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Soc. Sci. Med. Vol. 40, No. 2, pp. 265-274, 1995 Copyright © 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/95 $7.00 + 0.00

S U N T A N N I N G AND SUN PROTECTION: A REVIEW OF THE PSYCHOLOGICAL L I T E R A T U R E
STEPHEN ARTHEY and VALERIEA. CLARKE Department of Psychology, Deakin University, Geelong, Victoria, 3217 Australia and Anti-Cancer Council of Victoria, Victoria, Australia Abstract--Excessive sun exposure has been linked to skin cancer and to premature aging, drying and wrinkling of the skin, predominantly among Caucasians. This review examines the psychological literature on suntanning and sun protection behaviours among Caucasians. The research is examined in relation to: methods of study; attitude and normative beliefs towards suntanning and sun protection; differences in suntanning and sun protection knowledge and behaviour as a function of age and gender; and, attempts to change sun related behaviours. A consistent finding across studies is that many people show a high level of knowledge of the dangers of excessive sun exposure and the need for sun protection, however, this knowledge often does not transfer into behaviour, with many people, particularly adolescents, still desiring and actively seeking a suntan. The implications of these findings for intervention studies are discussed.

Key words--review, suntanning, sun protection, health promotion

Australia has the highest incidence of skin cancer in the world, with an estimated two out of every three people expected to develop at least one skin cancer in their lifetime [1]. As skin cancer is the most prevalent form of cancer [1], it is important to exploit all avenues for prevention. There are approx. 140,000 cases of skin cancer diagnosed and treated in Australia each year [1,2] and thousands of other cases that go undiagnosed. Approximately 1000 people die in Australia each year from skin cancer, most from melanoma (85%). Virtually all reported cases of skin cancer are among Caucasians. Aborigines, African-Americans and other darker skinned groups are at a lower risk of developing skin cancer because their melanocytes, located in the epidermal layer of the skin, are able to produce more melanin than the melanocytes of Caucasians [3]. This produces a darker skin colour and also provides increased protection from the harmful effects of ultra-violet radiation (UVR) exposure. Current aetiological evidence suggests that there is a causal link between excessive sun exposure and skin cancer [4--6]. Therefore, decreasing the amount of sun exposure is the primary objective of behavioural research in skin cancer prevention. Such prevention has generally taken the form of increasing public awareness and knowledge of the dangers of excessive sunlight exposure and educating the public as to the best ways to avoid over-exposure. A typical example of the combination of these methods into a public education program is the Anti-Cancer Council of Victoria's (ACCV) 'SunSmart' campaign, which has also incorporated messages advising structural change in the environment (e.g. school policy, pro-

vision of shade, etc.). Recent research suggests that these campaigns have significantly raised the public's level of knowledge of the dangers of over-exposure to the sun [7]. Increasing knowledge has been the primary method of behavioural prevention strategies in Australia. It has been shown that the public's level of knowledge of the dangers of over-exposure is good [7, 8]. However, it has also been found that levels of attitude to suntanning [9, 10] and actual sun related behaviour [11, 12] are not always congruent with the knowledge of risks people possess.

METHODS OF STUDY Research has mostly used survey/questionnaire designs and has examined a number of variables including people's level of knowledge of the dangers of over-exposure [9, 13], the perceived benefits of having a suntan [9, 10], and usual behaviour and level of sun protection when outdoors [12]. Although the majority of research has relied on survey techniques [e.g. 7,9, 11, 12, 14, 15] some experimental designs have also been used [e.g. 16, 17]. As with most areas of applied psychology research, true experimental designs are difficult to conduct because of the number of extraneous variables that cannot be controlled. However, there have been a variety of quasiexperimental, intervention designs attempting to improve sun protection knowledge, attitudes and behaviour. The major limitation of many of these designs has been the lack of an appropriate control group. 265

All. making the study of predictions of intention likely to throw light on the determinants of sun related behaviour. 27]. However. such as within schools [e. 28] or sun protection behaviours [e. and an assessment of the effects of positive reinforcement and modelling on behaviour [17]. public behaviour such as cigarette smoking [25]. "SunSmart" [7]. INTENTIONS There are strong theoretical reasons that. In an attempt to resolve the problem of selfreporting of behaviours. 12. The type of sun protection preferred varies as a function of both age and gender with younger people Direct observation and measurement of behaviour is limited by practical and ethical considerations. 29]. CLARKE use to record their activities. particularly children. increasing the amount of skin cancer and sun protection information taught in schools [22]. Although focus groups are often conducted in the development of questionnaires and surveys. "Are you dying to get a suntan?" [14]. usually over a five day period. Intentions to get a suntan predict actual (lack of) sun protective behaviours [28]. Both of these techniques are useful in understanding the beliefs underlying attitudes and intentions towards a behaviour. Implications of study designs Psychological research into suntanning and sun protection behaviour is a relatively new area of health promotion and disease prevention research. self-report diaries. Australia may have decreased over recent years [7]. This suggests that many people still have a positive attitude towards having a suntan. They are taking more precautions when in the sun and are more willing to encourage others. to engage in sun protection [7]. 13. the majority of the research has focussed on gathering descriptive data on knowledge and attitudes towards sun protection and to a lesser extent suntanning. MEASUREMENT OF SUN-RELATED BEHAVIOUR Intentions to protect the skin from the sun through the use of protective clothing and/or a sunscreen have been shown to be predicted by knowledge of the negative effects of the sun on the skin [15]. Failure to tell people they are being watched may be unethical while informing them they are being observed may influence their behaviour (Hawthorne effect). there has been a lack of breadth in the types of information they have collected. their confidence in their ability to successfully engage in sun protective behaviours. While questionnaire/survey designs dominate this field. possibly to present a socially desirable image. There has been little or no examination of people's perception of their risk of getting skin cancer. As a result of this. While the level of knowledge of sun protection and skin cancer is generally high. Although self-reports of behaviour have been shown to be accurate in other areas of health research focussing on observable. The theory of reasoned action [30] proposes that behaviour is predicted by the behavioural intention. which in turn is predicted by attitudes and subjective norms. As desire for a suntan decreases. Since intention can be self-reported. that subjects .g. and devising interventions to increase people's knowledge and change their attitudes and ultimately their sun protection behaviour. the authors' were unable to find any published examples of focus group research nor of one-to-one interviews. it is a more accessible dependent variable in research than is behaviour. some studies have assessed behavioural intentions in relation to suntanning behaviour [e.266 STEPm~NARTHEYand VALERIEA. weather and sun protection in two hour blocks. direct dissemination of information to the public [19-21]. the behaviour itself.g.g. 31]. PREDICTORS OF INTENTIONS Varying the style of information presentation has been the mainstay of intervention designs in sun protection education with strategies including emotional and/or informative video or mass media presentations [10. or in their perceptions of those who do (and do not) engage in sun protective behaviours. for volitional behaviours (of which sun related behaviour is an example). However. and attitudes to suntanning [28]. or most of these strategies have also been combined into public education campaigns such as "Slip! Slop! Slap!" [23]. their level of motivation to engage in sun protective behaviours. 