Characteristics of the SunSmart program with reference to health education and health promotion concepts

The SunSmart prevention campaign is ain initiative which was launched in the 1980s to promote awareness of skin cancers and the dangers of exposure to ultraviolet light. The Sunsmart program reflects the concept of health promotion and aims to improve health education by using a combination of behavioural, communitybased, policy-based and environmental-based methods. This article examines the SunSmart initiative, its strengths and weaknesses and makes suggestions for future modifications. The SunSmart initiative The SunSmart prevention campaign, launched by the Anti-Cancer Council of Victoria, is a sun protection program designed to prevent skin cancers, including cutaneous melanomas [1]. The campaign first began in the early 1980s as the ‘Slip! Slop! Slap!’ program [2]. This was a very limited campaign which used a cartoon seagull named Sidto promote awareness of skin cancer and the dangers of ultraviolet light from the sun [3]. Sid advocated for sun protection by encouraging the public to slip on a shirt, slop on sunscreen and slap on a hat. The program was so successful that it continued to run, and in the 1990s was operated under the banner of SunSmart. It was estimated in 2009, that the SunSmart program will save 120,000 disability-adjusted lifeyears in Victoria [4]. Today, the SunSmart campaign uses a modified message “Slip! Slop! Slap! Seek! Slide!” which also promotes individuals to seek shade and slide on sunglasses [5]. The program utilises a number of methods to reduce the incidence of skin cancers and its associated morbidity. The campaign employs structural and environmental changes, legislative changes as well as mass media education to promote its message. SunSmart is run within a number of settings including schools, kindergartens, work place and sporting and outdoor events. The Sunsmart campaign incorporates features of both primordial and primary prevention. Primordial prevention focuses on the underlying social factors that contribute to the development of a disease, e.g. using legislations and policies to prevent disease [6]. The SunSmart campaign incorporates aspects of primordial prevention by campaigning for the legislation to ban indoor-tanning solaria. Tanning using a solarium increases the risk of developing a melanoma by 22% in all users, and in 98% of user under the age of 35 [7]. The death of a young girl, Clare Oliver, from metastatic melanoma, ignited intense media coverage of the dangers of solaria [7]. After decades of campaigning the Victorian state government announced that it would be banning solariums by December 2014, a move which the remaining states followed shortly thereafter [8]. These statutory changes were pivotal in changing the social and cultural views on solaria. Primary prevention focuses on reducing the risk factors which cause the disease [9]. The SunSmart intervention also incorporates features of primary prevention by disseminating education on skin cancer via mass media campaigns and involvement of SunSmart schools and kindergartens. The program encourages behaviour modification via education and encouraging protective clothing and sunscreen use. Characteristics of the initiative Health promotion focuses on well-being and the factors that contribute to this [10]. This employssocial, cultural and political. Education is one aspect of health promotion [10]. The World Health Organisation defines health education as the ‘combination of learning experiences designed to help individuals and communities improve their health by increasing their knowledge or influencing their attitudes’[10]. The Sunsmart programreflects the concept of health promotion and aims to improve health education by using a combination of behavioural, community-based, policy-based and environmentalbased methods. For example, the program could be considered community-based because it is run within a number of different community settings including schools, organisations, workplaces and sporting organisations. Communities organisations are encouraged to join via funding from the government and may receive grants for equipment [11]. The environmental-based characteristics of SunSmart are highlighted through the funding of shade sails via the SunSmart Grant Scheme [11]. Under this program funding is provided so that schools, kindergartens and community organisations can provided shaded areas for members of the community to shield themselves from the sun [11]. Audits of the schools are conducted to ensure that there is a sufficient amount of shading outdoors provided to students [12]. The SunSmart initative is also a policy-based initiative. Policies are Correspondence to: Eshini Perera, Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia, Tel: 396542426; E-mail: eshinip@gmail.com Received: November 10, 2014; Accepted: November 28, 2014; Published: December 02, 2014 Perera E (2014) Characteristics of the SunSmart program with reference to health education and health promotion concepts Glob Dermatol, 2014 doi: 10.15761/GOD.1000109 Volume 1(2): 24-26 used both at the level of school and kindergarten and at the level of the state Government. Schools and kindergartens that are enrolled in the SunSmart program use policies, including the ‘No hat no play’ rule where children are required to wear a hat which protects their face,neck and ears [13]. Participating organisation must produce a set of sunprotective policies to abide by and are regularly audited to ensure that the policies are being adhered to [12]. Policies are also used at the level of the state government, as discussed before, where SunSmart and the Cancer council were instrumental in pushing for the ban against solariums. Lastly, the initative is also behavioural–based, that is, behaviourmodification of children and members of the community are encouraged. The‘Slip, Slop, Slap, Seek! Slide!’ message, quite overtly, encourages children and the general public to seek protection from the sun to prevent skin cancer. SunSmart schools encourage children to seek shade and wear protective clothing, sunscreen and shades using the SunSmart policies for early childhood education. Policies within the SunSmart schools also include ‘role modelling’ whereby staff must wear protective sun hats, apparel, sunglasses and sunscreen when the UV levels are above 3 [12]. The idea behind this concept is that the SunSmart behaviours are reinforced to students via the actions of staff members. Strengths and weaknesses of the SunSmart program Effective health promotion consists of creating a supporting environment; strengthening community action; promoting equity and diversity; encouraging the development of personal skills; promoting positive health behaviours; and the development of healthy public policies. The SunSmart initiative aims to promote a supportive environment by ensuring the appropriate infrastructure is available to schools and organisations. Childcare centres are required to have adequate sun-protection policies to be accredited [14]. Schools and communities are empowered to take action through these resources and by participating in the SunSmart program. The initiative also encourages the development of personal skills by providing education and information to children, parents and the general public. The ‘Slip! Slop!Slap!’ message empowers the public to make their own decisions regarding skin cancer prevention and how to apply the sun-protective behaviours to their everyday life. In theory, SunSmart schools should have a higher rate of hatwearing and sun-protective behaviours. Evidence in the literature is contradictory: one study found that SunSmart schools have better sun-protection practices than non-SunSmart schools [15]. On the other hand, a recent study found that sun protective behaviours were not significantly improved in SunSmart schools [14,16]. The authors proposed that this may be due to the low numbers of adult rolemodels wearing hats [16]. This suggests that there still could be further improvement in creating a more encouraging environment. Moreover, the same author found that the regular policy reviews and policies for planning outdoor events were not adequately addressed [17]. In fact, only 58% of early childhood services had policies for informing parents [14]. Whilst the program encourages young children to modify their behaviours it is not necessarily equitable. That is, not all children have access to the SunSmart message. In 2013, 90% of Victorian primary schools were registered with SunSmart compared to 47% of schools in Greater Western Sydney [12,18]. Overall, SunSmart schools had more comprehensive sun-protective policies compared to schools not enrolled in the program [19]. Furthermore, there was a difference in policies among remote, regional and [19] metropolitan schools with more sun protection practices in remote schools. Some schools only apply these policies to primary school-aged students while secondary school-aged students missed out [19]. Promotion is heavily focused on children and does not focus on high schools or the workplace to the same extent. In fact, 75% of secondary school aged students in Canberra reported having more than 1 sunburn in the last summer [20]. Enhancing the SunSmart program Whilst the SunSmart program is a highly effective campaign, a study published in 2013 found that sun-protective behaviours rapidly improved from 1987 to 1995 and then again in 1997-2007 and had some decline in more recent years, therefore further strategies could be used to enhance the public health impact [8]. Currently the program focuses on early-learning-aged and school-aged children. Incentives to improve hat-wearing rates and to improve sun-protection policies could be given to SunSmart schools. Incentives could be given to schools that include both primary and secondary school students. There is comparatively a small focus on adolescents and even less on adults and the elderly. A 


The SunSmart initiative
The SunSmart prevention campaign, launched by the Anti-Cancer Council of Victoria, is a sun protection program designed to prevent skin cancers, including cutaneous melanomas [1]. The campaign first began in the early 1980s as the 'Slip! Slop! Slap!' program [2]. This was a very limited campaign which used a cartoon seagull named Sidto promote awareness of skin cancer and the dangers of ultraviolet light from the sun [3]. Sid advocated for sun protection by encouraging the public to slip on a shirt, slop on sunscreen and slap on a hat. The program was so successful that it continued to run, and in the 1990s was operated under the banner of SunSmart. It was estimated in 2009, that the SunSmart program will save 120,000 disability-adjusted lifeyears in Victoria [4].
