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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

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STEPm~NARTHEYand VALERIEA. CLARKE use to record their activities, weather and sun protection in two hour blocks, usually over a five day period, have been used successfully in structured contexts, such as within schools [e.g. 12, 26, 27]. In an attempt to resolve the problem of selfreporting of behaviours, some studies have assessed behavioural intentions in relation to suntanning behaviour [e.g. 28] or sun protection behaviours [e.g. 12]. However, self-reports of intention should also be interpreted cautiously, 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.
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, 13, 18], direct dissemination of information to the public [19-21], increasing the amount of skin cancer and sun protection information taught in schools [22], and an assessment of the effects of positive reinforcement and modelling on behaviour [17]. All, or most of these strategies have also been combined into public education campaigns such as "Slip! Slop! Slap!" [23], "SunSmart" [7], "Are you dying to get a suntan?" [14], and the "Arizona Sun Awareness Project" [24].

Implications of study designs

Psychological research into suntanning and sun protection behaviour is a relatively new area of health promotion and disease prevention research. As a result of this, the majority of the research has focussed on gathering descriptive data on knowledge and attitudes towards sun protection and to a lesser extent suntanning, and devising interventions to increase people's knowledge and change their attitudes and ultimately their sun protection behaviour. As a result, much of the existing information is from questionnaire/survey design procedures. Although focus groups are often conducted in the development of questionnaires and surveys, the authors' were unable to find any published examples of focus group research nor of one-to-one interviews. Both of these techniques are useful in understanding the beliefs underlying attitudes and intentions towards a behaviour, the behaviour itself, and ensuring that researchers are 'looking' in the right place. While questionnaire/survey designs dominate this field, there has been a lack of breadth in the types of information they have collected. There has been little or no examination of people's perception of their risk of getting skin cancer, their level of motivation to engage in sun protective behaviours, their confidence in their ability to successfully engage in sun protective behaviours, or in their perceptions of those who do (and do not) engage in sun protective behaviours.
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], skin type [12], previous experience with skin cancer [13, 29], and attitudes to suntanning [28]. Intentions to get a suntan predict actual (lack of) sun protective behaviours [28].
INTENTIONS

There are strong theoretical reasons that, for volitional behaviours (of which sun related behaviour is an example), intention to perform the behaviour is the immediate antecedent of the relevant behaviour [30, 31]. Since intention can be self-reported, it is a more accessible dependent variable in research than is behaviour, making the study of predictions of intention likely to throw light on the determinants of sun related behaviour. 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.

Attitudes toward suntanning and sun protection

A suntan has been associated with looking and feeling attractive and healthy [9, 10] and a belief that it is easier to enjoy the summer with a tan [8]. While the level of knowledge of sun protection and skin cancer is generally high, many people appear to believe that the benefits of a suntan outweigh the risks involved in getting the tan [10]. This suggests that many people still have a positive attitude towards having a suntan, although there is some evidence that desire for a suntan in Victoria, Australia may have decreased over recent years [7]. As desire for a suntan decreases, people are becoming more willing to engage in sun protection behaviours. They are taking more precautions when in the sun and are more willing to encourage others, particularly children, to engage in sun protection [7]. 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. Failure to tell people they are being watched may be unethical while informing them they are being observed may influence their behaviour (Hawthorne effect). Although self-reports of behaviour have been shown to be accurate in other areas of health research focussing on observable, public behaviour such as cigarette smoking [25], there is some concern that self-reports may over-estimate sun protection behaviours [11], possibly to present a socially desirable image. However, self-report diaries, that subjects

Suntanning and sun protection more likely to use sunscreen while older people are more likely to cover-up with clothing [32]. Although survey data suggest that males are more likely to wear a hat than are females [32], 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]. Subjective norms The belief that a suntan makes you look more attractive and healthy [9, 10] suggests that the perceived opinions of others are having an important effect on people's suntanning, and consequently sun protection, behaviour. In a recent Melbourne survey, 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]. Sunbathers were more likely to have friends who sunbathed [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, 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]. Modelling of appropriate sun protective behaviours by lifeguards at two pools in Virginia, U.S.A. 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]. This suggests that significant others can influence behaviour, but further research is required to determine whether this finding is situation specific, being only relevant to swimming locations or whether behaviour will generalize to other situations. Knowing someone who has had skin cancer is a strong predictor of intention to engage in sun protective behaviours [13]. However it is not possible to tell if this effect is from the impact of the subjective norm, or the developing of an awareness of the relationship between skin cancer and inappropriate sun related behaviour.