26. as the strong social influence component of suntanning and sun protection may result in people responding with the intention they believe is socially expected rather than their actual intention. there is some concern that self-reports may over-estimate sun protection behaviours [11]. although there is some evidence that desire for a suntan in Victoria. many people appear to believe that the benefits of a suntan outweigh the risks involved in getting the tan [10]. 12]. previous experience with skin cancer [13. people are becoming more willing to engage in sun protection behaviours. 18]. As a result. self-reports of intention should also be interpreted cautiously. intention to perform the behaviour is the immediate antecedent of the relevant behaviour [30. 10] and a belief that it is easier to enjoy the summer with a tan [8]. much of the existing information is from questionnaire/survey design procedures. Attitudes toward suntanning and sun protection A suntan has been associated with looking and feeling attractive and healthy [9. and the "Arizona Sun Awareness Project" [24]. have been used successfully in structured contexts. skin type [12]. and ensuring that researchers are 'looking' in the right place.

Suntanning and sun protection more likely to use sunscreen while older people are more likely to cover-up with clothing [32]. reporting a relaxed mood and having friends who sunbathed. even though the medical benefits of heliotherapy were discredited in the 1940s and 1950s. medium. SSM 40/2--I A suntan has also long been associated with health. having a suntan remained popular [9]. but still more attractive than untanned characters. Having a suntan came to be seen as healthy. McHoskey and Gimbel [10] found that people who were portrayed as intentionally seeking a suntan were described by U. 267 SUNTANS A suntan has been a status symbol among Caucasians since the industrial revolution [9]. in Harper's Bazaar various celebrities were cited: "I love to get roasted.S. but also in a significant number of cases as being 'vain' and 'egotistical'. Sunbathing was found to be related to having a positive attitude toward risk taking. porcelain looking skin was fashionable because it indicated that the person was wealthy and did not work outdoors. 480]. Suntanning as a fashion statement is reported to have begun with Coco Chanel the French fashion designer [34]. or the developing of an awareness of the relationship between skin cancer and inappropriate sun related behaviour. in conjunction with posters describing appropriate sun protection behaviour was found to increase sun protection behaviour by children an average of 20% and by adults an average of 15% [17]. They used an interview and questionnaire procedure with beachgoers in California and found that the desire to have a suntan was motivated by the desire to present an image of being attractive. and consequently sun protection. Sunbathers were more likely to have friends who sunbathed [9]. working class. "I feel it is necessary to be tanned". while parents' and peers' suntan level at the end of the summer school holidays was a predictor of adolescent students' suntan level at the end of the summer school holidays [28]. For example. but further research is required to determine whether this finding is situation specific. Although a suntan has strong social benefits [9] there may also be social (as well as health) costs associated with having a suntan. an optimistic . characters described as having intentionally developed a suntan were perceived as being significantly less attractive than characters who had developed a suntan as a result of an outdoor lifestyle. behaviour. being only relevant to swimming locations or whether behaviour will generalize to other situations. In a recent Melbourne survey. much of the working class spent their days in factories and having a suntan became associated with being wealthy and having an abundance of leisure time to spend outdoors. This association began in the early 1900s as part of the "beliotherapy" craze in Europe [9]. or dark). healthy and active. p. college subjects as not only 'hot' and 'sexy'. p 491]. Subjective norms The belief that a suntan makes you look more attractive and healthy [9. Miller. and moral character" [9. Adolescent students' belief that their parents and peers think they should have a suntan has been shown to be a strong predictor of intention to get a suntan. Subjects were found to perceive suntanned characters as more attractive than untanned characters.S. the high incidence of melanotic and nonmelanotic skin cancers on the trunk of the body in males suggests they are less likely to wear a shirt or use other upper body protection than are females [33]. however. the majority of people worked outdoors in the agricultural fields and a suntan was associated with the poorer. This suggests that significant others can influence behaviour. The first research into sunbathing was reported by Kecsling and Friedman in 1987 [9]. half the respondents had families who thought a suntan was a good thing and over two-thirds had a majority of friends with this belief [8]. I turn almost black. However it is not possible to tell if this effect is from the impact of the subjective norm. intelligence. [10] found that irrespective of subjects' suntan level (light. 10] suggests that the perceived opinions of others are having an important effect on people's suntanning. having pale. At that time. and. Using a vignette procedure. Knowing someone who has had skin cancer is a strong predictor of intention to engage in sun protective behaviours [13]. Before then. After the industrial revolution. Although survey data suggest that males are more likely to wear a hat than are females [32]. Other characteristics that could be inferred from having a suntan included "superior physique. "A good tan makes any woman look at least ten years younger" [35]. Heliotherapy w a s exposure to the sun on a daily basis as both a preventative measure and as a cure for diseases such a s tuberculosis and various skin ailments. Modelling of appropriate sun protective behaviours by lifeguards at two pools in Virginia.A. Ashton. Of particular interest was the finding that "sunbathers seem less concerned with their actual health than with the appearance of health" [9. U. having little knowledge about skin cancer. It makes me feel healthy". Optimistic bias An optimistic bias [36] is an individual's belief that something negative is less likely to happen to them than it is to happen to others of the same age and sex. Miller et al. The popularity of the suntan increased through the 1940s to the 1970s with articles and quotes listing the benefits of having a suntan frequently appearing in magazines.

