A randomised controlled trial of a theory-based intervention to improve sun protective behaviour in adolescents ('you can still be HOT in the shade') : study protocol

Background: Most skin cancers are preventable by encouraging consistent use of sun protective behaviour. In Australia, adolescents have high levels of knowledge and awareness of the risks of skin cancer but exhibit significantly lower sun protection behaviours than adults. There is limited research aimed at understanding why people do or do not engage in sun protective behaviour, and an associated absence of theory-based interventions to improve sun safe behaviour. This paper presents the study protocol for a school-based intervention which aims to improve the sun safe behaviour of adolescents. Methods/design: Approximately 400 adolescents (aged 12-17 years) will be recruited through Queensland, Australia public and private schools and randomized to the intervention (n = 200) or 'wait-list' control group (n = 200). The intervention focuses on encouraging supportive sun protective attitudes and beliefs, fostering perceptions of normative support for sun protection behaviour, and increasing perceptions of control/self-efficacy over using sun protection. It will be delivered during three × one hour sessions over a three week period from a trained facilitator during class time. Data will be collected one week pre-intervention (Time 1), and at one week (Time 2) and four weeks (Time 3) post-intervention. Primary outcomes are intentions to sun protect and sun protection behaviour. Secondary outcomes include attitudes toward performing sun protective behaviours (i.e., attitudes), perceptions of normative support to sun protect (i.e., subjective norms, group norms, and image norms), and perceived control over performing sun protective behaviours (i.e., perceived behavioural control). Discussion: The study will provide valuable information about the effectiveness of the intervention in improving the sun protective behaviour of adolescents.

Application of an appearance-based intervention to improve sun protection outcomes of outdoor workers in Queensland, Australia

