Australasian Marketing Journal 19 (2011) 212222

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Australasian Marketing Journal

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Reducing barriers to sun protection Application of a holistic model for social marketing
Geraldine McLeod a,, Andrea Insch b,1, James Henry b,1
a b

Canterbury Child Development Research Group, Department of Psychology, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand Department of Marketing, University of Otago, P.O. Box 56, Dunedin 9054, New Zealand

a r t i c l e

i n f o

a b s t r a c t
Reducing high rates of sunburn occurrence, linked to the development of skin cancers, has been the focus of sustained social marketing campaigns in Australasia. Despite substantial investment in public health warnings, barriers to preventing sunburn and associated skin cancers remain. The purpose of this article is to illustrate through a holistic model of sunburn how social marketing interventions can be made at both the macro- and micro-environmental levels to minimise the remaining barriers to sun protection. This is achieved though a review of population studies that identify the barriers to preventable sunburn. Integration of the barriers suggests that a holistic approach is needed to understand sun protection behaviour among the general population. This approach supplements existing public health promotion approaches which tend to target an individuals knowledge and attitude toward sun protection and tanning. From this holistic model of sunburn, the implications for social marketers and directions for future research are presented. 2011 Australian and New Zealand Marketing Academy. Published by Elsevier Ltd. All rights reserved.

Article history: Available online 17 June 2011 Keywords: Sunburn Barriers to sun protection Conceptual model social marketing Public policy Implications

1. Introduction Primary prevention of skin cancer has become a priority in countries such as Australia, US, Canada, UK and New Zealand, where the risk of skin cancer is particularly acute due to the genetic composition of the population. Certain genetic inuences (e.g., European origins) that possess phenotypes of very sun-sensitive and moderately sun-sensitive skin types (type I or II) (Fitzpatrick, 1988), and light coloured (blue/green) eyes in a high UVR (ultraviolet radiation) environments intensify the risk of skin cancer (WHO, 2003; Elwood, 2004). In environments where high levels of ambient solar UVR are recorded, up to 95% of skin cancers have been attributed to excessive sun exposure (Armstrong, 2004). Lucas et al. (2008) reported that . . .there are almost two billion incident sunburns in a single year, creating a global disease burden of almost 300,000 DALYs (Disability Adjusted Life Years) (p. 661). With the aim of reducing the occurrence of sunburn, primary prevention social marketing campaigns, often disseminated through mass media channels, have been implemented in various countries around the world. These campaigns aim to raise awareness of the consequences of sunburn and to educate individuals regarding its prevention. Despite reported rising levels of knowledge of the risks and dangers of sunburn and skin cancer, there
Corresponding author. Tel.: +64 3 366 7001 x7098; fax: +64 3 364 2838.
E-mail addresses: geraldine.mcleod11@gmail.com (G. McLeod), andrea.insch@ otago.ac.nz (A. Insch), james.henry@otago.ac.nz (J. Henry). 1 Tel.: +64 3 479 4005.

is no evidence to suggest that there is an overall decline (WHO, 2006). Thus, barriers to the prevention of sunburn still exist, even though individuals are knowledgeable of the reasons and benets of such preventive behaviour. This suggests that individuals may be either unwilling or unable to change their behaviour, indicating a need to create environments which facilitate these desired sun protection outcomes. Therefore, . . .a more holistic approach to the promotion of sun safety may be required (Peattie et al., 2001, p. 277). A holistic approach would de-emphasise individual responsibility for optimal sun protection practices by making the individuals overall environment more sun protective. Therefore, the purpose of this paper is to show a holistic model of the pathway to sunburn, to illuminate potential barriers to sun protection. The holistic model was developed based on Hill and Boulters (1996) model of sunburn and skin cancer, and a review of international population studies of sunburn. This supplements existing approaches which tend to emphasise an individuals knowledge, attitudes and behaviours towards sun protection and tanning. From this holistic model of sunburn, a number of implications for public policy and future social marketing campaigns are provided, as well as directions for future research.

2. Primary prevention of sun cancer Primary prevention of skin cancer has been the focus of social marketing campaigns to reduce skin cancer incidence (Arthey and Clarke, 1995; Dobbinson and Hill, 2004; Streetly and Markowe,