subjects with a high self-reported suntan level displayed a significantly reduced bias compared to subjects in the other two suntan categories. are the most determined to get a suntan.g. where the media often uses models with dark suntans to advertise fashion products and promote 'good health' [48]. 13]. are more aware of the premature aging effects of the sun and perceive a suntan as a greater threat to attractiveness than do males. Suntans and health People report feeling healthier with a suntan [32]. Among these pressures are those of fashion and attractiveness. Adolescents have been shown to have a high level of knowledge of the dangers of over-exposure but engage in few skin-protective behaviours [12]. Approving comments such as 'You look so good with a tan' and a suntan being associated with a 'healthy glow' are likely to encourage people to continue suntanning despite the dangers. 41]. 15].g. At the same time adolescents become susceptible to social pressure from the media and their peers [e. Age Adolescents are the group who. Although they still had a significant optimistic bias. it is encouraging to find that the most desired level of tan is a medium tan rather than a dark tan. [9. GROUP DIFFERENCES IN BELIEFS Gender There are marked gender differences in health beliefs and behaviour. In the media there has been a change toward using paler models. However. Stern. this may be an inaccurate belief. Relative to males. Currently. however. in advertising [54]. light tan. 15]. medium tan and dark tan) and in two types of attire (casual clothing and swimwear). particularly females. there is no medical evidence to suggest that a suntan improves health. Borland and Gason [16] who examined adolescents' attractiveness and healthiness judgements of male and female models with four suntan levels (no tan. 10] that a suntan is considered to be indicative of both health and beauty. Interestingly. By use of mathematical models based on epidemiological data. possibly indicating that public education programs on the dangers of excessive sun exposure are having an effect on people's beliefs. Level o f tan Although both Keesling and Friedman [9] and Miller et al. and the most resistant to adult advice on what to wear and how to behave in the sun [42]. being more concerned with appearance than are males [40. Knowledge of the dangers of over-exposure is higher in females than in males with females reporting more protection of their skin.S. females have a higher level of knowledge of skin . what is considered beautiful is not always healthy. as a whole. Subjects rated the medium suntan level as being most attractive and healthy with a trend towards darker suntan levels being rated as more healthy and attractive than lighter suntan levels. CLARKE cancer [9. It is possible that females. spend the most time in the sun [19]. are more likely to use sunscreens regularly [9. engage in more skin-protective behaviours [9. [10] have found that a suntan is perceived to be both attractive and healthy. Unfortunately. Females may also be exposed to more skin cancer information than are males as they tend to read more magazines [7] and it is likely that more detailed information is available from this source than from other information sources such as television or radio. 12]. that many females are still ignorant of the consequences of suntanning. Females are generally more concerned with health and health behaviours than are males [38] and engage in more preventative medical behaviours than do males [39]. indicating either. females consider a suntan to be more healthy than it is attractive [16]. This issue was addressed in an experimental study conducted by Broadstock. Weinstein and Baker [52] calculated that the regular use of SPF 15 sunscreens in the first 18 years of life would reduce the lifetime incidence of non-melanocytic skin cancers by approx. It is during adolescence that parental influence wanes and the responsibility for personal health shifts increasingly to the adolescent [43]. This belief is likely to have developed as a result of direct and/or indirect positive reinforcement from others. and perceive a lighter suntan level to be healthier and more attractive [16]. but consider the benefits of a suntan to outweigh these risks. 32] and the U.268 STEPHENAaTrmY and VALERIEA. or they believe the benefits of a suntan outweigh the risks. While it has been shown that brief exposure to UV radiation does result in an elevation in mood as a result of elevation of fl-endorphin and fl-lipotropin in the hypothalamic-pituitary-adrenal axis [37]. have fewer barriers to covering-up [13. it appears as if those with dark suntans are at least partially aware of the risks associated with excessive sun exposure. Although the trend is reversed for males. Adolescence is the time when much of the damage that will lead to skin cancers in later life occurs [49-51]. However. females still report desiring a suntan [9. 10] and see a suntan as being a sign of health [16]. 44--47]. neither study identified the level of suntan considered to be the most attractive or the most healthy. This finding confirms the generally held belief and the findings from correlational studies in Australia [e. Many 'teenage' bias was evident in their ratings of their chances of developing skin cancer. believe they have a higher susceptibility to skin cancer [13]. 78%. the media portrays beauty and health as being inter-related. It is not enough to educate adolescents on the dangers of their behaviour. it is necessary to change the lifestyle and fashion that favours a suntan [53]. So far the trends are encouraging. This is particularly evident in suntanning.