Outdoor workers are exposed to high levels of ultraviolet radiation (UVR) and may thus be at greater risk to experience UVR-related health effects such as skin cancer, sun burn, and cataracts. A number of intervention trials (n=14) have aimed to improve outdoor workers’ work-related sun protection cognitions and behaviours. Only one study however has reported the use of UV-photography as part of a multi-component intervention. This study was performed in the USA and showed long-term (12 months) improvements in work-related sun protection behaviours. Intervention effects of the other studies have varied greatly, depending on the population studied, intervention applied, and measurement of effect. Previous studies have not assessed whether: - Interventions are similarly effective for workers in stringent and less stringent policy organisations; - Policy effect is translated into workers’ leisure time protection; - Implemented interventions are effective in the long-term; - The facial UV-photograph technique is effective in Australian male outdoor workers without a large additional intervention package, and; - Such interventions will also affect workers’ leisure time sun-related cognitions and behaviours. Therefore, the present Protection of Outdoor Workers from Environmental Radiation [POWER]-study aimed to fill these gaps and had the objectives of: a) assessing outdoor workers’ sun-related cognitions and behaviours at work and during leisure time in stringent and less stringent sun protection policy environments; b) assessing the effect of an appearance-based intervention on workers’ risk perceptions, intentions and behaviours over time; c) assessing whether the intervention was equally effective within the two policy settings; and d) assessing the immediate post-intervention effect. Effectiveness was described in terms of changes in sun-related risk perceptions and intentions (as these factors were shown to be main precursors of behaviour change in many health promotion theories) and behaviour. The study purposefully selected and recruited two organisations with a large outdoor worker contingent in Queensland, Australia within a 40 kilometre radius of Brisbane. The two organisations differed in the stringency of implementation and reinforcement of their organisational sun protection policy. Data were collected from 154 male predominantly Australian born outdoor workers with an average age of 37 years and predominantly medium to fair skin (83%). Sun-related cognitions and behaviours of workers were assessed using self-report questionnaires at baseline and six to twelve months later. Variation in follow-up time was due to a time difference in the recruitment of the two organisations. Participants within each organisation were assigned to an intervention or control group. The intervention group participants received a one-off personalised Skin Cancer Risk Assessment Tool [SCRAT]-letter and a facial UV-photograph with detailed verbal information. This was followed by an immediate post-intervention questionnaire within three months of the start of the study. The control group only received the baseline and follow-up questionnaire. Data were analysed using a variety of techniques including: descriptive analyses, parametric and non-parametric tests, and generalised estimating equations. A 15% proportional difference observed was deemed of clinical significance, with the addition of reported statistical significance (p<0.05) where applicable. Objective 1: Assess and compare the current sun-related risk perceptions, intentions, behaviours, and policy awareness of outdoor workers in stringent and less stringent sun protection policy settings. Workers within the two organisations (stringent n=89 and less stringent n=65) were similar in their knowledge about skin cancer, self efficacy, attitudes, and social norms regarding sun protection at work and during leisure time. Participants were predominantly in favour of sun protection. Results highlighted that compared to workers in a less stringent policy organisation working for an organisation with stringent sun protection policies and practices resulted in more desirable sun protection intentions (less willing to tan p=0.03) ; actual behaviours at work (sufficient use of upper and lower body protection, headgear, and sunglasses (p<0.001 for all comparisons), and greater policy awareness (awareness of repercussions if Personal Protective Equipment (PPE) was not used, p<0.001)). However the effect of the work-related sun protection policy was found not to extend to leisure time sun protection. Objective 2: Compare changes in sun-related risk perceptions, intentions, and behaviours between the intervention and control group. The effect of the intervention was minimal and mainly resulted in a clinically significant reduction in work-related self-perceived risk of developing skin cancer in the intervention compared to the control group (16% and 32% for intervention and control group, respectively estimated their risk higher compared to other outdoor workers: , p=0.11). No other clinical significant effects were observed at 12 months follow-up. Objective 3: Assess whether the intervention was equally effective in the stringent sun protection policy organisation and the less stringent sun protection policy organisation. The appearance-based intervention resulted in a clinically significant improvement in the stringent policy intervention group participants’ intention to protect from the sun at work (workplace*time interaction, p=0.01). In addition to a reduction in their willingness to tan both at work (will tan at baseline: 17% and 61%, p=0.06, at follow-up: 54% and 33%, p=0.07, stringent and less stringent policy intervention group respectively. The workplace*time interaction was significant p<0.001) and during leisure time (will tan at baseline: 42% and 78%, p=0.01, at follow-up: 50% and 63%, p=0.43, stringent and less stringent policy intervention group respectively. The workplace*time interaction was significant p=0.01) over the course of the study compared to the less stringent policy intervention group. However, no changes in actual sun protection behaviours were found. Objective 4: Examine the effect of the intervention on level of alarm and concern regarding the health of the skin as well as sun protection behaviours in both organisations. The immediate post-intervention results showed that the stringent policy organisation participants indicated to be less alarmed (p=0.04) and concerned (p<0.01) about the health of their skin and less likely to show the facial UV-photograph to others (family p=0.03) compared to the less stringent policy participants. A clinically significantly larger proportion of participants from the stringent policy organisation reported they worried more about skin cancer (65%) and skin freckling (43%) compared to those in the less stringent policy organisation (46%,and 23% respectively , after seeing the UV-photograph). In summary the results of this study suggest that the having a stringent work-related sun protection policy was significantly related to for work-time sun protection practices, but did not extend to leisure time sun protection. This could reflect the insufficient level of sun protection found in the general Australian population during leisure time. Alternatively, reactance caused by being restricted in personal decisions through work-time policy could have contributed to lower leisure time sun protection. Finally, other factors could have also contributed to the less than optimal leisure time sun protection behaviours reported, such as unmeasured personal or cultural barriers. All these factors combined may have lead to reduced willingness to take proper preventive action during leisure time exposure. The intervention did not result in any measurable difference between the intervention and control groups in sun protection behaviours in this population, potentially due to the long lag time between the implementation of the intervention and assessment at 12-months follow-up. In addition, high levels of sun protection behaviours were found at baseline (ceiling effect) which left little room for improvement. Further, this study did not assess sunscreen use, which was the predominant behaviour assessed in previous effective appearance-based interventions trials. Additionally, previous trials were mainly conducted in female populations, whilst the POWER-study’s population was all male. The observed immediate post-intervention result could be due to more emphasis being placed on sun protection and risks related to sun exposure in the stringent policy organisation. Therefore participants from the stringent policy organisation could have been more aware of harmful effects of UVR and hence, by knowing that they usually protect adequately, not be as alarmed or concerned as the participants from the less stringent policy organisation. In conclusion, a facial UV-photograph and SCRAT-letter information alone may not achieve large changes in sun-related cognitions and behaviour, especially of assessed 6-12 months after the intervention was implemented and in workers who are already quite well protected. Differences found between workers in the present study appear to be more attributable to organisational policy. However, against a background of organisational policy, this intervention may be a useful addition to sun-related workplace health and safety programs. The study findings have been interpreted while respecting a number of limitations. These have included non-random allocation of participants due to pre-organised allocation of participants to study group in one organisation and difficulty in separating participants from either study group. Due to the transient nature of the outdoor worker population, only 105 of 154 workers available at baseline could be reached for follow-up. (attrition rate=32%). In addition the discrepancy in the time to follow-up assessment between the two organisations was a limitation of the current study. Given the caveats of this research, the following recommendations were made for future research: - Consensus should be reached to define "outdoor worker" in terms of time spent outside at work as well as in the way sun protection behaviours are measured and reported. - Future studies should implement and assess the value of the facial UV-photographs in a wide range of outdoor worker organisations and countries. - More timely and frequent follow-up assessments should be implemented in intervention studies to determine the intervention effect and to identify the best timing of booster sessions to optimise results. - Future research should continue to aim to target outdoor workers’ leisure time cognitions and behaviours and improve these if possible. Overall, policy appears to be an important factor in workers’ compliance with work-time use of sun protection. Given the evidence generated by this research, organisations employing outdoor workers should consider stringent implementation and reinforcement of a sun protection policy. Finally, more research is needed to improve ways to generate desirable behaviour in this population during leisure time.