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1995). The mass media campaigns used typically comprise the multi-component promotional vehicles of print, broadcast and Internet media to disseminate health information and behavioural guidelines to the target audience using a dened theme or logo and set of messages (Saraiya et al., 2004). Campaigns are usually evaluated through market research to assess behaviour change, increases in knowledge and understanding of the message. These indicators of effectiveness may be used to inuence public health policy, or to develop more effective approaches and interventions to address the problem (Heller, 2005). A series of social marketing sunburn and skin cancer prevention programmes have been sponsored in Australia and New Zealand. Arguably one of the best known programmes developed by the Cancer Council of Victoria, Australia (formally the Anti-Cancer Council), was launched in 1980 (ACCV, 1989). Known as Slip (slip on a shirt), Slop! (slop on some sunscreen), Slap! (slap on a hat), the campaign advised individuals to guard against skin cancer and was illustrated with Sid the Seagull. The aims of the programme were to reduce over-exposure to UVR, by modifying or reducing behaviours that increase the risk of sunburn and skin cancer. The campaign also encompassed some secondary prevention behaviours of early detection and was expanded to SunSmart in 1988 (Borland et al., 1990). The Australian SunSmart campaign has reportedly been effective based on awareness and recall measures (Borland et al., 1990; Marks, 1999). Specically, awareness of the SunSmart phrase increased from 6% before the campaign to 46% two weeks after the end of the campaign (Borland et al., 1990). Additionally, nearly half of all respondents indicated they had encouraged others to use sun protection, 89% were able to complete the Slip!, Slop!, Slap! slogan and were also able to describe the purpose of the campaign appropriately (Borland et al., 1990; Marks, 1999). Using the Australian SunSmart survey data, Dobbinson et al. (2008) examined trends in attitudes and knowledge, UVR exposure, sun protection, and sunburn from 1987 to 2002. The study found that reductions in sunburn were consistent with the survey years where reported use of sun protection was higher. In addition, a reduction in positive attitudes towards tanning, improvements in hat use, sunscreen use, body coverage, and reduced outdoor exposure (occurrence and duration) were found. When population level exposure to SunSmart advertising on television was also linked to the survey an association between sun protection behaviour and SunSmart advertising on television was observed. However, no association was found for SunSmart television advertising and sunburn. Modelled largely on the Australian campaign, the New Zealand melanoma awareness and prevention programme began in 1988, using the same message, Slip!, Slop!, Slap!, also branded as SunSmart (Watts et al., 2002). Successive campaigns, portraying the SunSmart messages, have been launched in New Zealand, during summer months. These have included television advertising, media releases, and resources prepared for primary and secondary schools, general practitioners (GP), and sports clubs (Reeder, 2001; Watts et al., 2002). Some secondary prevention campaigns to increase detection of early skin cancer, in particular melanoma, have also been developed. Social marketing campaigns have been run systematically through government agencies and not-for-profit community organisations such as the Cancer Society of New Zealand (CSNZ) and the Royal New Zealand Plunket Society.

3. Barriers to sun protection This article aims to report the commonalities of and associations between the domains of: attitudes towards and knowledge of sun protection and tanning, sun protection behaviours, and

sunburn. In particular these reported commonalities and associations are focussed on respondents aged 15 years or older from general population studies. The purpose of this was twofold: to describe current knowledge of population studies that have replicated or used similar methods to the Australian study by Hill and Boulter (1996), and to identify links and commonalities between the domains so that a conceptual model could be developed for this article. Relevant studies were obtained from Medline, Medline review and the Cochrane data base of systematic reviews, using combinations of key words (sun, UVR, exposure, national, melanoma, skin cancer, health promotion, public, education, prevention, protection, programme, primary prevention, campaign, attitudes, knowledge and cross-sectional). The databases were initially searched in the week beginning 8th January 2007. Alerts were enabled on these databases and the resulting studies were assessed. Reference sections of articles that met the criteria were also examined for other potentially relevant studies. For the purposes of this review, studies had to be published in English. Studies were excluded that recruited and focused solely on respondents with a personal or family history of skin cancer as they were not considered to represent the general population. This review did not aim to assess intervention studies, although, those that reported prevalence and associations for a domain of interest were included. It should be noted that while the aim was to review studies of respondents aged 15 years and older, many studies also included younger adolescents and these were also reviewed. A summary of the major studies included in the review is provided in Table 1. In the studies reviewed, outdoor status, and hence UVR exposure, was high particularly on weekends or non-working days and during summer months. Males tended to report longer durations outdoors. Male duration was linked with paid work while female duration outdoors was linked to tanning. The main activity undertaken and climate inuences the UVR received by the participant. This is due to the body position, prescribed duration, clothing worn, shade availability, and its utilisation. A longer duration spent outdoors appears to be associated with sunburn and many respondents reported spending up to an hour outside before using any sun-protection. The type of outdoor activity was associated with sunburn. In particular, participation in water-based recreation, sport and passive recreation, and the consumption of alcohol was strongly associated with sunburn (Brown et al., 2006; Mukamal, 2006). Knowledge that excessive UVR and tanning are risk factors for future development of skin cancer was high. However, despite high SunSmart knowledge, positive attitudes towards tanning were also high among respondents. For example, cross sectional telephone surveys of the Australian population (1469 years), revealed that respondents knowledge that skin cancer is a dangerous disease was 97% and sun exposure ages the skin was 88%, yet the majority of respondents considered tanning a social norm (50%) and agreed that a tan gives a healthy appearance (Hill et al., 1992, 1993). Higher positive attitudes towards tanning were found to be negatively associated with sun protection. Attitudes toward tanning may be slowly changing. Dobbinson et al. (2008) indicated that preference for a tan decreased signicantly from the baseline survey year in 1987/88 (42%) to survey year 2001/02 (59%). However, this nding still indicates that over 40% of respondents preferred a tan. Overall, sun protection was generally low and many respondents used no sun protection at all. For example, Miles et al. (2005) UK study reported that less than 40% of respondents reported use of sun protection of sunscreen, shade or clothing. Sex differences were found for sun protection practices; females were associated with sunscreen utilisation and males with hat utilisation. Differences between groups based on age and skin sun-sensitivity were found, which inuenced sun protection. Specically,