this campaign. Slap' campaign. there was no reported increase in sun protection measures following the campaign. stimulating messages through stories. However. their children and their partners [14]. the ASAP targets the elderly because they have the highest incidence of precancerous and cancerous skin lesions. Adolescents are a vital target for skin cancer prevention programs. an outdoor worker intervention that involved participants receiving individual screening by a dermatologist. as well as an education session on skin cancer and sun protection increased the participants' sun protection behaviours by 16% compared to a control group [27]. pressure to tan) the ASAP emphasizes the consequences of excessive sun exposure and aims to deliver messages aimed at changing perceptions of the pressure to tan. Similarly.Suntanning and sun protection magazines (again predominantly directed at females) are discussing the long-term effects of over-exposure to the sun. With children's limited understanding. Concentrating on increasing public knowledge and changing attitudes toward the sun. Other major public education campaigns such as the 'Arizona Sun Awareness Project' (ASAP) [24] and the English 'Are You Dying to Get a Suntan' campaign [14] have also reported success in increasing knowledge and the amount of sun protection people adopt. This is similar to findings in other areas of behavioural health research. ACCV brochures. mostly in relation to its effects on beauty rather than health [48]. Females between 16 and 34 years were the target group as they are the main purchasers of sun protection products for themselves. Compared with a control group who were not exposed to the campaign. had three components: magazine advertising. Over exposure during this period can increase later risk [49-51] and they are the age group who spend the most time in the sun [19]. launched in 1989. with most people still reporting that they considered a suntan personally important and synonymous with health and beauty [14]. The ASAP is a large scale. The emphasis here is on susceptibility and much of the prevention efforts are communicated through the media. The aim at this level is to provide children with a basic understanding of skin cancer prevention. shirt and shade use by its outdoor workers [56]. ATTEMPTS T O INDUCE BEHAV1OUR C H A N G E Media campaigns to effect behaviour change in sun protection have been running in Victoria since the summer of 1981 [23] when the Anti-Cancer Council of Victoria began its 'Slip. The English 'Are You Dying to Get a Suntan?' campaign. Slop. . where those with higher levels of education are more likely to be aware o f the health risks associated with their behaviour [55]. and a wellknown Australian swimming personality (Dawn Fraser) as a role model to promote covering-up when in the sun. Particular subgroups of the population spend more time in the sun than do other groups and the identification and targeting of these high exposure groups may be beneficial in reducing the incidence of skin cancer. adolescents and the elderly [24] and employs different strategies for each of these age groups. Education 269 People with higher levels of education are more aware of the dangers of over-exposure and are also more likely to report covering-up when in the sun [8]. it is important to convey the message in the form that will be most acceptable and relevant to this group. a report from the dermatologist on their current level of skin damage and personal risk of developing more extensive skin damage or skin cancer. puppet shows. rather than emphasizing message content. the experimental group increased their shirt use and their overall sun protection. One such program is Telecom Australia's 'Cover Yourself Against Skin Cancer' which was designed to increase hat. Magazines were chosen as the main forum of the campaign in preference to newspapers because of the longer 'life' of the former and in preference to television because of the cost. if there is to be a decrease in adolescent sun exposure. Finally. lapel buttons. with the goal of making people more aware of the dangerous effects of excessive sun exposure and means of preventing over exposure [14]. skin cancer and sun protection education campaign developed and run by the Arizona Cancer Centre that focuses on three main age groups: children. and the more recent and extensive 'SunSmart' program have been effective. Leaflets were distributed through community pharmacists and with airline in-flight magazines. However. particularly among young females (the target audience).e. nor any change in attitudes towards suntans. music and colour. Because there is social pressure against sun protection at this age (i. The campaign used marketing techniques including a video. attention span and personal control over health behaviour the ASAP focuses on providing attractive. The advertisement focused on the epidemiology of malignant melanoma because this is the most lethal form of skin cancer. The advertisement was successful in raising awareness of the dangers of over exposure to the sun. with many Victorians reporting taking increased precautions when in the sun and displaying high levels of knowledge of the dangers of over exposure to the sun [7]. These two studies suggest that specialized campaigns can be successful in addition to the more general sun protection campaigns such as SunSmart. of which the elderly are heavy consumers [24]. Outdoor workers are a group who are at particular risk for skin cancer and sun related skin damage and therefore may need particular attention in education and behaviour change programs. leaflets and public relations activities.