Investigating mothers' decisions about their child's sun-protective behaviour using the Theory of Planned Behaviour

This study tested the utility of the Theory of Planned Behaviour (TPB) to predict mothers’ decisions to ensure their child engages in sun-protective behaviours. Mothers (N = 162) of children aged four or five years completed standard TPB items (attitude, subjective norm, perceived behavioural control, intention) and additional variables of role construction, mothers’ own sun safe behaviour, planning and past behaviour. One week later, participants (N = 116) reported their behaviour. Results found support for the TPB constructs, role construction, past behaviour and the mediating role of planning. These findings can inform strategies to prevent skin cancer.

Personalised electronic messages to improve sun protection in young adults

The incidence of all skin cancers, including melanoma, continues to rise. It is well known that ultraviolet (UV) radiation is the main environmental risk factor for skin cancer, and excessive exposure at a young age increases the risk of developing skin cancer. The aim of this study was to determine the acceptability and feasibility of delivering sun protection messages via electronic media such as short message services (SMS) to people 18-40 years, and explore factors associated with their acceptability. Overall, 80% of participants agreed that they would like to receive some form of sun protection advice; of these, 20% prefer to receive it via SMS and 42% via email. Willingness to receive electronic messages about the UV index was associated with being unsure about whether a suntanned person would look healthy and greater use of sun protection in the past. Careful attention to message framing and timing of message delivery and focus on short-term effects of sun exposure such as sunburn and skin ageing should increase the acceptability of such messages to young people. We conclude that sun protection messages delivered to young adults via electronic media appear feasible and acceptable.

Vitamin D intake, sun exposure and 25-hydroxy vitamin D status in Peritoneal dialysis (PD) and Haemodialysis (HD) patients

