This is a regular feature in Cancer Forum describing behavioural applications in cancer prevention.
Australian has five behavioural research centres: the Centre for Health Promotion and Cancer Prevention Research (CHPCPR) of the University of Queensland, the Cancer Education Research Program (CERP) of The Cancer Council New South Wales, the Centre for Behavioural Research in Cancer (CBRC) of The Cancer Council Victoria, the Centre for Behavioural Research in Cancer Control (CBRCC) at Curtin University of Technology Perth, and the Centre for Cancer Control Research (CCCR), of the Anti-Cancer Foundation of South Australia.
This report has been edited by Allison Boyes (CERP) from the reports received.
Reasons for presentation and treatment of non-melanocytic skin cancers at an advanced stage
While most non-melanocytic skin cancers (NMSC) are easily treatable, a proportion is not given effective treatment until the cancer is advanced. Approximately 324 people died from NMSC in Australia in 1997 and these were all potentially preventable deaths. Michele Bandaranayake, a CERP PhD student, and supervisors Prof Bruce Armstrong and A/Prof Afaf Girgis undertook a prospective case-control study of people with histopathologically diagnosed NMSC to examine the patient, practitioner and disease factors contributing to delay in presentation and treatment of NMSC at an advanced stage. Cases were patients classified as having advanced NMSC based on set criteria. Computer assisted telephone interviews were conducted with patients to explore issues relating to the NMSC that they had been treated for, especially in relation to determinants of delay. The nature of the treatment given was ascertained by a survey of the primary treating practitioners. Information about the histopathology of the primary NMSC was abstracted from pathology records. Of the 1,221 cases and 1,279 controls contacted for consent, 79% of cases and 80% of controls consented to participate. Data analysis was carried out on 723 eligible cases and 789 controls. Some of the preliminary findings suggest that more cases (47.4%) compared to controls (44.4%) had presentation delay greater than four weeks. Cases who were employed were more likely to delay seeing their doctor than those not in paid employment, (59.1% employed versus 44.2% unemployed). A similar finding was seen amongst controls (55.5% and 40.8%). A similar proportion of cases and controls lived alone, however of those cases that lived alone, a higher proportion had greater delay compared to controls (47.9% versus 36.9%). Future analysis will focus on the possible determinants of presentation delay and the different types of delay related to advanced stage NMSC.
Impact of the SunSmart media campaign
Australia has the highest incidence of skin cancer in the world. Exposure to UV in sunlight is considered to be the main cause of skin cancer in Australia. A main component of the evaluation of the SunSmart campaign in Victoria includes a regular assessment of the impact of media and other specific strategies on the sun-related knowledge, attitudes and behaviours of the population. Over the summer months of 2001/2002 a telephone survey of 1,426 adults in Victoria was conducted on Monday evenings about the previous weekend’s outdoor activities. Although the media buy for the latest SunSmart commercial Timebomb was limited by funds, awareness levels were similar to those achieved in the previous year by the end of the campaign. A small increase in pro-tan attitudes and behaviour was cause for concern, while in general more people chose to avoid the sun to protect themselves on summer weekends. The prevalence of use of other sun protection behaviours on summer weekends appeared to be stable. Nonetheless, a small proportion of the population suffered sunburn on summer weekends. Moreover, questions about the reasons for the sunburn experienced suggest that there is a continued need for prompts for protection and messages about the limitations of sunscreens and promotion of other forms of protection.
The efficacy of an early childhood sun protection program for mothers
A study was undertaken to develop, implement and evaluate a behavioural based intervention program to assist mothers in sustaining or increasing the sun protection of their young children up to the age of three years. Six hundred and four women (302 pairs) were recruited at the birth of their child. Women with similar backgrounds were paired and at their child’s first birthday were randomly assigned to receive either the intervention program or other non-sun protection information. All program materials focused on the social, structural, and environmental aspects of sun protection through skill development and education. The intervention was delivered during the first three years of childhood. Follow-up was conducted with 402 women (201 pairs), representing 67% of the original sample. Results indicate that after three years, 57% of the women exposed to the intervention program reported always protecting their children with sunscreen, compared to 47% of the women who did not receive the intervention. Furthermore, while not statistically significant, women who received the intervention were more likely to use sunscreen themselves than women who did not receive the intervention. There was no significant change in the use of hat wearing or protective clothing. Overall, an educational program had limited impact on mothers who were doing a good job of protecting their children from the sun. Together with the national SunSmart campaign that occurred during the time of our program, women continued to perform at a reasonable rate to protect their children. It is difficult to disentangle the effects of that campaign, and our intervention on both the intervention and control groups toward sun protection compared to no treatment. Our research demonstrates that a strictly behavioural approach is insufficient to maintain behaviour change and that more environmental policies need to be put in place to protect children from the sun.