Of this group 73% thought the skin protection/examination message related to them and over half of them had examined their skin after viewing the program. An examination of the number of pigmented lesions sent to a major Victorian pathology laboratory in the three months following the presentation of the second episode of the program (February 1988). it is uncertain what effect this will have on their sun related behaviour. A telephone interview procedure was used to measure the effect of three television programs on melanoma. The videotape was largely ineffective. found a 143% increase in the number of melanomas removed compared with the same period twelve months earlier. They focused on a young man who had developed an invasive melanoma on the central part of his back which had metastasized by the time he sought medical treatment. intensive intervention that comprised a 'Skin Safe' program developed by the NSW Cancer Council designed to help children gain knowledge and develop attitudes and skills to reduce their risk of getting skin cancer was found to be more successful in increasing sun protection behaviour than was a standard 30 min lecture that focused on the dissemination of information on skin cancer and sun protection [26]. Fifteen people reported intending to visit the doctor for a suspicious looking skin lesion. Skin protection is beginning to become a part of the curriculum in these schools. Viewers of the show also reported being more aware of the relationship between sun exposure and skin cancer and reported taking more precautions to avoid sunburn than did non-viewers of the program. 90% of schools offered some health education program in Years 7 to 10. radio and television. was that "while acknowledging a degree of risk. [22] targeted pre. However. Theobald et al. Australia. The videotape discussed the powerful allure of suntanning to many people. 75% offered one in Year 11 and 69% of schools offered one in Year 12. approx. U. magazines. presented over a two year period [18]. although it is possible that this desire may decrease and their attitudes may change if they continue to engage in sun protective behaviour (i. However. suggesting that while the programs had made more people aware of the consequences of over-exposure.S. newspapers. a four week. was the method by which subjects were recruited. with students reporting that they were more likely to cover-up when in the sun [22]. while Miller et al. Arizona. CLARKE Television a n d video Skin protection/education programs such as SunSmart make use of a wide variety of media to present their information including billboards. in 1990 in Australia. The tape also presented the skin cancer experiences of a woman in her late 20s who had a history of suntanning and occasional sunburning. After the show. is also developing a school-based skin cancer prevention program.270 STEPHEN ARTHEY and VALERIEA. particularly those of college age. there was no change in the proportion of students reporting that they still desired a suntan. . it has had mixed success in studies looking at its effectiveness in communicating skin protection information. 113 adults who had seen the program were interviewed. most subjects do not believe suntanning is as risky as the experts claim" [p. Although television has been shown in other contexts to have greater impact than either written or oral presentations [57]. An important difference between the studies by Theobald et al.and early adolescents with a six unit curriculum designed to teach students to understand the dangers of the sun. with 85% of these schools having introduced it within the last five years [59]. being rated as unconvincing by subjects with either low.e. [I0] used a videotape presentation documenting the risks associated with sun exposure. examined viewers intentions to have any abnormal skin lesions checked by a doctor. It was taught within the health education program in 74% of Australian schools. For example. these groups have frequently been targeted for interventions to reduce sun exposure and increase sun protection. but emphasized the overwhelming evidence of the carcinogenic properties of sun exposure.A. Ramstack et al. Theobald et al. medium or high suntan levels. [18] and Miller et al. of whom three actually did so within four weeks of the program. skin cancer and what students can do to protect themselves from over-exposure. A change was found in self-reported behaviour following the program. This series of programs thus resulted in more people checking their skin for melanoma and seeking appropriate treatment if they found any abnormal skin lesions. A general conclusion by Miller et al. Schools Schools are starting to recognize the need for policies and education programs in relation to sun protection. People who voluntarily watch a program are likely to have an interest in the subject matter and should be more responsive to the information presented [58]. [10]. The majority of these programs are implemented through schools. interviewed subjects after they voluntarily watched the program. italics in original]. 1293. Miller et al. The television programs were considered to be informative and emotionally arousing. In Newcastle. reciprocal determinism).s subjects were completing the experiment to gain extra course credit. viewers of the program still continued to value a suntan. Interventions directed at children a n d adolescents Due to the high amounts of sun exposure during childhood and adolescence. in addition to the country in which they were conducted.

