Workshop Report
Canadian National Workshop on Measurement of Sun-related Behaviours

Chris Lovato, Jean Shoveller, Christina Mills and an Expert Panel

Introduction

Skin cancer has been described as an emerging epidemic in North America.^1-3 The National Cancer Institute of Canada estimates that 66,000 new cases of skin cancer will be diagnosed in 1999 in Canada.⁴ Epidemiologic evidence suggests that cumulative exposure to sunlight is necessary for the development of squamous cell carcinoma, whereas intense sun exposure and sunburns received during childhood are more important in the development of melanoma and basal cell carcinoma of the skin.^5-9

Sun exposure and protection are at least partly under the control of individuals. Therefore, it is important to pursue behavioural interventions as an essential component of a comprehensive set of skin cancer prevention strategies. In turn, monitoring sun-related behaviours is important in the development and evaluation of interventions as well as in surveillance of behavioural change across populations. One of the greatest challenges facing behavioural researchers in skin cancer prevention is the lack of comparability of measures across studies. The identification of a standard set of items would enhance the quality of research and program evaluation in Canada and contribute to similar efforts in other parts of the world.

The idea for the workshop described in this paper emerged from recommendations identified at the 1997 Workshop on Research, Policy and Program Planning on Sun Protective Behaviours.¹⁰ At the 1997 workshop, participants developed a set of recommendations for research initiatives related to sun protection efforts in Canada. One of the primary recommendations was to develop a standard set of definitions and core items to assess sun-related behaviours. In response, Chris Lovato, Jean Shoveller and Christina Mills agreed to co-chair the 1998 Canadian National Workshop on Measurement of Sun-Related Behaviours. The purpose of this workshop was to develop consensus on a standard set of measures for program evaluation and for monitoring of sun exposure and protective behaviours in Canada.

Before the workshop took place, a systematic review of the published literature was conducted to collect reports and instruments previously used to measure sun-related behaviours. The search of electronic databases (e.g. MEDLINE, CancerLit) included peer-reviewed and non-peer-reviewed publications and was limited to English-language articles published between 1990 and 1998. In addition, the reference lists of each of the publications retrieved were scanned. Members of the workshop planning committee also recommended published reports and unpublished instruments for inclusion. Finally, scientists working in the field were asked for copies of instruments that had not been published previously. As a result, a total of 112 publications and instruments were identified.

Five background papers were commissioned, which synthesized and critically assessed the literature and available instruments in the areas of sun exposure, sunburn, protective behaviours, artificial tanning and phenotype. Each background paper provided recommendations regarding standardized operational definitions and core items that could be used in routine behavioural surveillance efforts and program evaluation. Participants were provided with the background papers before the workshop.

Summary of Workshop Proceedings

The workshop was held on October 29-30, 1998, at the University of British Columbia. Invited participants (17 in total) included skin cancer researchers and representatives from Health Canada, Environment Canada, the Canadian Dermatology Association and the Canadian Association of Optometrists. A representative from the US Centers for Disease Control and Prevention was also invited to attend. Participants engaged in a series of small group discussions about the background papers and identified specific recommendations for operational definitions and core items. These recommendations focused on measurement issues related to sunburn, phenotype, sun exposure and protective behaviours. Participants also identified priorities for further research on measurement of sun-related behaviours. Two themes emerged over the two-day meeting: the unique characteristics of sun-related behaviours and the challenges associated with data collection and measurement.

Participants identified a number of factors that differentiate sun-related behaviours from other health behaviours (e.g. those related to nutrition, tobacco).

In discussing the background papers and the unique nature of sun-related behaviours, workshop participants also identified a number of points related to data collection and measurement.

The workshop resulted in a set of recommendations that will be useful to those conducting research and program evaluations in this area. Overall, workshop participants identified measurement research as a high priority.

Recommendations

Core Items

Six core items were developed for inclusion in omnibus-style behaviour surveillance surveys and smaller scale evaluation efforts. Table 1 lists the recommended core items in order of priority-sunburn, phenotype, sun exposure and sun protection-and summarizes the rationale for each item. These core items are recommended for inclusion in population-based surveys, including the Canadian National Population Health Survey. The items were developed for use in personal interviews, telephone interviews or self-administered survey formats. They are suitable for wider dissemination within Canada and internationally to other researchers in skin cancer prevention.

