completely by staying inside was modified adolescents marginally decreased from 1993 long-running survey that tracked Western by omitting the phrase ‘when being in the 30,31 onwards, while sunscreen use decreased Australians’ knowledge and behaviours sun for an hour or more’. Response categories between 1993 and 2002, and then remained relating to sun exposure. No data collection were never (1), rarely (2), sometimes (3), constant between 2003 and 2010. The occurred in 2004/05 due to a lack of funding. usually (4), and always (5). only increase in recent years was for staying The respondents were residents of Western indoors during peak UV times, with a slight Australia, where the risk of developing skin Statistical analysis rise in the frequency of this behaviour from cancer is – together with Queensland – the Due to the ordinal nature of the response 31 40 2006 to 2010. It appears that the smaller highest in Australia. Average UV radiation categories, separate ordinal regression changes observed in more recent years may levels in Western Australia are 11 or higher at analyses were conducted with each of the be indicative of a plateau effect following noon during the summer months. six sun-protection behaviours as dependent the large improvements in sun-protection Respondents were recruited over a period measures, controlling for the effects of behaviours observed in prior decades. of approximately 6 weeks each summer via age, gender, and skin colour. In addition, random digit dialling. The total usable sample Monitoring sun-protection behaviours the remaining protection behaviours were consisted of 5,053 14–17 year olds, with an among adolescents is crucial to identify entered as covariates to control for influences equal representation of males and females. trends that can inform interventions to that arise from the likelihood of engaging in Table 1 reports the number of respondents promote better sun-protection practices in other forms of sun-protection. Year of survey by age, gender, and skin colour. The seven this vulnerable age group. New approaches was the predictor variable of interest. The first skin colour categories were ‘very fair’, ‘fair’, are needed because although adolescents survey year (2001/02) served as the baseline ‘medium’ , ‘olive’ , ‘dark’ , ‘very dark’ , and ‘black’ tend to be knowledgeable about sun- year to which all other years were compared. and referred to self-reported skin colour related health risks, this knowledge has not For ease of interpretation, the regression without a tan. generally translated into appropriate changes coefficients were transformed into odds 33-37 in sun-protection behaviour. The present ratios. P-values of 0.05 or less were considered Measures of sun-protection study aimed to provide more comprehensive statistically significant for all reported behaviours and updated information relating to changes analyses. in Australian adolescents’ sun-protection The frequency of engaging in six sun- To evaluate the overall trend in adolescent behaviours by analysing a decade of protection behaviours was measured, five of outdoor sun protection during the survey sun-protection data (2001/02 to 2011/12) which related to protection when outdoors period, the outdoor protection behaviours involving more time points and more recent were combined into a composite score by Table 1: Gender, age and skin colour of adolescents years than reported in previous research. In computing the mean of the five behaviours surveyed (N = 5,053). addition, a larger number of sun-protection pertaining to outdoor protection (wearing n % behaviours were tracked over time. Extending a hat, wearing protective clothing, using Gender previous research, the focus was on various sunscreen, wearing sunglasses, and seeking Male 2,532 50.1 behaviours that reduce the risk of UV Female 2,521 49.9 shade) for each respondent. A hierarchical radiation when outdoors and the complete Age linear regression analysis was conducted avoidance of UV radiation by staying inside. 