Therefore. Adolescents have high levels of knowledge of the dangers of over-exposure and of the precautions necessary to prevent skin damage. barriers to taking precautions in the sun were discussed. but as is common with interventions directed at youth. It has been effectively argued that 10 to 15 years is the most distant practical time-frame that is salient to most people [61]. Some campaigns have found increases in self-reported sun protection behaviour [e. the risk factors and the precautions to reduce the likelihood of skin cancer followed by an elaboration of the important facts in the video. level of knowledge of skin cancer and sun protection was not a predictor of intention to get a suntan or of actual suntan level attained [28]. some have reported changes in attitudes towards sun protection [e. 60].g. armed with their observation. Perceived Role of knowledge in behaviour change Knowledge based methods to change adolescents' suntanning attitudes and behaviour have been found to have limited effectiveness.A. however it appears that people may exaggerate the amount of sun protective behaviours they are actually using. 26. 57]. increase the urgency of the message on the dangers of . but based on the findings of Bennett's et al. if at all [9]. 7. lmmedia~ T of reward~punishment People believe that skin cancer is a disease of the elderly and therefore they will not get it for at least another 20 to 30 years. and some go to great lengths to get. Then. [11] observed children and their parents at the beach and then interviewed both the parents and their children regarding the amount of sun protection their family usually adopted.g. the psychologist should return to the laboratory and attempt to reproduce the event under controlled conditions and. The majority of the interventions discussed here have reported an increase in knowledge following the intervention [e.. Perceived susceptibility to skin cancer and sun damage was the strongest predictor of intentions to take precautions suggesting that a procedure similar to Mermelstein and Riesenberg's worksheet to help personalize risk may have potential in increasing adolescent sun protection behaviour. Unfortunately. any theory that is used to direct research in the behavioural prevention of skin cancer must have a social influence component to account for the pressures of peers and fashion that are important factors in people's desire to have a suntan. 14. Finally. This suggests that for people to begin to change their behaviour it is necessary to reduce the time-frame that they associate with the consequences of over-exposure to the sun. [11] and a lack of reported attitude change towards suntans. but this knowledge has not been transferred into behaviour [12]. Skin protection provides an excellent opportunity to apply Cialdini's [65] Full-Circle Social Psychology principle. They found that children's observed sun protection behaviour was less than the sun protection behaviour the children reported. particularly adolescents. 271 over-exposure to the sun and demonstrate the existence of virtually immediate rewards for covering-up when in the sun. FUTURE DIRECTIONS Most psychological research is theory driven. Second. if successful. students were given a worksheet to help them assess their personal risk of skin cancer. Knowledge has been shown to affect self-reported behaviour. 27. directed at adolescents in the U. a suntan. Research can also be driven from an applied perspective. Cialdini [65] says it is important for psychologists to go out into the real world and observe events as they take place.S. devise a theory to explain why the event occurs. Similarly. The psychologist devises a theory and then designs an experiment to test the theory. 26]. but only a few have reported observed behaviour change as a result of the intervention [e. 22. At present the public has been found to have a high level of knowledge of the dangers of over-exposure to the sun. behavioural intentions remained unchanged [60]. however many people still desire. Any intervention to reduce sun exposure will have limited effect unless the subject wants to decrease their sun exposure. Research has indicated that many people. 17. Skin protection and suntanning both have strong social influence components associated with them. The size of the reward does not appear to be as important as its immediacy [64]. First. have a positive attitude towards suntans and sun exposure.g. Further. Bennetts et al. the accuracy of these self-reports must be questioned. Compliance with sun protection campaigns The research on increasing sun protection behaviour provides a clear example that knowledge change does not necessarily produce behaviour change. 24].Suntanning and sun protection A brief school-based intervention (one 45 min lesson). students were shown a video tape of the dangers of skin cancer. neither the generality nor the durability of this behaviour change was examined. suggesting that people's current beliefs on skin cancer puts the time-frame beyond their practical limits for concern and action. The intervention focused on increasing knowledge and changing attitudes by a three step procedure. people tend to over-evaluate the threat associated with shortterm risks compared to those in the long-term [62] while immediate gratifications are more valued than are those in the distant future [63]. Some of the major barriers encountered by behavioural scientists in this area are that having a suntan is seen as being both healthy and attractive and people do not cover-up because it is not 'cool' to do so.g. significantly increased students' knowledge and perceived susceptibility to skin cancer.

. Centre for Behavioural Research in Cancer. suggesting that now is an appropriate time to begin looking at ways to directly influence people's behaviour. CLARKE result in changes to behaviour [70]. Behavioral community intervention to reduce the risk of skin cancer. Appl. their emphasis may change. Effects of suntan on judgements of healthiness and attractiveness by adolescents. N. Keesling B. Borland R. the Telecom outdoor worker 'Cover yourself against skin cancer' campaign and the modelling of appropriate sun protection behaviour by lifeguards at two U. and Gason R. Hill D. 1989. complementing and enhancing the focused interventions. 68]. ethnic origin. 1984. 16. CONCLUSIONS At present there appears to be a belief in public education campaigns and intervention studies that raising the public's level of knowledge of the dangers of over-exposure to the sun will result in more people using appropriate protection when they are in the sun. acting as reminders. 1987. Sun protection behaviour of children and their parents at the beach. A. J. 9. sunburn. J. and Foley P. Cameron I. AntiCancer Council of Victoria. Atkin [71] reports that health education programs which rely solely on increasing the public's level of knowledge are likely to have only limited success in changing behaviour. this belief appears to have only been partially supported by people's behaviour with many still valuing a suntan despite their high level of knowledge of the dangers of over exposure. Rassaby J. beliefs.. . 