Review of breast cancer screening messages
Sandra Jones has completed a review of breast cancer screening messages targeted to women in Australia. This included a review of pamphlets produced by health professionals and a review of media coverage of breast cancer. The pamphlet study found a number of inconsistencies in terms of the stated lifetime risk of breast cancer, risk factors (other than being a woman and increasing age), and the specific representation of symptoms. On a positive note, the majority of the pamphlets included information on breast self-examination, clinical breast examination and mammography, and the information provided was quite consistent. The media study covered all items (advertising and editorial) appearing in the 10 top-selling Australian women’s magazines and three weekend newspapers over the six-month period from December 2000 to May 2001which included any reference to breast cancer. A total of 31 advertisements and 42 non-advertising items were identified. There was considerable misinformation, particularly in relation to the apparent age of breast cancer sufferers, with less than 40% of the women written about, and less than 10% of photographs used, being women over the age of 50.
Cancer statistics monograph series
The Centre released the first publication in its cancer statistics monograph series, entitled Cancers of the digestive system. Cancers of the digestive system have received little publicity in South Australia, although accounting for around 30% of cancer deaths. The published behavioural research was reviewed for cancers of each organ site and the conclusion drawn that at least 40% of them could be prevented, principally through dietary change, not smoking, not drinking excess alcohol, having moderate levels of exercise, and in some instances, through proper food storage and hygiene, and infection control measures.
The Centre has also completed preparation of its second release in this series, entitled Sun-related cancers of the skin and lip. While the age-sex standardised incidence of invasive melanoma has almost doubled in South Australia since 1977-81, a plateau has occurred in 1992-2000. It likely that sun-protection programs have made an important contribution to arresting the incidence incline. A detailed comparison of 1992-96 and 1997-99 data point to a downturn in melanoma incidence in South Australians under 50 years of age. Early detection initiatives have been accompanied by an increase in proportion of invasive melanomas diagnosed when thin (<=0.75mm thickness) from approximately 40% in South Australia in 1980-83 to 57% in 1996-2000. Case survivals have increased and a downward trend is now apparent in melanoma mortality in residents under 70 years of age. The monograph has highlighted sectors of the South Australian population that warrant special attention in further sun-protection and early-detection initiatives.
Data were collected on sun-protective behaviours and attitudes of South Australian 12-17 year olds as an adjunct to the triennial Australian School Students Alcohol and Drug survey. While knowledge of the link between UV exposure and skin cancer was fairly high, there was less certainty about the importance of sunburn. Sun protection practices fell short of knowledge and a sharp rise in reported sunburn in the previous summer. While the results showed a decline in perceived desirability of a tan, and a less frequent deliberate use of briefer clothing, there was the indication of a trend away from some protective behaviours in recent years. Other data collected in the South Australian Health Omnibus and Health Monitor surveys for residents aged 15 years and over indicated that risk of being burnt once or more during summer was higher in the younger age groups, males, people with skin types that were prone to burning, those born in Australia or the United Kingdom, and those who did not regularly wear a hat or clothing that could be protective. These results highlight the importance of targeting young people, in addition to other high-risk groups, in promotional campaigns. Data collected in 1990, 1993, 1996 and 1999 indicated that sunscreen use by adults increased, whereas hat wearing declined. While use of protective clothing increased initially, it then declined. These data are being used to plan ongoing sun-protection initiatives.
Fake tan lotions and sunburn
Staff of the Centre were authors of a report on the use of fake tanning lotions in South Australia that was published in the Medical Journal of Australia. Data collected by household interview for 2,005 adults indicated that use of fake tans was more common in young women and people with household incomes over $40,000. While users of fake tans were more likely to use sunscreens, they were less likely to take other precautions, like wearing hats or protective clothing. Also, they were more likely to report repeated sunburn during the prior summer. Based on the results, the Foundation considered that there was no justification for altering its policy of not promoting fake tan lotions to reduce sunburn.