Today, the SunSmart campaign uses a modified message "Slip! Slop! Slap! Seek! Slide!" which also promotes individuals to seek shade and slide on sunglasses [5]. The program utilises a number of methods to reduce the incidence of skin cancers and its associated morbidity. The campaign employs structural and environmental changes, legislative changes as well as mass media education to promote its message. SunSmart is run within a number of settings including schools, kindergartens, work place and sporting and outdoor events.
The Sunsmart campaign incorporates features of both primordial and primary prevention. Primordial prevention focuses on the underlying social factors that contribute to the development of a disease, e.g. using legislations and policies to prevent disease [6]. The SunSmart campaign incorporates aspects of primordial prevention by campaigning for the legislation to ban indoor-tanning solaria. Tanning using a solarium increases the risk of developing a melanoma by 22% in all users, and in 98% of user under the age of 35 [7]. The death of a young girl, Clare Oliver, from metastatic melanoma, ignited intense media coverage of the dangers of solaria [7]. After decades of campaigning the Victorian state government announced that it would be banning solariums by December 2014, a move which the remaining states followed shortly thereafter [8]. These statutory changes were pivotal in changing the social and cultural views on solaria.
Primary prevention focuses on reducing the risk factors which cause the disease [9]. The SunSmart intervention also incorporates features of primary prevention by disseminating education on skin cancer via mass media campaigns and involvement of SunSmart schools and kindergartens. The program encourages behaviour modification via education and encouraging protective clothing and sunscreen use.

Characteristics of the initiative
Health promotion focuses on well-being and the factors that contribute to this [10]. This employssocial, cultural and political. Education is one aspect of health promotion [10]. The World Health Organisation defines health education as the 'combination of learning experiences designed to help individuals and communities improve their health by increasing their knowledge or influencing their attitudes' [10]. The Sunsmart programreflects the concept of health promotion and aims to improve health education by using a combination of behavioural, community-based, policy-based and environmentalbased methods. For example, the program could be considered community-based because it is run within a number of different community settings including schools, organisations, workplaces and sporting organisations. Communities organisations are encouraged to join via funding from the government and may receive grants for equipment [11].
The environmental-based characteristics of SunSmart are highlighted through the funding of shade sails via the SunSmart Grant Scheme [11]. Under this program funding is provided so that schools, kindergartens and community organisations can provided shaded areas for members of the community to shield themselves from the sun [11]. Audits of the schools are conducted to ensure that there is a sufficient amount of shading outdoors provided to students [12]. The SunSmart initative is also a policy-based initiative. Policies are Correspondence to: Eshini Perera, Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia, Tel: 396542426; E-mail: eshinip@gmail.com used both at the level of school and kindergarten and at the level of the state Government. Schools and kindergartens that are enrolled in the SunSmart program use policies, including the 'No hat no play' rule where children are required to wear a hat which protects their face,neck and ears [13]. Participating organisation must produce a set of sunprotective policies to abide by and are regularly audited to ensure that the policies are being adhered to [12]. Policies are also used at the level of the state government, as discussed before, where SunSmart and the Cancer council were instrumental in pushing for the ban against solariums.