TABLE 1 Recommended core items for measuring sun-related behaviours
Item	Comment
SQ1: A sunburn is any reddening or discomfort of your skin that lasts longer than 12 hours after exposure to the sun or other UV [ultraviolet] sources, such as tanning beds or sunlamps. In the past year, has any part of your body been sunburned? Yes/No Universe: All respondents SQ2: Did any of your sunburns involve blistering? Yes/No Universe: Respondents who had a sunburn in previous year SQ3: Did any of your sunburns involve pain or discomfort that lasted for more than one day? Yes/No Universe: Respondents who had a sunburn in previous year	Sunburn These three items have been chosen as the most important items to be asked in an omnibus survey because they measure sunburn and also provide indirect measures of sun exposure and protective behaviours. If there is limited space, this series of items should be used. "Past year" was identified as the time frame for reporting because sunburns are not of high frequency or routine events. Use of this term also allows for ease of administering the item during any time of the year.
SQ4: Would you say the untanned skin colour of your inner upper arm is ... Light (white, fair, ruddy) Medium (olive, light brown, medium brown) Dark (dark brown, black) Universe: All respondents	Phenotype Phenotype is one of the primary risk factors associated with skin cancer. This item allows for more precise interpretation of the data collected using the above sunburn items.
SQ5: During this past June through August, on a typical weekend or day off from work, approximately how much time did you spend in the sun between 11 am and 4 pm? <30 minutes per day 30 minutes to 1 hour per day 1-2 hours per day 2+ hours per day Universe: All respondents	Sun exposure Sun exposure is a risk factor associated with skin cancer. In Canada, peak UVB exposure from the sun occurs during June through August between the hours of 11 am and 4 pm.
SQ6: Think of the most recent weekend or day off from work when you spent 30 or more minutes in the sun. Did you ... Seek shade: Yes/No Wear a hat that shaded your face, ears and neck: Yes/No Wear a shirt with long sleeves: Yes/No Wear long pants or a long skirt: Yes/No Use sunscreen with SPF 15+ on all exposed skin: Yes/No Universe: Respondents who spent 30+ minutes per day in the sun	Sun protection To maximize the accuracy of recall, this item should be used only if the survey is administered between the beginning of June and the end of September. The Canadian Dermatology Association has identified these five actions to protect against skin damage during exposure to the sun for 30+ minutes. All five actions are endorsed in the consensus statement generated at the National Workshop on Public Education Messages for Reducing Health Risks from Ultraviolet Radiation.

Further Research

The recommended core items should be pilot tested to assess their validity and reliability. In general, validation studies of self-report items should be considered a priority-for example, studies to validate self-reported phenotype against objective measures of skin colour and self-reported sun exposure against the results of daylight exposure monitors. Scales and indices that provide a composite score representing exposure and protective behaviours should be developed and validated.

International Collaboration

To advance the quality of measurement of sun-related behaviours and expand knowledge in this area of ultraviolet radiation research, an international collaboration to develop consensus regarding operational definitions and core items should be undertaken. On the basis of the success of the 1998 Canadian National Workshop on Measurement of Sun-Related Behaviours, it is recommended that this approach be considered for an international meeting.

Discussion

As skin cancer continues to be a public health problem in North America, surveillance will be required to monitor the prevalence of sun-related behaviours at the population level. As communities continue to demand interventions to prevent skin cancer, there will be an increasing need to evaluate the efficacy of programs. The recommended core items here are based on the accumulated evidence currently available. There are limitations to these items, including the accuracy of self-reported data. Further, the items developed during the workshop focused on adolescent and adult populations. Since reduction of exposure to UVB during childhood is critical to reducing the risk of skin cancer, measures need to be developed for use with this age group (e.g. parental proxy reports). New strategies also need to be developed to collect data from children themselves. The core items focus on behaviour and do not attempt to assess attitudes or barriers; local program evaluations may need to include supplemental items to address these areas. Finally, the survey items have not been tested and will require further assessment.

The process used in this workshop was influenced by previous efforts to establish standardized measures for use in tobacco control research.¹¹ The background papers developed and disseminated to participants before the workshop facilitated a common understanding of the conceptual and methodologic issues. The workshop process could also be applied to other areas, such as measurement of nutrition and physical activity.

To advance the development of knowledge related to health behaviour change, more comparability across research studies is required in Canada as well as internationally. In organizing this workshop, we noted that although there is an established body of research in sun protection, it is extremely difficult to compare results across studies because of the wide variations in the way behaviours are measured. Common barriers to evaluating interventions are the availability of measures and standards of acceptability. The establishment and use of core items help to address both issues.