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SUNTANS A suntan has been a status symbol among Caucasians since the industrial revolution [9]. Before then, the majority of people worked outdoors in the agricultural fields and a suntan was associated with the poorer, working class. At that time, having pale, porcelain looking skin was fashionable because it indicated that the person was wealthy and did not work outdoors. After the industrial revolution, 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. SSM 40/2--I

A suntan has also long been associated with health. This association began in the early 1900s as part of the "beliotherapy" craze in Europe [9]. 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. Having a suntan came to be seen as healthy, and, even though the medical benefits of heliotherapy were discredited in the 1940s and 1950s, having a suntan remained popular [9]. Suntanning as a fashion statement is reported to have begun with Coco Chanel the French fashion designer [34]. 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. For example, in Harper's Bazaar various celebrities were cited: "I love to get roasted. I turn almost black. It makes me feel healthy"; "I feel it is necessary to be tanned"; "A good tan makes any woman look at least ten years younger" [35]. Other characteristics that could be inferred from having a suntan included "superior physique, intelligence, and moral character" [9, p. 480]. The first research into sunbathing was reported by Kecsling and Friedman in 1987 [9]. 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, healthy and active. Sunbathing was found to be related to having a positive attitude toward risk taking, having little knowledge about skin cancer, reporting a relaxed mood and having friends who sunbathed. Of particular interest was the finding that "sunbathers seem less concerned with their actual health than with the appearance of health" [9, p 491]. Although a suntan has strong social benefits [9] there may also be social (as well as health) costs associated with having a suntan. Using a vignette procedure, Miller, Ashton, McHoskey and Gimbel [10] found that people who were portrayed as intentionally seeking a suntan were described by U.S. college subjects as not only 'hot' and 'sexy', but also in a significant number of cases as being 'vain' and 'egotistical'. Subjects were found to perceive suntanned characters as more attractive than untanned characters, however, 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, but still more attractive than untanned characters. 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. [10] found that irrespective of subjects' suntan level (light, medium, or dark), an optimistic

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STEPHENAaTrmY and VALERIEA. CLARKE cancer [9, 13], believe they have a higher susceptibility to skin cancer [13], have fewer barriers to covering-up [13, 15], are more likely to use sunscreens regularly [9, 15], engage in more skin-protective behaviours [9, 12], and perceive a lighter suntan level to be healthier and more attractive [16]. Although the trend is reversed for males, females consider a suntan to be more healthy than it is attractive [16]. It is possible that females, being more concerned with appearance than are males [40, 41], are more aware of the premature aging effects of the sun and perceive a suntan as a greater threat to attractiveness than do males. 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. Knowledge of the dangers of over-exposure is higher in females than in males with females reporting more protection of their skin. However, females still report desiring a suntan [9, 10] and see a suntan as being a sign of health [16], indicating either, that many females are still ignorant of the consequences of suntanning, or they believe the benefits of a suntan outweigh the risks. Age Adolescents are the group who, as a whole, spend the most time in the sun [19], are the most determined to get a suntan, and the most resistant to adult advice on what to wear and how to behave in the sun [42]. 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]. It is during adolescence that parental influence wanes and the responsibility for personal health shifts increasingly to the adolescent [43]. At the same time adolescents become susceptible to social pressure from the media and their peers [e.g. 44--47]. Among these pressures are those of fashion and attractiveness. Currently, the media portrays beauty and health as being inter-related. Unfortunately, what is considered beautiful is not always healthy. This is particularly evident in suntanning, where the media often uses models with dark suntans to advertise fashion products and promote 'good health' [48]. Adolescence is the time when much of the damage that will lead to skin cancers in later life occurs [49-51]. By use of mathematical models based on epidemiological data, Stern, 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. 78%. 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. In the media there has been a change toward using paler models, particularly females, in advertising [54]. Many 'teenage'