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Table 1 Summary of cross-sectional replication studies. Author/date and Country Baade et al. (1996) Australia Study year and design 1988/89 Crosssectional telephone interview 199192 As above 1998 National Populationbased telephone survey of parents and children 1998 As above Sample information Key Findings Attitudes/knowledge n = 1699, M = 50%, and F = 50%. 1469 years, RR = 50% n = 2317, M = 48% and F = 52% 1469 years RR = 45% n = 1192 pairs of children 1118 years and their parents RR = 58% Like a tan (46%) Like a tan (33%) Exposure Sunday mean = 125 min Sunday mean = 112 min Sun protection Use of hat (46%), shade utilisation (31%), sun-screen (25%), and sun protection index mean = 55% Increase in use of hat (56%), shade (36%), sun-screen (33%), and sun protection index mean = 61% One-third of adolescents did not use any protection. Adolescents most common sun protection was sunscreen and sunglasses. Females were more sun protective Sunburn Sunburn on previous Sunday = 21% Sunburn on previous Sunday = 20%

Cokkinides et al. (2001) (2002) (2004), Davis et al. (2002) US

Feel healthier and better with a tan (M = 43% vs. F = 38%). Those with sun sensitive skin less likely to agree they look better with a tan (45% vs. 50%). Articial UVR use, high Pro-Tan attitudes Attitudes towards tanning were high but declined between survey years from 57% to 51%

At weekends, adolescents pent 7 8 h outdoors which varied by activity; girls with sunbathing and boys with paid work also. Longer duration outdoors was associated with sunburn. Exposure did not vary by age, sex and skin type

72% P1 sunburn, associated with white race, younger age (<16 years), sun-sensitive skin, desire a tan, and water sport. 39% reported use of sunscreen and were sunburned In 2004, 69% reported P1 sunburns during past summer vs. 72% in 1998 Sunburn lowest among oldest respondents (11%) but highest among the youngest respondents (46%)

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Cokkinides et al. (2006) US Coups et al. (2008) US

Dobbinson et al. (2008) Australia

Duquia et al. (2007) Brazil

2005 Crosssectional interview survey, National Health Interview Survey (NHIS) 19872002 Series of crosssectional telephone surveys 2004/05 Crosssectional representative survey 1992 Face-toface interview

n = 1196 (1998) and n = 1613 (2004) M/F 1118 years n = 28,235 RR = 69%

Sunscreen use increased across survey years Indoor tanning was highest among those 1829 years (20%) Younger respondents had highest infrequent use of sun protection (clothing, sunscreen, choosing shade). P2 risky outdoor behaviours were reported by 80% of respondents 1824 years

n = 11,589, 1469 years

Advertising was found to inversely inuence tan preference and increase hat use and body coverage. Like tan increased until 1994/95 and decreased to 2001/02

Outdoor activity, mean time outdoors was 128 min in 1987/88 which decreased to 122 min in 2001/02

Hat ranged from 21% to 39%. Sunscreen ranged from 12% to 27%

Evidence that television campaigns inuence sun protection and attitudes

n = 3136 adults. P20 years. RR = 94%

Duration P 20 min undertaken by n = 911 (29%). Duration differed by activity; median beach exposure = 10 days, median outdoor sports = 16 days, and work = 70 days. M exposure highest

Hall et al. (1997) US

n = 10,048, M = 48%, F = 52%, 1775+ years

Hall et al. (2003) US

2000 Crosssectional household interview

n = 32,374, P18 years

Sunscreen use was 14% for work, 30% outdoor sports, and 61% for beach activities. Females and those with sun-sensitive skin and higher education used sunscreen most often 53% very likely to use sun protection and seek shade when out-doors P1 h. Males, younger respondents and non-sun-sensitive skin types were less likely to use sun protection Shade use and long sleeved shirts appeared protective against sunburn. Hat use and sunscreen were not signicantly protective from sunburn

36% respondents reported P1 sunburn in the past year, most commonly reported by young people, white non-Hispanic males more likely than females, and those with sun-sensitive skin

Hill et al. (1992) and Hill et al. (1993) Australia

1988 Crosssectional telephone interview

n = 1655. Age 1469. RR = 54%

Skin cancer is a dangerous disease (97%), sun exposure ages the skin (88%), feel healthy with a tan (50%), social norm for tanning (50%)

M mean = 140 min, F mean = 114 min

M body exposure index score 28% higher than F score. Hat M = 23%, F = 25%, M = 16%

Hill et al. (1992)

1989

As above. n = 1387. RR=?

Skin cancer is a dangerous disease (97%), sun exposure ages the skin (88%), feel healthy with a tan (46%), social norm for tanning (37%) Skin cancer is a dangerous disease (99%), sun exposure ages the skin (93%), feel healthy with a tan (39%), social norm for tanning (29%)

Hat use higher among males, sunscreen highest among females. Clothing coverage was similar between M and F

Hill et al. (1992)

1990

As above. n = 1376 RR=?