Lastly, the initative is also behavioural-based, that is, behaviourmodification of children and members of the community are encouraged. The'Slip, Slop, Slap, Seek! Slide!' message, quite overtly, encourages children and the general public to seek protection from the sun to prevent skin cancer. SunSmart schools encourage children to seek shade and wear protective clothing, sunscreen and shades using the SunSmart policies for early childhood education. Policies within the SunSmart schools also include 'role modelling' whereby staff must wear protective sun hats, apparel, sunglasses and sunscreen when the UV levels are above 3 [12]. The idea behind this concept is that the SunSmart behaviours are reinforced to students via the actions of staff members.

Strengths and weaknesses of the SunSmart program
Effective health promotion consists of creating a supporting environment; strengthening community action; promoting equity and diversity; encouraging the development of personal skills; promoting positive health behaviours; and the development of healthy public policies. The SunSmart initiative aims to promote a supportive environment by ensuring the appropriate infrastructure is available to schools and organisations. Childcare centres are required to have adequate sun-protection policies to be accredited [14]. Schools and communities are empowered to take action through these resources and by participating in the SunSmart program. The initiative also encourages the development of personal skills by providing education and information to children, parents and the general public. The 'Slip! Slop!Slap!' message empowers the public to make their own decisions regarding skin cancer prevention and how to apply the sun-protective behaviours to their everyday life.
In theory, SunSmart schools should have a higher rate of hatwearing and sun-protective behaviours. Evidence in the literature is contradictory: one study found that SunSmart schools have better sun-protection practices than non-SunSmart schools [15]. On the other hand, a recent study found that sun protective behaviours were not significantly improved in SunSmart schools [14,16]. The authors proposed that this may be due to the low numbers of adult rolemodels wearing hats [16]. This suggests that there still could be further improvement in creating a more encouraging environment. Moreover, the same author found that the regular policy reviews and policies for planning outdoor events were not adequately addressed [17]. In fact, only 58% of early childhood services had policies for informing parents [14].
Whilst the program encourages young children to modify their behaviours it is not necessarily equitable. That is, not all children have access to the SunSmart message. In 2013, 90% of Victorian primary schools were registered with SunSmart compared to 47% of schools in Greater Western Sydney [12,18]. Overall, SunSmart schools had more comprehensive sun-protective policies compared to schools not enrolled in the program [19]. Furthermore, there was a difference in policies among remote, regional and [19] metropolitan schools with more sun protection practices in remote schools. Some schools only apply these policies to primary school-aged students while secondary school-aged students missed out [19]. Promotion is heavily focused on children and does not focus on high schools or the workplace to the same extent. In fact, 75% of secondary school aged students in Canberra reported having more than 1 sunburn in the last summer [20].

Enhancing the SunSmart program
Whilst the SunSmart program is a highly effective campaign, a study published in 2013 found that sun-protective behaviours rapidly improved from 1987 to 1995 and then again in 1997-2007 and had some decline in more recent years, therefore further strategies could be used to enhance the public health impact [8]. Currently the program focuses on early-learning-aged and school-aged children. Incentives to improve hat-wearing rates and to improve sun-protection policies could be given to SunSmart schools. Incentives could be given to schools that include both primary and secondary school students.
There is comparatively a small focus on adolescents and even less on adults and the elderly. A recent SunSmart television advertisement called "The Dark Side of Tanning" was launched aimed at teens [21]. The campaign discouraged tanning and educated adolescents on the dangers of tanning. Campaigns via facebook have also been advertised. Maximising social media and popular teen celebrities may expose teens to the SunSmart message and potentially change the culture of sunprotection.
Another target group is males. One strategy is to make the use of hats and sunscreens in the outdoor work place mandatory as part of occupational health and safety. Future strategies to target this group include potentially using sporting celebrities in advertisement campaigns. This may entice young males to modify their sun-protective behaviours. Also, incorporating sun-protective behaviours by using the sporting culture, which is popular in Australia, may attract young males and other members of the community. For example, provision of sunscreen and adequate shading or umbrellas at sporting events (including the Australian Open, cricket and football events) may assist in influencing a sun-protective culture.
Ultimately future strategies should aim to enhance the participation of the community and empower the public, regardless of the type of medium used to deliver the message of sun protection.