bias was evident in their ratings of their chances of developing skin cancer. Interestingly, subjects with a high self-reported suntan level displayed a significantly reduced bias compared to subjects in the other two suntan categories. Although they still had a significant optimistic bias, it appears as if those with dark suntans are at least partially aware of the risks associated with excessive sun exposure, but consider the benefits of a suntan to outweigh these risks. Level o f tan Although both Keesling and Friedman [9] and Miller et al. [10] have found that a suntan is perceived to be both attractive and healthy, neither study identified the level of suntan considered to be the most attractive or the most healthy. This issue was addressed in an experimental study conducted by Broadstock, Borland and Gason [16] who examined adolescents' attractiveness and healthiness judgements of male and female models with four suntan levels (no tan, light tan, medium tan and dark tan) and in two types of attire (casual clothing and swimwear). 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. This finding confirms the generally held belief and the findings from correlational studies in Australia [e.g. 32] and the U.S. [9, 10] that a suntan is considered to be indicative of both health and beauty. However, it is encouraging to find that the most desired level of tan is a medium tan rather than a dark tan, possibly indicating that public education programs on the dangers of excessive sun exposure are having an effect on people's beliefs. Suntans and health People report feeling healthier with a suntan [32], however, this may be an inaccurate belief. 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], there is no medical evidence to suggest that a suntan improves health. This belief is likely to have developed as a result of direct and/or indirect positive reinforcement from others. 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.
GROUP DIFFERENCES IN BELIEFS

Gender There are marked gender differences in health beliefs and behaviour. 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]. Relative to males, females have a higher level of knowledge of skin

Suntanning and sun protection magazines (again predominantly directed at females) are discussing the long-term effects of over-exposure to the sun, mostly in relation to its effects on beauty rather than health [48]. However, if there is to be a decrease in adolescent sun exposure, it is important to convey the message in the form that will be most acceptable and relevant to this group.
Education

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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]. This is similar to findings in other areas of behavioural health research, where those with higher levels of education are more likely to be aware o f the health risks associated with their behaviour [55].
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, Slop, Slap' campaign. Concentrating on increasing public knowledge and changing attitudes toward the sun, this campaign, and the more recent and extensive 'SunSmart' program have been effective, 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]. 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. The ASAP is a large scale, skin cancer and sun protection education campaign developed and run by the Arizona Cancer Centre that focuses on three main age groups: children, adolescents and the elderly [24] and employs different strategies for each of these age groups. With children's limited understanding, attention span and personal control over health behaviour the ASAP focuses on providing attractive, stimulating messages through stories, puppet shows, music and colour, rather than emphasizing message content. The aim at this level is to provide children with a basic understanding of skin cancer prevention. Adolescents are a vital target for skin cancer prevention programs. 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]. Because there is social pressure against sun protection at this age (i.e. 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. Finally, the ASAP targets the elderly because they have the highest incidence of precancerous and cancerous skin lesions. The emphasis here is on susceptibility and

much of the prevention efforts are communicated through the media, of which the elderly are heavy consumers [24]. The English 'Are You Dying to Get a Suntan?' campaign, launched in 1989, had three components: magazine advertising, leaflets and public relations activities, with the goal of making people more aware of the dangerous effects of excessive sun exposure and means of preventing over exposure [14]. 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. The advertisement focused on the epidemiology of malignant melanoma because this is the most lethal form of skin cancer. Females between 16 and 34 years were the target group as they are the main purchasers of sun protection products for themselves, their children and their partners [14]. Leaflets were distributed through community pharmacists and with airline in-flight magazines. The advertisement was successful in raising awareness of the dangers of over exposure to the sun, particularly among young females (the target audience). However, there was no reported increase in sun protection measures following the campaign, nor any change in attitudes towards suntans, with most people still reporting that they considered a suntan personally important and synonymous with health and beauty [14]. 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. One such program is Telecom Australia's 'Cover Yourself Against Skin Cancer' which was designed to increase hat, shirt and shade use by its outdoor workers [56]. The campaign used marketing techniques including a video, ACCV brochures, lapel buttons, and a wellknown Australian swimming personality (Dawn Fraser) as a role model to promote covering-up when in the sun. Compared with a control group who were not exposed to the campaign, the experimental group increased their shirt use and their overall sun protection. Similarly, an outdoor worker intervention that involved participants receiving individual screening by a dermatologist, a report from the dermatologist on their current level of skin damage and personal risk of developing more extensive skin damage or skin cancer, 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]. These two studies suggest that specialized campaigns can be successful in addition to the more general sun protection campaigns such as SunSmart. 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.