Inadequate vitamin D levels have been linked to bone disease but more recently have been associated with wider health implications. Limited studies suggest a high prevalence of Vitamin D deficiency in dialysis patients, although evidence is lacking on whether this is due to dietary restrictions, limited mobility and time outdoors or a combination of these. The aim of this study was to assess the contributions of diet, supplements and sunlight exposure to serum Vitamin D (25(OH)D) levels in dialysis patients. Cross-sectional data were obtained from 30 PD (Mean±SD age 56.9±16.2 y; n=13 male) and 22 HD (Mean±SD age 65.4±14.0 y; n=18 male) patients between 2009 and 2010. Serum 25(OH)D was measured and oral vitamin D intake estimated through a food-frequency-questionnaire and quantifying inactive supplementation. Sunlight exposure was assessed using a validated questionnaire. Prevalence of inadequate/insufficient vitamin D differed between dialysis modality (31% and 43% insufficient (<50nmol/L); 4% and 34% deficient (<25nmol/L) in HD and PD patients respectively (p=0.002)). In HD patients, there was a significant correlation between diet plus supplemental vitamin D intake and 25(OH)D (ρ=0.84, p<0.001). Results suggest a higher frequency of 25(OH)D inadequacy/deficiency in PD compared to HD patients. No other relationships between intake, sun exposure and 25(OH)D were seen. This could reflect limitations of the study design or the importance of other factors such as age, ethnicity and sun protection as interactions in the analysis. Understanding these factors is important given Vitamin D’s emerging status as a biomarker of systemic ill health.

Groundwater overuse and farm-level technical inefficiency : evidence from Sri Lanka

Extraction of groundwater for onion and other cash crop production has been increasing rapidly during the last two decades in the dry zone areas of Sri Lanka. As a result of overuse, the quantity of available groundwater is gradually declining, while water quality is deteriorating. The deteriorating water quality has a negative impact on agricultural production, especially for crops (such as onions) that are sensitive to increases in salinity levels. This issue is examined with respect to onion production in Sri Lanka. A stochastic frontier production function (SFPF) is used, in which technical efficiency and the determinants of inefficiencies are estimated simultaneously. The results show that farmers are overusing groundwater in their onion cultivation, which has resulted in decreasing yields. Factors contributing to inefficiency in production are also identified. The results have important policy implications.

Identifying critical sun-protective beliefs among Australian adults

We investigated critical beliefs to target in interventions aimed at improving sun-protective behaviours of Australian adults, a population at risk for skin cancer. Participants (N = 816) completed a Theory of Planned Behaviour belief-based questionnaire and a 1-week follow-up of sun-protective behaviour. A range of behavioural, normative and control beliefs correlated with sun-protective behaviour, with no and only minimal differences observed in correlations between beliefs and behaviour by gender and age, respectively. A range of key beliefs made independent contributions to behaviour; however, the behavioural belief about being less likely to tan (β = 0.09); normative belief about friends (β = 0.20); and control beliefs about forgetfulness (β = −0.14), inconvenience (β = −0.17), knowing I will be in the sun for a long time (β = 0.16) and more fashionable sun-protective clothing (β = 0.13) were significant critical beliefs guiding people’s sun-protective behaviour. Our study fills a gap in the literature by investigating an at-risk population for skin cancer and using an established theoretical framework to identify critical beliefs that guide Australian adults’ decisions to sun protect. Attention to these critical beliefs will assist health campaigns and interventions aimed at combating the increasing rates of skin cancer for adults.

Assessing the impacts of lifetime sun exposure on skin damage and skin aging using a non-invasive method

Background: Ultraviolet radiation exposure during an individuals' lifetime is a known risk factor for the development of skin cancer. However, less evidence is available on assessing the relationship between lifetime sun exposure and skin damage and skin aging. Objectives: This study aims to assess the relationship between lifetime sun exposure and skin damage and skin aging using a non-invasive measure of exposure. Methods: We recruited 180 participants (73 males, 107 females) aged 18-83 years. Digital imaging of skin hyper-pigmentation (skin damage) and skin wrinkling (skin aging) on the facial region was measured. Lifetime sun exposure (presented as hours) was calculated from the participants' age multiplied by the estimated annual time outdoors for each year of life. We analyzed the effects of lifetime sun exposure on skin damage and skin aging. We adjust for the influence of age, sex, occupation, history of skin cancer, eye color, hair color, and skin color. Results: There were non-linear relationships between lifetime sun exposure and skin damage and skin aging. Younger participant's skin is much more sensitive to sun exposure than those who were over 50 years of age. As such, there were negative interactions between lifetime sun exposure and age. Age had linear effects on skin damage and skin aging. Conclusion: The data presented showed that self reported lifetime sun exposure was positively associated with skin damage and skin aging, in particular, the younger people. Future health promotion for sun exposure needs to pay attention to this group for skin cancer prevention messaging. (C) 2012 Elsevier B.V. All rights reserved.