Evaluation of support for and compliance with smoke-free dining
The Tobacco Control Research and Evaluation Program has completed an evaluation of levels of support and compliance among the South Australian community and restaurateurs in relation to smoke-free dining. Two data sets were analysed. The first was collected in 1997, 1998 and 1999 in cross-sectional Health Omnibus Surveys of more than 3,000 South Australians. The second was obtained through face-to-face interviews of restaurateurs and venue inspections. Data were collected after legislation was introduced, and replicated in June 2000, to check for changes over time. Results included evidence of consistent increases in community support (smokers and non-smokers) for smoke-free dining, as well as increased support among restaurant owners and managers. South Australians reported that their enjoyment of dining out had increased since the legislation took effect. High rates of compliance with the legislation were evident, as well as in the provision of totally smoke-free dining among sectors (such as hotels) where exemptions to the legislation could have been sought.
Population based study of cancer survivors’ physical and psychosocial well being
Improvements in the treatment and early detection of cancer have contributed to an increase in the long-term survival rate of cancer patients. However, little is known about the later effects that cancer and its treatment has on cancer survivors, their ongoing concerns, how the issues they face change over time and the type of support they need. Allison Boyes and colleagues are undertaking a population-based study to identify the prevalence and predictors of the physical and psychosocial outcomes reported by cancer survivors, and how these outcomes change with time since diagnosis. This includes a cross-sectional study of long-term survivors who are five years post-diagnosis and a longitudinal study of recent cancer survivors who will be followed for five years from six months post-diagnosis. Information about the survivors will be obtained from their cancer notification to the Central Cancer Registry as well as a self-report survey which includes reliable and valid instruments assessing anxiety, depression, quality of life, supportive care needs, coping and social support. These data will help guide the development of policies and services that are tailored to the needs of Australian cancer survivors at various stages of recovery or disease progression.
Direct mail cervical screening intervention
As part of PapScreen Victoria’s communication and recruitment strategy, over 200,000 under-screened women aged between 50 and 69 years will be sent a personalised letter inviting them to have a Pap test. Two versions of the letter will be randomly assigned to the women; one with a gain-framed message and one with a loss-framed message. A subset of women will be monitored to assess the impact of message framing on cervical screening behaviour. The study, conducted by Madeline Fernbach, will continue until October.
Evaluation of the SunSmart Schools Program
The SunSmart Schools program has been a promising strategy promoting the development of policy on sun protection in the primary school setting. In 1997 and 1998 an evaluation study of the SunSmart Schools program underway in most states was initiated to assess the impact on sun protection policy and practices in primary schools. A follow-up survey has recently been conducted with data collection coordinated by Suzanne Dobbinson. A total of 970 questionnaires were sent out to schools in October and November 2001, with response rates to date fairly high in most states. Preliminary results are expected to be available in April.
Assessment of Queensland secondary schools’ requirements for supporting sun protective behaviour
The documented decrease in sun protective behaviours from primary school to senior secondary school illustrates the need for sun protection programs in secondary school settings. Schools can play a major role in reducing students’ exposure to ultraviolet (UV) radiation. However, a standard approach of education, skills training and social support is less effective and innovative approaches, which address behaviour, curriculum and environment are required. Dr Warren Stanton and colleagues are conducting a Queensland Health funded project to assess the requirements of Queensland secondary schools for supporting sun protective behaviour. A statewide survey will be conducted to assess the level of implementation of sun protection policies and explore facilitators and inhibitors to the implementation of these policies. Qualitative research with principals, teachers, students and parents will also be conducted to explore innovative methods for improving the sun protective knowledge, awareness and behaviours of Queensland secondary school communities. The project will contribute to the implementation of strategies identified for the secondary school setting in the recently finalised Queensland Skin Cancer Prevention Strategic Plan 2001-2005.
Evaluation of the Me No Fry media campaign
In December 2001, the Cancer Foundation of WA implemented the first year of a three-year mass media campaign, “Me No Fry”. The objective of the campaign is to promote and reinforce the importance of sun protective behaviour among Western Australian children aged 12 to 17 years. A series of cross-sectional telephone surveys of the target population will be conducted to assess campaign outcomes. Six post-surveys will be conducted at two-weekly intervals following commencement of the campaign. In each survey, approximately 75 respondents will be interviewed, and males and females will be equally represented. A baseline survey was conducted with a total of 150 respondents prior to the implementation of the campaign.