Progress is being made regarding implementation of the workshop recommendations. The core items presented in Table 1 are currently being considered for inclusion in the Canadian National Population Health Survey. The items have also been presented at the 1999 biennial meeting of the Canadian Society of Epidemiology and Biostatistics. A number of workshop participants are conducting research in the following areas: pilot testing the core items, validating self-reported exposure and skin colour, and constructing an index for sun exposure and protective behaviours. In addition, researchers are developing items for use in measuring parents' reports of their children's sun-related behaviours.

These recommended core items will be useful to researchers and program evaluators addressing sun-related behaviours. Researchers should continue to conduct measurement studies in order to improve the quality of surveillance and evaluation tools. Efforts are currently under way to promote international consensus regarding measurement.

Acknowledgements

The workshop was supported by funding from Health Canada and the Terry Fox Workshop Program, which is administered by the National Cancer Institute of Canada.

References

1. Gallagher RP, Hill GB, Bajdik CD, et al. Sunlight exposure, pigmentary factors, and risk of nonmelanocytic skin cancer. I. Basal cell carcinoma. Arch Dermatol 1995;131:157-63.

2. Gallagher RP, Hill GB, Bajdik CD, et al. Sunlight exposure, pigmentary factors, and risk of nonmelanocytic skin cancer. II. Squamous cell carcinoma. Arch Dermatol 1995;131:164-9.

3. Rivers JK. Melanoma. Lancet 1996;347:803-7.

4. National Cancer Institute of Canada. Canadian cancer statistics 1999. Toronto: NCIC, 1999.

5. Gallagher RP, MacLean DI, Yang P, Coldman AJ, Silver HK, Spineli JJ, Beagrie M. Suntan, sunburn, and pigmentation factors and the frequency of acquired melanocytic nevi in children. Similarities to melanoma: the Vancouver mole study. Arch Dermatolol 1990;126:770-6.

6. Rosso S, Zanetti R, Martinez C, et al. The multicentre south European study 'Helios': different sun exposure patterns in the etiology of basal cell and squamous cell carcinoma of the skin. Br J Cancer 1996;73:1447-54.

7. Weinstock MA, Colditz GA, Willett WC. Nonfamilial cutaneous melanoma incidence in women associated with sun exposure before 20 years of age. Pediatrics 1989;84:199-204.

8. Gibbons L, Anderson L, eds. Proceedings of the Symposium on Ultraviolet Radiation-related Diseases. Chronic Dis Can 1992;13(5 Suppl): S1-42.

9. Mills CJ, Trouton KJ, Gibbons L. Symposium report: Second Symposium on Ultraviolet Radiation-related Diseases. Chronic Dis Can 1997;18(1):27-38.

10. Ashbury FD, Rootman I. Workshop report: research, policy and program planning on sun protective behaviours. Cancer Prev Control 1998;2(3):129-32.

11. Mills C, Stephens T, Wilkins K. Workshop report: summary report of the Workshop on Data for Monitoring Tobacco Use. Chronic Dis Can 1994;15(3):105-10.

Workshop participants

Richard Gallagher,* Jason Rivers* (BC Cancer Agency); Loraine Marrett (Cancer Care Ontario and University of Toronto); Angus Fergusson (Environment Canada); Christina Mills,* Pascale Reinhardt-Poulin, Yvon Deslauriers (Health Canada); Fredrick Ashbury-facilitator (PICEPS Consultant Inc.); Louise DeGuire (Montreal Department of Public Health); Sharon Campbell* (National Cancer Institute of Canada); Cynthia Jorgensen (US Centers for Disease Control and Prevention); Chris Lovato,* Jean Shoveller,* Larry Peters (University of British Columbia); Louise Potvin (University of Montreal); Irving Rootman (University of Toronto); Anthony Cullen (University of Waterloo)

* Member of workshop planning committee

Chris Lovato and Jean Shoveller, Centre for Community Child Health Research, Department of Health Care and Epidemiology, University of British Columbia

Christina Mills, Cancer Bureau, Laboratory Centre for Disease Control, Health Canada, Ottawa, Ontario

Expert Panel: List of workshop participants at end of article

Correspondence: Dr Chris Lovato, Associate Professor, Centre for Community Child Health Research, L408 - 4480 Oak Street, Vancouver, British Columbia V6H 3V4; Fax: (604) 875-3569; E-mail: lovato@interchange.ubc.ca

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