Hat use higher among males, sunscreen highest among females. Clothing coverage was similar between M and F Sun protection was predicted by males, younger children (11 13 years), access/ownership of the broad rimmed hat. Preferred forms of sun protection were sunscreen (57%), hats (21%), shirts (15%), and avoiding the sun (7%). 54% males and 44% females adequately protected

Sunburn recall from previous weekend: M = 14%, F = 9%. Sunburn highest among younger and those with sun-sensitive skin. Sunburn water-based recreation (53%), nonwater sport (27%), and passive recreation (23%). 71% tried to avoid sunburn Sunburn, M = 12%, F = 8%. Sunburn highest among younger respondents and those with sunsensitive skin and moderately sunsensitive skin. 75% tried to avoid sunburn Sunburn, M = 10%, F = 5%. Sunburn highest among younger respondents and those with sunsensitive. 76% tried to avoid sunburn

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Lower et al. (1998) Australia

? Survey and self-report diary

n = 3642 School students, 1116 years

Melia and Bulman (1995) UK

1993 Face-toface

n = 2025, M = 47%, F = 53%, 16+ years. RR = 77%

Attempted to tan (33%). Light skinned adults need a tan (20%)

P1 sunburn in the previous summer (M = 39%, F = 34%). Sunburn decreased with age, but increased among those with sunsensitive skin. Sunburn was associated with socio-economic status, or region

Miller et al. (1996) US

1995 Telephone survey

n = 1001, adults P 18 years

Miles et al. (2005) UK

2003 Face-toface interview

n = 2768 selected, 1848 interviewed, aged 18+ years. Mean age 49 years. RR = 67% n = 802 respondents M = 43.5% and F = 56.5%, P18 years, median age 42 years

Nikolaou et al. (2009) Greece

2007 Questionnaire based telephone interview

Knowledge of melanoma (42%): type of skin cancer (35%) and knew risk factors of excessive sun exposure and sunburn and possession of a sun-sensitive skin type (95%) Endorsed attractive (51%), healthier (66%). Awareness of sun protection: stay in shade (56%), cover up with clothing (50%), or use sun screen (75%) Knowledge sun causes skin ageing and wrinkles was signicantly different (M = 86, F = 94). Healthier/prettier when tanned, and high SPF prevent the skin from tanning were not signicantly different by sex

Darker skin type III/IV (83%). Duration P 2 h was associated with darker skin type and younger age

The use of sun protection was low for use of sunscreen (37%), shade (37%) or clothing (38%). Females report more use of sunscreen and shade than males Sunglasses (F = 89%, M = 76%), sunscreen (F = 89%, M = 63%).

56% had no previous history of sunburn, while 19% P 1

Purdue et al. (2001) Canada

1996 Telephone survey

n = 4023, adults P 15 years

53% of sample reported one or more sunburns during the previous Summer. Factors associated with sunburn included: younger, male, sun-sensitive skin, higher income, higher knowledge of UV index 215 (continued on next page)

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Table 1 (continued) Author/date and Country Purdue (2002) Canada Study year and design 1996 Telephone survey Sample information Key Findings Attitudes/knowledge n = 1027 adults, with light skin spending 30+ min per day of UVR exposure during leisure time (72%) Exposure Sun protection 81% always or often performed at least one type of behaviour. Of these only 9% used 4 methods of sun protection, often or always; avoid sun 43%, seek shade 44%, wear protective clothing 47%, apply sunscreen 40% Sunscreen use increased from 35% to 54% Sunburn

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Robinson et al. (1997) US

1986 and 1996 Crosssectional telephone survey 1996 Crosssectional telephone survey of white adults

n = 1,0128 (1986) and n = 1010 (1996), adults P 18 years

Rhainds et al. (1999) Canada

n = 1003, 1860 years

A tan is healthy declined between the survey years from 66% to 56%, but increased from 3% to 12%. No signicant difference was found for a change in intention to obtain a tan Tanning for: improve appearance(57%), pre-vacation (28%), relax (12%) or health (11%). Over 3% of respondents who believed that an articial UVR was harmful had used one in the past year

Outdoor exposure P 1 h during the weekend (93%)

Sunburn occurrence increased from 30% to 39%. In 1996, sunburn M = 47%, F = 32%. Respondents 18 24 years (52%)

Articial UVR in past 5 years (20%), in past 12 months (11%). Highest for female (59%), 1834 years (60%), and single had higher frequencies. Skin type I and II had lower frequencies (21%). Adverse reaction/health effects (26%) and inversely related to skin type Very likely to wear protective clothing (23%), stay in the shade 27%) or use sunscreen (30%). Females indicated use of more sun protective behaviours. Protective clothing and shade seeking increased linearly with age Sunburn past 12 months (31.7%). Sunburn most frequent for nonHispanics, males and younger respondents

Santmyire et al. (2001) US

Saraiya et al. (2002) US

1998 Crosssectional National Health Interview Survey (NHIS) of adult US population 1999 Crosssectional BRFSS population telephone survey

n = 32,440, 17+ years

n = 156,354 P 18 years

Key: ? = unclear, M = male, F = female, RR = response rate.