14 years 1,135 22.5 with the composite score as the dependent 15 years 1,444 28.6 Based on previously identified trends among variable and survey year as a continuous 16 years 1,423 28.2 30,31 Australian adolescents, it was predicted predictor variable, controlling for the effects 17 years 1,051 20.8 that outdoor protection behaviours would of age, gender, and skin colour. Skin colour either stabilise or continue to decrease. Very fair 522 10.3 In addition, in accordance with research Fair 1,615 32.0 Results indicating greater engagement in screen- Medium 1,608 31.8 based activities among adolescents and Sun-protection behaviours Olive 1,096 21.7 the results of a cluster randomised controlled Dark 189 3.7 Means, standard errors, proportions of trial indicating that students used rather Very dark 18 0.4 respondents in each response category, than avoided newly shaded areas on school Black 5 0.1 adjusted odds ratios (AORs) with 95% 2016 vol . 40 no . 5 Australian and New Zealand Journal of Public Health 469 © 2016 Public Health Association of Australia Koch et al. Article confidence intervals, and p -values for all protection behaviour that was practised least and ‘usually’ , which means that the sun-protective behaviours are presented for frequently across all survey years (in 2001/02 measure may lack sensitivity to detect small each survey year separately in Table 2. Trends 31% usually or always, M = 2.70; in 2011/12 improvements in this frequency range. were examined for each of the six behaviours 26% usually or always, M = 2.65). Adolescents While the frequency of staying in the under investigation. most frequently reported wearing covering shade and staying inside significantly clothes ‘rarely’ or ‘sometimes’ (53% across all Protection From Sun when Outdoors. In all increased between 2001/02 and 2011/12, survey years). survey years from 2005/06, respondents both behaviours dropped significantly in reported less frequent hat use compared to Composite scores for outdoor protection survey year 2005/06. Although summers 2001/02. This finding was replicated when behaviours. Over the study period, a small in the highly populated areas of Western excluding respondents from the analysis but significant decrease in outdoor sun- Australia tend to be hot and dry with who indicated they usually or always stay protection behaviour was found (β = -0.063, generally low variability, weather statistics inside. The frequency of wearing covering t (5051) = - 4.504, p < 0.001). The composite from the Australian Government Bureau of clothes was unchanged in most survey score was highest in the first two survey years Meteorology for the summer of 2005/06 years, including the most recent survey year (M = 3.17 in 2001/02 and M = 3.20 in 2002/03) show somewhat cooler conditions and 2011/12. The frequency of wearing sunscreen and lowest in 2009/10 (M = 3.05). Averaged more rainfall, which could explain the lower also remained relatively stable across the across all survey years, the composite score frequency of these two sun-protection survey years, although a significant drop in was M = 3.12. strategies. the frequency of this behaviour was noted for Use of sunscreen was the most frequently 2006/07 (AOR = 0.69). practiced sun-protection behaviour in all Discussion Compared to 2001/02, respondents reported 10 survey years, which is consistent with The present study investigated trends in more frequent use of sunglasses in most previous findings in samples of US and 27,44 sun-protection behaviours in adolescents of the following years. Use of sunglasses European adolescents. In the present living in a high-UV region over a 10-year peaked in 2006/07 (AOR = 1.65) and 2007/08 study, 64% of all adolescents reported using time period. The observed sun-protection (AOR = 1.62), but returned to baseline levels sunscreen either ‘usually’ or ‘always’ on sunny behaviours pertained to outdoor protection in the most recent survey year. An increase days in summer between 10am and 2pm (wearing a hat, wearing protective clothing, in the reported frequency of staying in when outdoors for an hour or more. However, using sunscreen, wearing sunglasses, the shade was observed in recent survey the composite score of all outdoor protection and seeking shade) and avoidance of sun years. In 2011/12, the reported frequency of behaviours averaged across