Agricultural biodiversity, farm level technical efficiency and conservation benefits : an empirical investigation

The issues involved in agricultural biodiversity are important and interesting areas for the application of economic theory. However, very little theoretical and empirical work has been undertaken to understand the benefits of conserving agricultural biodiversity. Accordingly, the main objectives of this PhD thesis are to: (1) Investigate farmers’ valuation of agricultural biodiversity; (2) Identify factors influencing farmers’ demand for agricultural biodiversity; (3) Examine farmers’ demand for biodiversity rich farming systems; (4) Investigate the relationship between agricultural biodiversity and farm level technical efficiency. This PhD thesis investigates these issues by using primary data in small-scale farms, along with secondary data from Sri Lanka. The overall findings of the thesis can be summarized as follows. Firstly, owing to educational and poverty issues of those being interviewed, some policy makers in developed countries question whether non-market valuation techniques such as Choice Experiment (CE) can be applied to developing countries such as Sri Lanka. The CE study in this thesis indicates that carefully designed and pre-tested nonmarket valuation techniques can be applied in developing countries with a high level of reliability. The CE findings support the priori assumption that small-scale farms and their multiple attributes contribute positively and significantly to the utility of farm families in Sri Lanka. Farmers have strong positive attitudes towards increasing agricultural biodiversity in rural areas. This suggests that these attitudes can be the basis on which appropriate policies can be introduced to improve agricultural biodiversity. Secondly, the thesis identifies the factors which influence farmers’ demand for agricultural biodiversity and farmers’ demands on biodiversity rich farming systems. As such they provide important tools for the implementation of policies designed to avoid the loss agricultural biodiversity which is shown to be a major impediment to agricultural growth and sustainable development in a number of developing countries. The results illustrate that certain key household, market and other characteristics (such as agricultural subsidies, percentage of investment of owned money and farm size) are the major determinants of demand for agricultural biodiversity on small-scale farms. The significant household characteristics that determine crop and livestock diversity include household member participation on the farm, off-farm income, shared labour, market price fluctuations and household wealth. Furthermore, it is shown that all the included market characteristics as well as agricultural subsidies are also important determinants of agricultural biodiversity. Thirdly, it is found that when the efficiency of agricultural production is measured in practice, the role of agricultural biodiversity has rarely been investigated in the literature. The results in the final section of the thesis show that crop diversity, livestock diversity and mix farming system are positively related to farm level technical efficiency. In addition to these variables education level, number of separate plots, agricultural extension service, credit access, membership of farm organization and land ownerships are significant and direct policy relevant variables in the inefficiency model. The results of the study therefore have important policy implications for conserving agricultural biodiversity in Sri Lanka.

Assessing eco-environmental performance of agricultural production in OECD countries : combination of soil surface, soil system and farm gate methods of nutrient auditing

Nitrogen balance is increasingly used as an indicator of the environmental performance of agricultural sector in national, international, and global contexts. There are three main methods of accounting the national nitrogen balance: farm gate, soil surface, and soil system. OECD (2008) recently reported the nitrogen and phosphorus balances for member countries for the 1985 - 2004 period using the soil surface method. The farm gate and soil system methods were also used in some international projects. Some studies have provided the comparison among these methods and the conclusion is mixed. The motivation of this present paper was to combine these three methods to provide a more detailed auditing of the nitrogen balance and flows for national agricultural production. In addition, the present paper also provided a new strategy of using reliable international and national data sources to calculate nitrogen balance using the farm gate method. The empirical study focused on the nitrogen balance of OECD countries for the period from 1985 to 2003. The N surplus sent to the total environment of OECD surged dramatically in early 1980s, gradually decreased during 1990s but exhibited an increasing trends in early 2000s. The overall N efficiency however fluctuated without a clear increasing trend. The eco-environmental ranking shows that Australia and Ireland were the worst while Korea and Greece were the best.