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older respondents appeared to use more sun protection and were also more consistent users. Those with sun-sensitive skin reported more frequent use of sun protection. Socio-economic differences were also found for sun protection, where higher socio-economic status was associated with use of sunglasses. Sun protection was also associated with higher educational achievement. Sunscreen was the most common and most preferred form of sun protection. However, sunscreen use is a controversial form of sun protection from a public health standpoint. The association between melanoma and sunscreen use has shown contradictory results, with no evidence of an association found in a metaanalysis by Dennis (2003). Sunscreen is now not recommended as a rst line of defence against UVR, but only as an adjunct to other forms of sun protection (Lautenschlager et al., 2007). This is due to evidence that not only is sunscreen used improperly, but sunscreen may be used to increase the duration outdoors among some groups that are intentionally exposing themselves to UVR. In addition to extending the duration outdoors among sunbathers, the sunscreen lotion itself is often not used optimally. That is, sunscreen is not used systematically, application is infrequent, too little is used, and coverage is not uniform (Autier et al., 2007). Sunburn occurrence was high. One study reported that participants experienced at least three sunburns per summer and blistering sunburns were also common (Benvenuto-Andrade et al., 2005). Sunburn was associated with a longer duration outdoors, sunscreen use, younger respondents, and those with sun-sensitive skin. Where inconsistencies in the results were found, they may be explained by the main limitation of the studies, which was a lack of standardised measures, making comparisons difcult. Often public health social marketing campaigns assume that increasing sun protection education and knowledge will result in the desired behaviours. However, this review indicated that positive attitudes towards tanning, high UVR exposure, sub-optimal sun protective behaviours, and consequently sunburn still exist despite large social marketing investment into sunburn reduction.

4. Scope and focus of previous sun exposure campaigns While some modest changes in sun protection behaviour have been detected, increasing exposure to SunSmart messages does not appear to greatly reduce preventable sunburn. It is therefore important to consider the context in which the social marketing campaigns are being undertaken. In recent years, much debate has focussed on awareness of optimal vitamin D levels for health (Calvo et al., 2005). Specically, UVR has been found to aid vitamin D (as 25-hydroxyvitamin D) uptake to counteract rickets and relieve psoriasis (Fitzpatrick, 1988; Diffey et al., 1982). Vitamin D insufciency has also been associated with muscle weakness, cardiovascular disease, some cancers (stomach, colorectal, liver, gall bladder, pancreas, lung, female breast, prostate, bladder and kidney), tuberculosis, and some autoimmune disorders (van der Mei et al., 2007; Lucas and Ponsonby, 2006; Tuohimaa et al., 2007; Peterlik and Cross, 2005). The public might be receiving mixed messages from the media about the health benets of moderate sun exposure during non-peak UVR during summer months. Thus, countries like New Zealand where certain populations (particularly those of Asian and Pacic descent) are found to have relatively low vitamin D levels (Scragg and Bartley, 2007), may be confused by conicting public health messages regarding UVR exposure. When funding for public health campaigns are reduced, their impact may be diminished. In addition, measures which address circumstances, typically beyond an individuals control, are needed to supplement education and awareness campaigns. Prior knowledge of how to be SunSmart is necessary to practice sun protection, but alone it is insufcient. In addition to the knowledge of the need

for sun protection, individuals require the motivation, ability and opportunity to act to achieve desired outcomes. Motivation relates to an individuals willingness to perform a specied behaviour to achieve consequences that serve their self interest (Moorman and Matulich, 1993; Rotter, 1954). As the consequences need to be highly probable, visible and immediate to motivate their prevention, taking action to reduce skin cancer (through the avoidance of sunburn) does not typically drive behaviour change. Individuals also require a certain level of skill and resources to achieve the desired behaviour (Moorman and Matulich, 1993). Access to additional resources, such as shade and protective clothing, creates the opportunity to encourage behaviour change (Rothschild, 1999). Likewise, certain facilities and resources might create barriers to SunSmart behaviours. As Rothschild (1999) explains, opportunities to act are a structural feature of the consumption environment, usually beyond the control of individuals. Instead, they can be provided through appropriate marketing programmes or legal interventions. For example, the Fashion to Die For campaign aimed to educate and protect consumers via social marketing and regulatory interventions by introducing minimum age and skin type standards for solarium operators (Cancer Council Victoria, 2010). Similarly, the publicity generated from a television advertising campaign featuring Claire Oliver, who died as a result of melanoma, led to strengthening of regulations governing the solaria industry in the Australian state of Victoria (State Government of Victoria, 2008). It is therefore evident that policy change may reduce sunburn and skin cancer in the long term. It is acknowledged that the SunSmart schools programme has holistically aimed to educate and reduce UVR exposure among school children (Cancer Society of New Zealand, 2011). However, this may not address the needs of other target audiences. In order to adequately identify the range of mechanisms for sunburn protection, a holistic conceptual model of sunburn is presented in the following section. Based on the model, a number of implications for public policy and social marketing campaigns are then discussed. This is a rst step in expanding the conceptualisation of sunburn to overcome existing barriers to sun protective behaviours in the general population.