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STEPHEN ARTHEY and VALERIEA. 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, newspapers, magazines, radio and television. Although television has been shown in other contexts to have greater impact than either written or oral presentations [57], it has had mixed success in studies looking at its effectiveness in communicating skin protection information. A telephone interview procedure was used to measure the effect of three television programs on melanoma, presented over a two year period [18]. Theobald et al. examined viewers intentions to have any abnormal skin lesions checked by a doctor. The television programs were considered to be informative and emotionally arousing. 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. After the show, 113 adults who had seen the program were interviewed. 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. Fifteen people reported intending to visit the doctor for a suspicious looking skin lesion, of whom three actually did so within four weeks of 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), found a 143% increase in the number of melanomas removed compared with the same period twelve months earlier. 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. 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. However, viewers of the program still continued to value a suntan, suggesting that while the programs had made more people aware of the consequences of over-exposure, it is uncertain what effect this will have on their sun related behaviour. Miller et al. [I0] used a videotape presentation documenting the risks associated with sun exposure. The videotape discussed the powerful allure of suntanning to many people, particularly those of college age, but emphasized the overwhelming evidence of the carcinogenic properties of sun exposure. The tape also presented the skin cancer experiences of a woman in her late 20s who had a history of suntanning and occasional sunburning. The videotape was largely ineffective, being rated as unconvincing by subjects with either low, medium or high suntan levels. A general conclusion by Miller et al. was that

"while acknowledging a degree of risk, most subjects do not believe suntanning is as risky as the experts claim" [p. 1293, italics in original]. An important difference between the studies by Theobald et al. [18] and Miller et al. [10], in addition to the country in which they were conducted, was the method by which subjects were recruited. Theobald et al. interviewed subjects after they voluntarily watched the program, while Miller et al.s subjects were completing the experiment to gain extra course credit. 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].
Schools

Schools are starting to recognize the need for policies and education programs in relation to sun protection. For example, in 1990 in Australia, approx. 90% of schools offered some health education program in Years 7 to 10, 75% offered one in Year 11 and 69% of schools offered one in Year 12. Skin protection is beginning to become a part of the curriculum in these schools. It was taught within the health education program in 74% of Australian schools, with 85% of these schools having introduced it within the last five years [59].
Interventions directed at children a n d adolescents

Due to the high amounts of sun exposure during childhood and adolescence, these groups have frequently been targeted for interventions to reduce sun exposure and increase sun protection. The majority of these programs are implemented through schools. In Newcastle, Australia, a four week, 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]. Arizona, U.S.A. is also developing a school-based skin cancer prevention program; Ramstack et al. [22] targeted pre- and early adolescents with a six unit curriculum designed to teach students to understand the dangers of the sun, skin cancer and what students can do to protect themselves from over-exposure. A change was found in self-reported behaviour following the program, with students reporting that they were more likely to cover-up when in the sun [22]. However, there was no change in the proportion of students reporting that they still desired a suntan, although it is possible that this desire may decrease and their attitudes may change if they continue to engage in sun protective behaviour (i.e. reciprocal determinism).

Suntanning and sun protection A brief school-based intervention (one 45 min lesson), directed at adolescents in the U.S.A., significantly increased students' knowledge and perceived susceptibility to skin cancer, but as is common with interventions directed at youth, behavioural intentions remained unchanged [60]. The intervention focused on increasing knowledge and changing attitudes by a three step procedure. First, students were shown a video tape of the dangers of skin cancer, the risk factors and the precautions to reduce the likelihood of skin cancer followed by an elaboration of the important facts in the video. Second, students were given a worksheet to help them assess their personal risk of skin cancer. Finally, barriers to taking precautions in the sun were discussed. 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.