survey years (M exposure by staying inside. Over the study staying in the shade was significantly higher = 3.12) speaks to the generally poor routine period, varying trends were observed for the compared to baseline (AOR = 1.36), however use of sun-protection measures among this behaviours under investigation. The reported the increase for 2010/11 was marginal (AOR group. frequency of wearing a hat when outdoors = 1.23, p = 0.095). There was only one year The observed increase in adolescent during peak UV hours decreased significantly (2005/06) in which respondents reported sun avoidance during peak UV times from 2001/02 to 2011/12, whereas use of staying in the shade less frequently compared is a favourable trend in terms of skin sunscreen and wearing covering clothes to baseline (AOR = 0.79). cancer prevention, but potential adverse were unchanged in most survey years relative Avoiding Sun by Staying Inside. Respondents consequences may be the development to 2001/02. In the first half of the survey reported staying inside more frequently since of vitamin D deficiency and decreases in period, the frequency of using sunglasses 2006/07 (average AOR = 1.48). Similar to the physical activity levels. The human body increased, peaking in 2006/07 and 2007/08. frequency of staying in the shade, adolescents depends on moderate levels of sunlight to However, in the most recent survey year, use 47-49 reported staying inside significantly less produce sufficient amounts of vitamin D, of sunglasses returned to the first survey year frequently only in 2005/06 (AOR = 0.66). and high rates of vitamin D deficiency have level. Combining the five outdoor protection been linked to avoidance of sun exposure in Differences in Compliance. In every survey behaviours into a composite score revealed high-UV countries due to excessive outside year, sunscreen use was the most frequently a slight but significant decline over time in heat and cultural dress codes. Although practiced sun-protection behaviour on sunny the frequency of practicing outdoor sun clinically significant vitamin D deficiencies days in summer between 10am and 2pm protection. (<30 nmol/L) are currently rare in Australia when being outdoors for an hour or more Avoiding sun exposure by staying inside and less common among adolescents than (in 2001/02 68% usually or always, M = 3.76; 51,52 consistently improved over time, and adults, attaining sufficient levels of natural in 2011/12 66% usually or always, M = 3.81 staying in the shade showed a trend towards vitamin D will become more difficult if time in 2011/12). In terms of response categories increased frequency in recent survey years. spent indoors keeps increasing. for this sun-protection behaviour, ‘usually’ However, favourable trends in these two was the most frequently reported behaviour sun-protection behaviours may be more Intervention implications frequency for sunscreen in all survey years, difficult to capture with the rating scales used with between 33 and 40% of respondents Considering the low compliance with because the majority of adolescents rated reporting this frequency. recommended sun-protection guidelines their enactment frequencies as ‘sometimes’ among adolescents found in this and Wearing covering clothes on sunny days for both sun-protection behaviours. Previous 24-26 previous studies, tailoring sun-protection in summer between 10am and 2pm when research has found particularly large intervals messages and interventions to the distinctive outdoors for an hour or more was the sun- between the response categories ‘sometimes’ 470 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 5 © 2016 Public Health Association of Australia Youth Trends in sun-protection behaviour Table 2: Trends in likelihood of different sun-protection behaviours in Western Australian adolescents from 2001/02 to 2011/12. Behaviour 2001/02 2002/03 2003/04 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 N = 609 N = 602 N = 600 N = 611 N = 502 N = 559 N = 455 N = 399 N = 415 N = 301 Wear a hat Mean (SE ) 3.22 (0.05) 3.14 (0.05) 3.27 (0.05) 3.04 (0.05) 2.85 (0.05) 2.79 (0.05) 2.74 (0.06) 2.61 (0.06) 2.61 (0.06) 2.72 (0.07) % never 14 14 13 16 21 20 24 