5. A holistic model of sunburn The conceptual model of sunburn model is based on Hill and Boulters (1996) model of sunburn and skin cancer and was extended by the ndings of the literature review. As such, it can potentially be applied to a variety of populations, with a range of climates, geographic locations and cultures. This behavioural process model is based on the way individuals behave in their local environment and is designed to explain sunburn caused by excessive UVR exposure but does not aim to cover the pathway to sunburn and skin cancer through the use of articial UVR (e.g., solaria). As seen in Fig. 1, the model aims to show the factors inuencing sunburn both at a societal macro-level, and an individual micro-level pathway. The model is divided into two sections. The outer circle represents the societal macro-level domains of the physical, policy, social, and climatic environments. Since each element has the potential to inuence the other, no directional inuences are indicated. The elements encapsulated within the outer circle depict the micro-level sunburn pathway of an individual on any given hypothetical day. Elements at the micro-level are sequential steps of an individuals progression through these stages. Choices that an individual makes along the pathway may increase the risk of sunburn and its associated severity. Each of the elements in the macro-level environment and the micro-level pathway are discussed in turn.

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Fig. 1. Holistic model of Sunburn.

5.1. Macro level 5.1.1. The physical environment The physical environment refers to the local environment in which physical activity is undertaken and where excessive UVR exposure has the potential to occur. There are various mechanisms to attenuate the intensity of the UVR in the physical environment to which the population is exposed during outdoor activity. For example, this may include the erection of shade sails, the planting of trees and the establishment of other sun protective structures within public areas (e.g., parks) (Diffey and Diffey, 2002). 5.1.2. The policy environment Government policy and/or law (both local and national) have the potential to reduce UVR exposure of the population. There are a variety of instruments and tools available, such as the creation of UVR social marketing campaigns or health promotion skin cancer reduction programmes, mandating the provision of UVR protection structures, or workplace sun protection policies. The physical environment, described above, inuences how the local environment is utilised. Accordingly, a sun protection policy that provides for additional sun protection within the physical environment, or schedules public events outside of peak UVR hours should be encouraged (Boldemann et al., 2006; Feldman et al., 2001). 5.1.3. The cultural and/or social environment The social environment is dynamic and changes with trends in both fashion and technology. It incorporates cultural norms for outdoor behaviour that may inuence outdoor activity, tanning preferences, clothing and additional sun protection choices. Social norms with regards to tanning are an important factor inuencing UVR exposure. A pro-tan culture has become pervasive since its emergence in the 20th Century among some European cultures. This is when a tan began to symbolise the afuence that permitted the leisure time to sunbathe or participate in outdoor recreational activity (Albert and Ostheimer, 2003). Increasing the knowledge of the population that sunburn may lead to the development of skin cancer in the future has not correspondingly reduced sun exposure (Guile and Nicholson, 2004).

5.1.4. The climatic environment The climatic environment governs the air temperature, wind speed, cloud cover and UVR in a geographic location and is inuenced by the latitude, elevation, pollution, and the ozone layer covering the area (Gies et al., 2004; Slaper and de Gruijl, 2004). Sunburn may be particularly problematic in areas with both pervasive UVR and weather patterns that allow sun-related outdoor activity to be undertaken within a social environment of positive attitudes towards tanning. 5.2. Micro level 5.2.1. Individual characteristics Individual characteristics are inuenced by all of the macro-level cultural and social environment, the physical environment, the policy environment, and climate. They consist of non-modiable and potentially modiable factors that may inuence UVR exposure and hence sunburn. Non-modiable characteristics include temporal (e.g., area of residence), physiological and/or genetic inuences (e.g., skin sun-sensitivity) and demographic characteristics (e.g., highest educational qualication and occupation). Potentially modiable characteristics include attitudes towards tanning and knowledge of optimal sunburn prevention and skin cancer (e.g., attempting to obtain a suntan during the summer). 5.2.2. Climate control clothing Climate control clothing is an anecdotal term that refers to clothing that enables the regulation of body temperature (and perspiration). The term refers to a base amount and type of clothing worn that is inuenced by the individuals characteristics, the local weather conditions, and the macro-level cultural and social environment. 5.2.3. Exposure Exposure refers to whether or not an individual has spent time outdoors and their subsequent level of UVR exposure. This is due to a combination of both the duration and the activity being undertaken, and any exposure modication by shade associated with the activity (e.g., walking under trees). The activity undertaken