Sun, sea, sex, sand and soap

A recent issue of Young People Now (November 1995) mentioned the new (UK) Channel 4 television soap opera Hollyoaks by Phil Redmond, which raises the issue of the role of ‘soaps’ in the daily lives of young people. Australian soaps are especially popular in Britain and of interest to those who work with young people, because they have a high proportion of youthful looking actors and actresses and frequently depict scenes involving young people and apparent ‘real’ teenage dilemmas.

Examining young recreational sportswomen's intentions to engage in sun-protective behavior : the role of group and image norms

Researchers examined the sun-protective intentions and behavior of young, Caucasian, Australian sportswomen aged between 17 and 35 years (N = 100). The study adopted a 2 x 2 experimental design, comparing group norms (supportive vs. non-supportive) and image norms (tanned vs. pale) related to sun protection and taking into account group identification with friends and peers in the sport. While no significant findings emerged involving image norms, regression analyses revealed a significant two-way interaction for group norm x identification on recreational sportswomen's intentions to engage in sun protection in the next fortnight. Participants identifying strongly with their group had stronger intentions to engage in sun protection when exposed to a norm reflecting fellow recreational sportswomen engaging in sun-protective actions in comparison to those exposed to a non-supportive group. In addition, while prior intentions to engage in sun protection were not significantly related to sun-protection behavior, post-manipulation intentions after exposure to the sun-protective information that was provided were significantly related to follow-up behavior. Overall, the findings supported the importance of group-based social influences, rather than tanned media images, on sun-protective decisions among young recreational sportswomen and provided a targeted source for intervention strategies encouraging sun safety among this at-risk group for repeated sun exposure.

A meta-analysis of pigmentary characteristics, sun sensitivity, freckling and melanocytic nevi and risk of basal cell carcinoma of the skin

Objective: To calculate pooled risk estimates of the association between pigmentary characteristics and basal cell carcinoma (BCC) of the skin. Methods: We searched three electronic databases and reviewed the reference lists of the retrieved articles until July 2012 to identify eligible epidemiologic studies. Eligible studies were those published in between 1965 and July 2012 that permitted quantitative assessment of the association between histologically-confirmed BCC and any of the following characteristics: hair colour, eye colour, skin colour, skin phototype, tanning and burning ability, and presence of freckling or melanocytic nevi. We included 29 studies from 2236 initially identified. We calculated summary odds ratios (ORs) using weighted averages of the log OR, using random effects models. Results: We found strongest associations with red hair (OR 2.02; 95% CI: 1.68, 2.44), fair skin colour (OR 2.11; 95% CI: 1.56, 2.86), and having skin that burns and never tans (OR 2.03; 95% CI: 1.73, 2.38). All other factors had weaker but positive associations with BCC, with the exception of freckling of the face in adulthood which showed no association. Conclusions: Although most studies report risk estimates that are in the same direction, there is significant heterogeneity in the size of the estimates. The associations were quite modest and remarkably similar, with ORs between about 1.5 and 2.5 for the highest risk level for each factor. Given the public health impact of BCC, this meta-analysis will make a valuable contribution to our understanding of BCC.

Sun, sea, sex, sand and conservatism in the Australian television soap opera

A recent issue of Young People Now (November 1995) mentioned the new (UK) television soap opera Hollyoaks by Phil Redmond, which raises the issue of the role of ‘soap operas’ (hereafter referred to as soaps) in the daily lives of young people. The term ‘soap’ originates with the sponsorship of radio and television programmes by companies such as Proctor and Gamble who in America in 1932 used a daytime radio domestic comedy, The Puddle Family to advertise Oxydol, a washing powder. The first British television soap was The Grove Family (BBC 1954-7) was followed by Emergency Ward Ten (ATV 1957-67), Coronation Street (Granada Television 1960-present) and Eastenders (BBC 1985-present). Australian soaps are especially popular in Britain and of potential interest to those who work with young people, because they have a high proportion of youthful looking actors and actresses and frequently depict scenes involving young people and apparent ‘real’ teenage dilemmas. On one level it may be commendable that actors who are young(ish) somewhere between the ages of 14 and 25 play roles that are ostensibly about young people and their alleged problems. However, the casting of young, largely unknown, actors reflects more the political economy of soaps in their relative cheapness and dispensability, rather than any genuine attempt to create an oppositional text for, about and by young people (Paterson 1986).