Implementation of the SunSmart program and population sun protection behaviour in Melbourne, Australia: Results from cross-sectional summer surveys from 1987 to 2017

Background Australia has one of the highest skin cancer rates in the world. 'SunSmart' is a multi-component, internationally recognised community-wide skin cancer prevention program implemented in Melbourne, Australia, since summer 1988-1989. Following recent reductions in melanoma rates among younger Australian cohorts, the extent of behaviour change and the potential contribution of prevention programs to this decline in melanoma rates are of interest. Sun protection is a multifaceted behaviour. Measures previously applied to monitor change over time in preventive behaviour for this population focused on individual behaviours. The omission of multiple behaviours that reduce exposure to ultraviolet radiation (UV) may have led to underestimates of behaviour change, meriting further analysis of long-term trends to contribute to this debate. Methods and findings A population-based survey was conducted in Melbourne in the summer before SunSmart commenced (1987-1988) and across summers in 3 subsequent decades (1988-2017). During summer months, residents (14-69 years) were recruited to cross-sectional weekly telephone interviews assessing their tanning attitudes, sun protection behaviour, and sunburn incidence on the weekend prior to interview. Quotas were used to ensure the sample was proportional to the population by age and sex, while younger respondents were oversampled in some years. The majority of the respondents reported their skin was susceptible to sunburn. Changes in sun protection behaviour were analysed for N = 13,285 respondents in multivariable models, cumulating surveys within decades (1987-1988: N = 1,655; 1990s: N = 5,258; 2000s: N = 3,385; 2010s: N = 2,987) and adjusting for relevant ambient weather conditions and UV levels on weekend dates. We analysed specific and composite behaviours including a novel analysis of the use of maximal sun protection, which considered those people who stayed indoors during peak UV hours together with those people well-protected when outdoors. From a low base, use of sun protection increased rapidly in the decade after SunSmart commenced. The odds of use of at least 1 sun protection behaviours on summer weekends was 3 times higher in the 1990s than pre-SunSmart (adjusted odds ratio [AOR] 3.04, 95% CI 2.52-3.68, p < 0.001). There was a smaller increase in use of maximal sun protection including shade (AOR = 1.68, 95% CI 1.44-1.97, p < 0.001). These improvements were sustained into the 2000s and continued to increase in the 2010s. Inferences about program effects are limited by the self-reported data, the absence of a control population, the cross-sectional study design, and the fact that the survey was not conducted in all years. Other potential confounders may include increasing educational attainment among respondents over time and exposure to other campaigns such as tobacco and obesity prevention. Conclusions With an estimated 20-year lag between sun exposure and melanoma incidence, our findings are consistent with SunSmart having contributed to the reduction in melanoma among younger cohorts. Author summaryWhy was this study done? In Australia, prevention programs have been implemented over 30 years encouraging the population to reduce their exposure to ultraviolet radiation (UV), the main cause of skin cancer. Prior research assessing the impact of these programs has focused on monitoring change in the prevalence of individual sun protection behaviours, and has largely overlooked sun avoidance and composite sun protection behaviours. This may have led to an underestimation of the behaviour change associated with these programs, given that effective sun protection involves multiple strategies. What did the researchers do and find? The prevalence of sun protection behaviour and sunburn incidence of residents of Melbourne, Australia, were analysed across 3 decades. Data were from a series of population-based cross-sectional surveys conducted in summers between 1987 and 2017. A considerably higher increase in sun protection behaviour than previously reported was revealed, with a rapid increase evident soon after the SunSmart program was established. What do these findings mean? The findings are consistent with the possibility that changes over the decades in sun protection behaviour have contributed to the decline in melanoma rates, and have substantial implications for the future delivery of skin cancer prevention programs.