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may also further inuence the clothing worn. Outdoor status and exposure are inuenced by the individuals characteristics, in addition to the outer circle domains of current climate conditions, cultural and social norms, the physical environment (e.g., available shade), and the policy environment (e.g., public holidays scheduled during summer). 5.2.4. UVR protection UVR protection refers to any additional protection utilised by the individual who is outdoors, in response to the current weather conditions. This protection may include additional body coverage of clothing, a hat, and/or sunscreen. UVR protection is also inuenced by the individuals characteristics, the sun protective measures already utilised for the purposes of the activity undertaken (and any associated shade that the activity is undertaken in) and the weather conditions. Furthermore, all macro-level domains of climate, the physical, social and cultural, and policy environment (e.g., workplace sun protection policies) inuence UVR protection. 5.2.5. Sunburn and sunburn severity Finally, sunburn (and the resulting severity) may occur amongst those meeting the criteria for being outdoors. This stage of the pathway assumes that, if sunburn has occurred, the individual has had both UVR exposure and inadequate sun protection in an environment with simultaneously elevated UVR levels. Sunburn and sunburn severity are also inuenced by the macro and micro-levels that inuence UVR protection above. These are the individual characteristics, the sun protective measures already utilised for the purposes of the activity undertaken (and any associated shade that the activity is undertaken in), the weather conditions, and the macro-level climate, physical, and the social and cultural environment. 6. Applications for public policy and social marketing To date the majority of public health promotion messages have targeted individuals potentially modiable factors to reduce UVR exposure and hence sunburn. Despite these initiatives population studies reveal that the occurrence of sunburn is still high, especially among certain segments (i.e., adolescents) (Davis et al., 2002). Therefore, a more extensive set of specic initiatives are needed that address each of the elements in the holistic model of sunburn. The model can be applied as a systematic framework to integrate various efforts, currently fragmented, to maximise the desired outcome reducing sunburn occurrence in the general population. That is, using a holistic approach, this model aims to promote mechanisms for enhancing sun protection and sunburn reduction at a societal level, de-emphasising the existing focus on individual responsibility. Each aspect of the model and the associated education, marketing and regulatory intervention strategies is discussed in turn. Elements in the macro-environment represent factors that an individual cannot control, but can be shaped collectively to lessen the risks of sunburn. Firstly, the local physical and climatic environments can be monitored and appropriate solutions implemented to reduce excessive UVR exposure. Modifying the physical and built environments to lessen exposure may involve ensuring adequate levels of shaded areas are available outdoors. Public and private areas could be assessed in terms of their shade access and density to ensure a minimal level of shade is available. Increasing shaded areas might involve the installation of shadesails in public areas. This has occurred to a limited extent in some regions in New Zealand where territorial authorities and some organisations in New Zealand installed shade-sails in public areas and at major events (Reeder and Jopson, 2006). Shade enhancing

initiatives might involve organisers of outdoor events encouraging participants to bring adequate shade devices such as gazebos and umbrellas and allow them to be hired at the event. Other shade initiatives may include planting trees to provide natural shade cover in parks and other outdoor areas. In addition to modifying the physical environment through structures that provide shade, other initiatives that raise awareness of the sun and UVR might be supported or even legislated through public health policies and programmes. For example, mechanisms to disseminate daily UVR intensity information should be strengthened and its access for at-risk groups improved (e.g., among certain outdoor occupations, holidaymakers, open and partly shaded recreation area users). To strengthen access to shade, UVR protection structures could be mandated, especially for at risk and potentially vulnerable groups. Specically, public policy should also be extended to public spaces where the most at risk individuals (e.g., young children or those with sun-sensitive skin types) spend time outdoors. Governments can also inuence the scheduling of public events to outside peak UVR hours and select venues with adequate shade to create physical environments that enable individuals to limit their sun exposure and reduce the possibility of sunburn. Outdoor workers may also be protected from excessive UVR through specic health and safety policies that encourage or even mandate employers to provide UVR-reduced work environments. This has begun in Australia (Cancer Council Victoria, 2009). In New Zealand, objective 7 of the Cancer Control Strategy was to . . .reduce the number of people developing occupational related cancers (p.29). The Occupational Safety and Health Service (OSH) is the organisation responsible for legislating UVR protection for outdoor workers (Ministry of Health and Cancer Control Trust, 2003). Policy measures, which might otherwise be adopted in a piecemeal or fragmented manner, need to be extended and endorsed nationally and systematically. Public health education and social marketing campaigns that seek to inuence the cultural and social environments face the challenge of shaping social norms. Previous research shows that social norms and the media are powerful in inuencing positive attitudes towards tanning and possession of a tan for appearance reasons (Cafri et al., 2006; Dobbinson et al., 2008). Social marketing campaigns to market the social desirability of a natural skin colour/ tone might target specic groups. For example, celebrities considered fashionable and held in high esteem could be featured in a campaign targeting highly impressionable teens and adolescents. The Americas Next Top Model competition developed by model Tyra Banks has advocated that young women should not tan. Tyra Banks has used graphic and alarming methods to show one young woman the negative consequences of tanning (The CW Television Network, 2011). Such campaigns could build on the requirements of the SunSmart Schools Accreditation Programme and complement existing mass media campaigns to reinforce the need to avoid sunburn when teens and young adults are seeking social acceptability while learning cultural norms. In addition to mass media campaigns, community based organisations (e.g., sporting and social clubs) can promote SunSmart behaviours amongst their members. In addition, these groups can provide access to resources that might present barriers to individuals engaging in sun protective behaviours. This would assist in addressing the barriers to sun protection, which are often factors beyond the control of an individual, such as the availability of sunscreen and other means of sun protection. Here the macro and micro levels directly overlap, as do other facets of the macro-level environment and the individual micro-level pathway to sunburn. Examining the holistic model of sunburn presented above, it can be seen that each macro-level element should be considered when designing appropriate measures to reduce the risk of sunburn at each step of the micro level pathway.