1979. 5. Behav. and Winett R. Holman C. Lombard D. Skills training has been shown to be important in reducing other problem behaviours such as smoking [e.. Med. and Noy S. Appl. Adolescent use of sun-protection measures.. J. and intentions in skin cancer prevention. Aust.. To date there has been no published research assessing what skills people need to successfully engage in sun protection. Psychosocialfactors in sunbathing and sunscreen use. 15. Giles G. K. 6.. S. but knowledge alone will not necessarily 1. Theobald T. 1984. 22. Specific group focused interventions are capable of providing situation specific information. Aust. H. Psychol. Psychol. Commun.g. 99. Borland R.S. 166. Green A. and Gimbel J. Br. W. Behav. Rather than being seen as a major source of information on sun protection they could take a support role. 17. 151. Med. J. McHoskey J. G. 619. Knowledge gains must precede any attempts to alter behaviour. 1990.. 10. K.. J. Aust.. 20. J. Ponsford M. 136. J. What price attractiveness? Stereotype and risk factors in suntanning behaviour. Cancer of the skin in urban blacks in South Africa. Interventions directed at specific high risk groups may be more effective at reducing sun exposure than the more general public education campaigns. 2. Analysis 24. pools both successfully increased skin protection behaviour in the environments at which the campaigns were aimed. White V. Knowledge gains should be seen as a first step toward behaviour change. 1984.. 3. E. "Are you dying to get a suntan?"--Thepre. Borland R. 373. sun-related attitudes and precautions against skin cancer: A survey of Melbourne residents in the summer o f 1987/1988. D. Other research necessary for developing successful interventions includes an identification of the stages of change [69] from seeking a suntan to long term maintenance of sun protection behaviours. J. The research discussed here indicates that the majority of the public have a high level of knowledge of the dangers of over-exposure to the sun. Marks R. J. Psychol. 179. Borland R. 1990. Behav. 72. However. Hill D. 296. and Gardner G. 49. 1990. and McGuire C. Nonmelanocytic skin cancer and solar keratoses in Victoria. Pigmentary traits. Being SunSmart: Changes in community awareness and reported behaviour following a primary prevention program for skin cancer control. However. Dermatology 25. Marks R. and Friedman H. 14. J. Change 7. 7. REFERENCES personal risk and motivation to change behaviour need to be assessed before implementation of an intervention and if perceptions of risk and motivation to change are low. 1988. Hlth Psychol.. 477. For example. J. 100. 1991. 8. Determinants of intentions to take precautions against skin cancer. Canfield D. Ashton W. Broadstock M. 126. Hennrikus D.58. which the more general campaigns are unable to do. G. and Selwood T.. Cockburn J. 13. Armstrong B. Z. General community-based campaigns are still required. 4. 12. can teach skills necessary to increase self-efficacy [66] to deal with peer and family pressure to get a suntan and can model appropriate sun protection behaviour that is relevant to the members of the group in their immediate environment. Appl. 33. National Cancer Inst. Summer activities. 11. J. 1992. Hlth Educ.. Nor has there been any research evaluating people's confidence in their ability to increase their sun protective behaviour and resist pressure from peers and family to expose themselves to the sun. Miller A. S. 1991. 2. 257. and family history as risk factors for cutaneous melanoma. and Swerissen H. an understanding of the reasons for relapse or discontinuance of sun protection. The epidemiology and prevention of cancer in Australia. 347. Dermatology. Soc. and Lee C. 71]. Br. J. benign nevi. Isaacson C. 1272. Soc. 1990. Aust. 13. 677.and post-campaign survey results. 279. and Marks R. Cody R. Bennetts K. 1983. Hill D. means of minimizing relapse and means of changing the behaviour of those who do relapse.g. the rates of progress through the stages. Neubauer T. 1990. 13. Behaviors. rather than as the main tool to alter behaviour [70. Sun exposure and the risk of melanoma. 6.272 STEPHENARTHEYand VALERIEA. Hlth 5. Similarly. Scott R. Med. 67] and unsafe sex [e.. other strategies need to be incorporated into the intervention to help personalize the risk and increase motivation to change.. 1988. Hlth Studies 8. A. Med. and Sanson-Fisher R. 157. Surgery . and Armstrong B. Melbourne. Incidence of non-melanocytic skin cancer treated in Australia. W.

1992. J. Abnormal Psychol. Stalking the elusive "vividness" effect. 38. Am. Svenson O. Can. 89. Sunscreen use and exposure: trends in the white population. 31. .. Preventive Med. Martin G. 50. Batsford. 1984. 475. Factors associated with the maintenance of positive health behaviour. Shepard E. and Sherman S. behaviour. 1987. 147. 122. Clarke V. and Hill D. Love affair with the sun. P. E. Anti-Cancer Council of Victoria. 63. Personality Soc. K. Springer. W. Trends in non-melanocytic skin cancer treated in Australia: The second national survey. 1993. Borland R. B. D. 805. 42. Larcombe I. C. 46. 53. Skin cancer--childhood protection affords lifetime protection. and McAlister A. 717. 1982 through 1991. 1983. Aust. 1980. J. B. health beliefs. F. Techn. C. C. Godkin G. Change 17. Acad. Weinstein N. Dermat. Girgis A. and Newman I. 196. K. Watts B. Plasma fl-endorphin and fl-lipotropin response to ultraviolet radiation.. Q. Psychol. Sanson-Fisher R. and Fisher E. 21. 3. 55. 120. Santi S.8 (dune). 51. 59. 1980. Chapman S.. J. and Hill D. Fishbein M. Approaches to communicating preventive behaviours. ultraviolet radiation. Momtaz K. Skin Cancer and Tanning. 1991. Marks R.. J. Levins P. 754. Hlth Psychol. and Fishbein M. Operation Cover-up: A nursing intervention with a difference. Public Hlth 9. 1968. 29. 26. Cancer. and eating habits. Rossi J. Fisher J. 514. 48. Thomson S.. Buller D. New York. and melanoma thickness. Developmental considerations in anorexia nervosa and obesity. Skin cancer comic book: evaluation of a public education vehicle. and Golding T. B. Scand. Am. 155. J.. Sanson-Fisher R. 1. Botvin G. Marks R. Evaluation of interventions to improve solar protection in primary schools. Bruch H. 261.. 