Cancer risk factors and behaviours
Interview surveys of the South Australian adult population were conducted in relation to diet, physical activity, alcohol consumption, perceptions of cancer risk, and effects of SunSmart media advertisements on awareness, recall and intention to change behaviour.
Sun-protection practices in early childhood
A survey was undertaken in 2001 of preschools and child care centres to assess sun-protection policies, shade levels, the promotion of personal protection, and rescheduling of outdoor activities to reduce UV exposure. Data from these surveys will be analysed in 2002.
Participation in the Breast Cancer Support Service
A study is being undertaken to identify population sectors in South Australia with limited coverage by the Breast Cancer Support Service. It will be assessed through follow-up inquiry whether these sectors are receiving appropriate support through other means, and if not, the nature of barriers to service acquisition, including psychosocial barriers.
Cancer incidence by country of birth
Compilation of data from 153 cancer registries around the world, and of Australian data by country of birth, is well advanced. The purpose is to determine risk profiles of Australians to different cancers according to their countries of birth, and in the context of the risks experienced in their countries of origin. Results will be used to target: investigations into the cultural and behavioural factors that underpin these differences; and health promotion and screening endeavours to reduce elevations in risk.
Assessment of public support for smoking bans
The Tobacco Control Research and Evaluation Program is examining data from a recent population survey to check for changes over time in levels of public support for smoking bans in bars and gaming venues.
CERP has had a number of recent grant successes. In collaboration with researchers at the Hunter Centre for Health Advancement, CERP was awarded funding from the NSW Health Promotion Demonstration Research Grants Scheme to evaluate the implementation of the NSW Health Guide for the treatment of nicotine dependent inpatients. In collaboration with researchers from the Newcastle Institute of Public Health, CERP was also awarded a consultancy to develop the NSW Health Cancer Services Framework. Dr Chris Paul has been awarded a one-year grant from the University of Newcastle Early Career Researcher Grants scheme to identify the potential for increased support for smoking cessation in pharmacies.
CBRC is delighted to announce that Victoria White, Senior Behavioural Scientist, submitted and received her PhD from the University of Melbourne in 2001. Vicki’s research thesis used a longitudinal twin design to study the roles of genes and environment in determining variation in smoking behaviours from adolescence through to early adulthood. The study found no evidence that genetic factors influenced the initiation or maintenance of smoking behaviours at this stage of life, except in females where the effect was small. Environmental factors shared by twins in the same pair explained the greatest amount of variation in the initiation of smoking, and a substantial part of this was explained by the smoking behaviour of friends and parents.
The Centre welcomed two new staff members this month. Professor Neville Owen has now settled into his new position as Director of the Centre and Professor of Health Promotion, School of Population Health. Eva Leslie has also joined the Centre as a Research Fellow, from the University of Wollongong and will be working closely with Professor Owen on a number of projects, primarily a newly funded NHMRC project investigating how people’s environments influence their habitual physical activity.
We had a busy time with conference presentations during the latter part of 2001. Nadine, Sandra and Geoffrey attended the 2001 Australia and New Zealand Marketing Academy Conference in Auckland in December, where Nadine and Sandra each presented three papers. Sandra also presented three papers at the American Psychological Association Conference in San Francisco, and two papers and a workshop at the Public Health Association Conference in Sydney. Nadine presented a paper at the WA State Cancer Conference and at the Multidisciplinary Meeting on Behavioural Research in Cancer Control at Curtin University.
The Centre for Cancer Control Research (CCCR) was recently established by the Anti-Cancer Foundation of South Australia. The Centre presently comprises of David Roder (epidemiologist), Kerri Beckmann (health researcher) and Jennifer Owen (administrative assistant). A key function is behavioural research, although the Centre’s role is broader, namely, the application of epidemiology and behavioural sciences in applied research and service delivery. The Centre works in partnership with the Tobacco Control Research and Evaluation Program and other staff of the Foundation, covering a broad field of behavioural research with a focus on tobacco control, sun protection, diet, alcohol consumption, physical activity, and psychosocial aspects of cancer management.