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There have been numerous interventions targeting the microlevel environment, covering a broad range of areas. For example, substitution of hazardous sunbathing behaviour for sunless tanning (Pagoto et al., 2010), or information and educational campaigns to increase sun protection (Bellamy, 2005) and even programmes to promote moderate sun exposure to ensure reduction of skin cancer risk while optimising vitamin D production (Breitbart et al., 2006). These interventions appear to be of some utility and it is important to expand these programmes. Innovative interventions also need to target and capture populations most resistant to the SunSmart message such as those as individuals who perceive themselves not at risk or of lower risk (e.g., moderately sun sensitive skin types). Furthermore, a sunscreen paradox has been found whereby sunscreen utilisation may increase the risk of sunburn due to inappropriate use and sub-optimal application (Autier et al., 2007). This could be related to a certain level of complacency linked to its use or failure to achieve required coverage and re-application. In order to improve the effectiveness of this sun protection method, mobile phone messages (e.g. text sms messages) could be sent as reminders to adequately apply and reapply sunscreen at required intervals. This reinforcement would serve to change behaviours about the use of sunscreen. In addition, public recreation areas, particularly open areas with minimal shade, could be supplied with sunscreen to enable users to apply if they are unprepared for the conditions, or if they forget to apply or bring a supply for their own use. The literature review indicated that many individuals are exposed to potentially risky levels of UVR during outdoor recreation. Additional interventions can be adopted to assist individuals to be more aware and informed of the risk of sun exposure and to monitor the length of time spent in the sun. Such mechanisms could include timing devices and mobile phone reminder services (i.e., text sms messages). This would build on existing UVR warning systems such as those developed by NIWA (Robinson and McKenzie, 2006), or the new iPhone application which provides a service that alerts users to real-time high UVR (Itunes, 2011). Exposure to, and duration of, sun exposure are also related to activities that individuals participate in outdoors. Hence, certain occupations are more at risk than others and targeted campaigns should be maintained for these segments. Depending on existing attitudes to sun protection in particular industries, accredited sun protective clothing could be legislated under Health and Safety regulations. Opportunities also exist to improve the range of sun protective clothing available to the general public. Commercial opportunities might become realised through direct sales to institutions like schools, sporting clubs and the armed forces. Individuals need adequate resources, the opportunity and often an incentive to follow the directions of the well known public health campaign Slip!, Slop!, Slap!. As well as enhancing UVR protective clothing and increasing its accessibility, an affordable range of fashionable sun protective eyewear could be developed and launched to target segments that may be unable to wear sunglasses due to affordability or are reluctant to wear sun protective sunglasses due to their perceived lack of style or fashion appeal. This could involve extending the range of options currently available through such outlets as the Cancer Council of Victoria (for examples, see http://www.cancervic.org.au/store/default.asp). Taken together and individually, these and other measures and initiatives would help to counteract sunburn which is largely preventable due to unintentional sun exposure. 7. Conclusions and recommendations for future research The aim of this paper was to widen the knowledge of the factors that contribute to sunburn, in order to understand the barriers to

sun protection behaviours among the population. A holistic model was shown, based on the conceptual model by Hill and Boulter (1996) and a literature review that incorporates the individual (micro-level) and physical, policy, social, and climatic environments (macro-level) inuences on sunburn. From this model, a number of recommendations were made for public policy makers and social marketers to enhance the effectiveness of existing policy tools and social marketing programmes. While this represents a contribution in itself, the model should be tested in future research. Previous cross-sectional studies have investigated many, but not all, of the variables presented in the model, thus the opportunity exists to extend previous research through the collection of additional variables. Specically, future research might expand on previous studies and employ a diary method and/or UVR dosimeters, together with in-depth interviews to capture participants record of experience with sunburn and related events (e.g., Wright and Reeder, 2005). This would provide objective measures as well as a depth of insight into the factors contributing to sunburn that are not currently accessible and assist with the development of additional interventions to enhance sun protective attitudes and behaviours. It would also capture the language that participants use to explain and reect on their outdoor experiences and in some cases use of indoor solaria (i.e., tanning beds) that led to sunburn and its consequences. The conicting messages that individuals might receive about the merits of moderate sun exposure, particularly for vitamin D synthesis, also requires attention to understand individuals perceptions of the right balance between sun safety, physical and social activity, and reported health benets. The adage knowledge is power might have implications in the case of knowledge of sun safety and perceived self-efcacy about health. Individuals who perceive themselves not at risk, or lower risk (e.g., moderately sun-sensitive skin) and in control of their health, might become complacent about sun protection and become more likely to experience sunburn. Thus, future social marketing campaigns should specically target such at-risk groups, as more targeted, in-depth interventions have been shown to be more effective in sun protection (Lombard et al., 1991; Jones and Leary, 1994). In addition, there is a need to monitor and track the effectiveness of supplementary and innovative interventions in future studies, and to examine the responsiveness of particular at risk groups in the general population. References
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