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over-exposure to the sun and demonstrate the existence of virtually immediate rewards for covering-up when in the sun. The size of the reward does not appear to be as important as its immediacy [64].

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. The majority of the interventions discussed here have reported an increase in knowledge following the intervention [e.g. 7, 26, 60], some have reported changes in attitudes towards sun protection [e.g. 26], but only a few have reported observed behaviour change as a result of the intervention [e.g. 17, 27, 57]. Unfortunately, neither the generality nor the durability of this behaviour change was examined. Some campaigns have found increases in self-reported sun protection behaviour [e.g. 14, 22, 24], but based on the findings of Bennett's et al. [11] and a lack of reported attitude change towards suntans, the accuracy of these self-reports must be questioned. FUTURE DIRECTIONS Most psychological research is theory driven. The psychologist devises a theory and then designs an experiment to test the theory. 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. Then, armed with their observation, the psychologist should return to the laboratory and attempt to reproduce the event under controlled conditions and, if successful, devise a theory to explain why the event occurs. Skin protection provides an excellent opportunity to apply Cialdini's [65] Full-Circle Social Psychology principle. At present the public has been found to have a high level of knowledge of the dangers of over-exposure to the sun, however many people still desire, and some go to great lengths to get, a suntan. Skin protection and suntanning both have strong social influence components associated with them. 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. Therefore, 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. Research has indicated that many people, particularly adolescents, have a positive attitude towards suntans and sun exposure. Any intervention to reduce sun exposure will have limited effect unless the subject wants to decrease their sun exposure. Perceived

Role of knowledge in behaviour change

Knowledge based methods to change adolescents' suntanning attitudes and behaviour have been found to have limited effectiveness. Adolescents have high levels of knowledge of the dangers of over-exposure and of the precautions necessary to prevent skin damage, but this knowledge has not been transferred into behaviour [12]. Similarly, 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]. Knowledge has been shown to affect self-reported behaviour, however it appears that people may exaggerate the amount of sun protective behaviours they are actually using. Bennetts et al. [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. They found that children's observed sun protection behaviour was less than the sun protection behaviour the children reported.

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, if at all [9]. It has been effectively argued that 10 to 15 years is the most distant practical time-frame that is salient to most people [61], suggesting that people's current beliefs on skin cancer puts the time-frame beyond their practical limits for concern and action. Further, 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]. 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, increase the urgency of the message on the dangers of

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STEPHENARTHEYand VALERIEA. CLARKE result in changes to behaviour [70]. Similarly, 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. Knowledge gains should be seen as a first step toward behaviour change, rather than as the main tool to alter behaviour [70, 71]. 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, suggesting that now is an appropriate time to begin looking at ways to directly influence people's behaviour.
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, other strategies need to be incorporated into the intervention to help personalize the risk and increase motivation to change. Interventions directed at specific high risk groups may be more effective at reducing sun exposure than the more general public education campaigns. For example, the Telecom outdoor worker 'Cover yourself against skin cancer' campaign and the modelling of appropriate sun protection behaviour by lifeguards at two U.S. pools both successfully increased skin protection behaviour in the environments at which the campaigns were aimed. Specific group focused interventions are capable of providing situation specific information, 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, which the more general campaigns are unable to do. General community-based campaigns are still required. However, their emphasis may change. Rather than being seen as a major source of information on sun protection they could take a support role; acting as reminders, complementing and enhancing the focused interventions. Skills training has been shown to be important in reducing other problem behaviours such as smoking [e.g. 67] and unsafe sex [e.g. 68]. To date there has been no published research assessing what skills people need to successfully engage in sun protection. 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. 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, the rates of progress through the stages, an understanding of the reasons for relapse or discontinuance of sun protection, means of minimizing relapse and means of changing the behaviour of those who do relapse. 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. However, 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. Knowledge gains must precede any attempts to alter behaviour, but knowledge alone will not necessarily

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