161. Self-control as choice management with reference to the behavioural treatment of obesity. 1980. Smith E. 60... Melbourne Centre for Behavioural Research in Cancer. Aust. Cancer Forum 7. The impact of a skin cancer control education package for outdoor workers. Hill D. J. T. "Goodbye sunshine": Effects of a television program about melanoma on beliefs. Preventing cigarette smoking among school children.. A. 58. Taylor S. 1981. 1988. In Annual Review of Disease Prevention (edited by Arnold C. 1987. 1982. J. 120. Drug Educ. Carr D. Belief. 1991. 28. 806.. Oper. A. J. L. L. Hlth Psychol. Tripodi D. W. J. Med. Putnam G. Cancer Detection Prevention 5. National Women's Magazine Study: Sun Protection. Arthey S. 54. J. l. 53. 47. 1982. Hill D. 1988. What are the limits to man's time and space perspectives? Toward a definition of a realistic planning horizon. Am. C. 221. In press. Addison-Wesley.. Information Processing 22. Cigarette smoking among children and adolescents: Causes and prevention. 1988. Harper's Bazaar June. and Parrish J. and Dorevitch A. The Austral. 25.. E. 17. 2. New Jersey. Staples M. and the skin. 45. Time perception and long term risk. and Wake F. Med. 22. and Hill D. Intuitive extrapolation of a growth function. Marks R. 1989.. Hlth Psychol. J. Chassin L. White S. R. Arch. 1. 25. Voluntary exposure to health communications. and Barrett D. and Watson A. Johnson E.. 15. P. 37. 44. 11. Marks R. November. G. and Giles G. Hibbard J. Melbourne Centre for Behavioural Research in Cancer. 62. 64. Stern R. 36. 18. 537. 27. Explaining adolescent students' suntanning intentions and behaviour during the summer school holidays. 20. Social class disparities in risk factors for disease: eightyear prevalence patterns by level of education. Mechanic D. 1992. Sex differences in health and illness orientation. Girgis A. 1992. The Med. J. 273 33. Forecasting Soc. A. Unrealistic optimism about future life events. L. Cognitive and social influence factors in adolescent smoking cessation. 39. 9. Compensation strategies in sun protection behaviours by a population with nonmelanoma skin cancer.. 97. 19. 1982. The History of Haute Couture. J. Hill D. 1985. 585. Clarke V. NSW Cancer Council Cancer Education Research Project. 14. E. 275. 1984.. Marks R. The hazards of sunlight: A report on the consensus development conference on sunlight. Prentice Hall. and Brown K. Hayes D. and Hill D. Preventive Med. 383. 1986. and Buller M. 1971.. Dermat. 1983. Sun protection: practical considerations. Behavioural change in adolescence: A major challenge for skin-cancer control in Australia. Gibbs A. de Marty D..Suntanning and sun protection 18. Weinstein M. 63. Res. 1677. D. A. 1984. London.. Rev. 1990. and Ajzen I. 11. S. 1993. and Sher K. 1986. 94. Marks R. Int. Patient Management. 2. The sun and sunscreen protection: recommendations for children. 166. family history of alcoholism. MA. Seminars Oncology Nursing. Australia 149. Nurses J. and Meyskens F. 154. L. Green L. 4. H.. Preventive Med. Public HIth 82. 35. 1983. Can. 21. Changing knowledge and attitudes about skin cancer risk factors in adolescents. 30. 657. 1989. and Biglan A. 737. Hlth Educ. Hocking B. Reading. 1980. and King M. 61. 1992. Psychol. J. Hurwitz S. Concern with appearance. Chassin L. G. 1984. J. Addictive Behav. Winkleby M. J. 1980. Best J. and LookingbiU D. 95. Addictive Behav. Theobald T. 1993. Self-awareness theory. B. Understanding Attitudes and Predicting Social Behavior. Community Hlth Educ. 1977. Sunshine and skin cancer: A schoolbased skin cancer prevention project. Dermat. Rassaby J. S. L. Hlth Soc. Attitude. 34. Psychol. 686. Q. Anti-Cancer Council of Victoria. 41. 24. 56. A. J. M. W.. A. 18. Cancer Educ.. 1992. M. E. A. J. 1265. 32. Behav. Int. Friedman L. 43. Mann L. Hazelkorn K. J. 53. School-based information relevant to the SunSmart program. 52. and Noy S.. Mermelstein R.. 1991.. 1988. In preparation. 49. 23.. Public HIth 58. J. Intention and Behavior: An Introduction to Theory and Research. Anti-Cancer Council of Victoria.). 39. 339. 56. J. Dermat. Marks R. A. Trends in tans and skin protection in Australian fashion magazines.. Jr. and Baker S. 654. A. McReynolds W. 57. 371. Risk reduction for non-melanocytic skin cancer with childhood sunscreen use. S. The Lancet duly. and Thompson S. 349. Preventive Med. 26.. Arch. 21. Theobald T. and Roy C. Melbourne Centre for Behavioural Research in Cancer. and Cleary P. Y. 40. Presson C. Slip Slop Slap: health education about skin cancer. S. 161. White V. J. Swinehart J. Fortmann S. M. 206. Murphy M. Melanoma prevention: Behavioral and nonbehavioural factors in sunburn among an Australian urban population. Lichenstein E. 10. Smoking onset among teens: an empirical analysis of initial situations. Ramstack J. and Riesenberg L. 7. 9. Psychiat. Robinson J. 19. 1988. Surgery and Oncol. and Ross C. 1975. Ajzen I. Bonieki G.. and adolescent alcohol involvement. 1987. 169. Borland R. and Yanagisako K. Evaluation of a workplace intervention to increase the use of solar protection in outdoor workers. Rev. Assessing the validity of self-reported adolescent cigarette smoking.. Svenson O.

). Res. 1983. 1993. C.. Bandura A. Cognitive Therapy Res. Boat B. 1992. Am. Full-cycle social psychology. Social Foundations of Thought and Action: A Social Cognitive Theory. 68. Theoretical foundations in campaigns. 65. Transaction Books. 69. CLARKE with adolescents. J. B. and Paisley W. Coping with contraception: cognitive and behavioural methods . 47.. and Stedman H. C. Beverly Hills. 7. McGuire W. 66. 71. In Communication Yearbook 3 (Edited by Nimmo D. Inc. New Jersey. 1981. 70. D. 1986. Cialdini R. Prentice-Hall. E. In search of how people change: applications to addictive behaviours. Greenberg R. Atkin C. and Schinke S. New Brunswick. Psychol. DiClemente C. 1981. J. and Norcross J. 1979.. Bauman K. Fowler M. 21. Appl. Theory Practice 8. The role of outcome and efficacy expectations in an intervention designed to reduce infants' exposure to environmental tobacco smoke. K.274 STEPHEN ARTHEY and VALERIEA. 67. 379.. P. 41-70. In Public Communication Campaigns (Edited by Rice R. Prochaska J. J. A.). Strecher V.. Psychol. G. Sage. 1102. Gilchrist L. E. Soc. 137. I. Hlth Educ. Research evidence on mass mediated health communication campaigns. O. pp. NJ.