26 26 23 % rarely 16 15 14 20 21 22 22 24 21 21 % sometimes 23 27 25 25 23 26 22 27 26 26 % usually 29 30 30 26 22 21 21 15 19 21 11 11 9 8 10 % always 19 15 18 14 13 Adjusted odds ra tio 1 0.90 1.08 0.75 0.58 0.53 0.47 0.39 0.40 0.47 95%CI 0.74–1.11 0.88–1.32 0.62–0.92 0.47–0.72 0.43–0.65 0.38–0.59 0.31–0.49 0.32–0.50 0.37–0.60 p-value 0.323 0.482 0.006 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 Wear covering clothes Mean (SE ) 2.70 (0.05) 2.70 (0.05) 2.64 (0.05) 2.77 (0.05) 2.85 (0.05) 2.64 (0.05) 2.68 (0.05) 2.53 (0.06) 2.60 (0.06) 2.65 (0.07) 18 18 21 16 19 19 25 23 17 % never 16 % rarely 29 27 28 25 26 28 30 27 27 30 % sometimes 25 27 27 23 25 28 26 25 25 26 % usually 25 24 24 25 24 20 21 19 20 19 % always 6 5 3 6 9 5 5 4 6 7 Adjusted odds ra tio 1 1.01 0.93 1.12 1.27 0.90 0.95 0.76 0.83 0.92 95%CI 0.83–1.24 0.76–1.14 0.92–1.37 1.03–1.58 0.73–1.10 0.76–1.18 0.61–0.96 0.66–1.04 0.72–1.19 0.538 p-value 0.899 0.499 0.268 0.026 0.304 0.627 0.021 0.104 Wear sunscreen Mean (SE ) 3.76 (0.04) 3.77 (0.4) 3.73 (0.4) 3.70 (0.04) 3.57 (0.05) 3.74 (0.04) 3.72 (0.05) 3.74 (0.05) 3.79 (0.05) 3.81 (0.06) % never 4 3 5 6 5 3 4 7 5 5 % rarely 10 7 8 8 11 11 11 9 8 9 % sometimes 18 23 19 21 29 24 22 22 25 21 35 39 36 35 37 % usually 36 37 40 37 33 % always 32 30 28 28 22 27 24 27 27 29 Adjusted odds ra tio 1 0.99 0.95 0.92 0.69 0.96 0.92 1.02 1.07 1.11 95%CI 0.80–1.21 0.77–1.17 0.75–1.14 0.56–0.86 0.78–1.19 0.74–1.15 0.81–1.29 0.85–1.34 0.86–1.43 p-value 0.898 0.632 0.457 0.001 0.715 0.469 0.856 0.581 0.438 Wear sunglasses Mean (SE 3.01 (0.06) 2.80 (0.06) 2.96 (0.06) 3.23 (0.07) 3.21(0.06) 3.19 (0.07) 3.12 (0.07) 2.98 (0.8) ) 2.79 (0.06) 2.98 (0.07) % never 34 29 32 29 25 25 30 25 24 33 % rarely 13 11 14 13 11 12 10 11 15 10 % sometimes 16 13 16 12 14 14 20 16 15 13 % usually 13 20 18 16 24 21 17 21 21 19 % always 24 27 21 29 27 28 24 28 25 26 Adjusted odds ra tio 1 1.30 0.98 1.23 1.65 1.62 1.24 1.56 1.45 1.19 95%CI 1.06–1.60 0.80–1.21 1.01–1.51 1.33–2.04 1.31–2.00 0.99–1.54 1.23–1.96 1.16–1.83 0.92–1.53 p-value 0.011 0.862 0.045 <0.001 <0.001 0.060 <0.001 0.001 0.187 Stay in shade Mean (SE ) 3.23 (0.03) 3.24 (0.03) 3.19 (0.03) 3.15 (0.03) 3.19 (0.03) 3.22 (0.03) 3.31 (0.03) 3.32 (0.04) 3.31 (0.04) 3.34 (0.04) % never 2 2 3 3 1 2 1 2 2 1 % rarely 14 16 16 17 13 13 12 9 10 10 45 47 47 45 45 % sometimes 47 46 46 54 49 % usually 35 33 35 23 34 35 37 40 37 39 % always 3 4 2 3 3 4 4 3 6 6 Adjusted odds ra tio 1 1.02 0.91 0.79 0.89 0.96 1.21 1.29 1.23 1.36 95%CI 0.82–1.26 0.73–1.14 0.63–0.98 0.70–1.12 0.77–1.20 0.96–1.53 1.01–1.65 0.96–1.57 1.04–1.77 p-value 0.871 0.414 0.029 0.302 0.745 0.112 0.045 0.095 0.027 Stay inside Mean (SE ) 3.12 (0.03) 3.06 (0.03) 3.15 (0.03) 2.97 (0.03) 3.28 (0.03) 3.30 (0.03) 3.21 (0.04) 3.27 (0.04) 3.31 (0.04) 3.27 (0.04) % never 3 5 1 4 1 2 2 2 1 1 % rarely 17 18 19 26 15 14 13 13 11 12 % sometimes 47 46 49 49 41 40 47 43 43 44 % usually 32 30 30 21 38 38 35 40 41 39 % always 2 1 1 1 4 5 3 3 4 5 1.47 Adjusted odds ra tio 1 0.89 1.04 0.66 1.46 1.58 1.26 1.47 1.62 95%CI 0.71–1.10 0.84–1.29 0.53–0.81 1.16–1.83 1.27–1.97 1.00–1.60 1.15–1.88 1.27–2.07 1.12–1.91 <0.001 0.001 <0.001 0.050 0.002 <0.001 0.005 p-value 0.264 0.724 Note. The results of ordinal regression models are presented, adjusting for the effects of age, gender, skin colour, and other protection behaviours. Survey year 2001/02 is the referent year. Means are estimated marginal means with covariates held constant. Frequency of behaviour was classified into the ordinal response categories never (1), rarely (2), sometimes (3), usually (4), and always (5). No data were collected in year 2004/05. a: SE = standard error ; b: CI = confidence interval 2016 vol . 40 no . 5 Australian and New Zealand Journal of Public Health 471 © 2016 Public Health Association of Australia Koch et al. Article characteristics of this age group is an and more time spent in front of screens has References important step to encourage behaviour been associated with lower levels of physical 1. Armstrong BK, Kricker A. The epidemiology of change. However, health education activity, which in turn are associated with UV induced skin cancer. 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