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Two studies suggest that educational messages about changes to sun-protection behaviour are more effective when the damage is done. However, in this high-risk group few were able to sustain their sun-protection behaviour in the long term despite their experience. Maintenance of long-term behaviour change continues to be problematic in other lifestyle change behaviours such as smoking, alcohol consumption, healthy eating, weight control and in the recreational use of drugs.23 Health promoters need to consider designing long-term randomised studies with specific behaviour outcome measures for each element of the intervention. Research on the role of knowledge in behaviour change has shown that knowledge alone does not necessarily lead to behaviour change. The relationship is complex and too many studies rely on a hypothesised link between the two, particularly when knowledge is stated as an outcome measure, thus weakening any evidence accruing from the intervention.

No randomised studies reported on the effectiveness of sun-protection policies in schools and communities. Only two direct observation studies and one survey were found, even though public health policy is deemed the appropriate context for the promotion of individual behaviour change for sun protection (for example the development of shaded areas in communities, on beaches, in school playgrounds and in other outdoor areas). Schofield et al. reported on the dissemination of sun protection polices in schools and their impact. The schools were randomised but the evidence regarding use of protective clothes, hat wearing and shade was from direct observational studies.24

Horsley et al. carried out a survey for the UK Department of Health in 1295 primary schools, 59 middle schools and 216 secondary schools (a 10% sample of schools).25 In 1995 the Health Education Authority in partnership with the Department of Health and the British Association of Dermatologists introduced Sun Awareness Guidelines to schools. Seven items from the guidelines (education, uniform, shade, outdoor activities, sunscreens, staff awareness and parent and governor alliances) were chosen as outcome measures. The results showed that most schools had taken at least one of the seven actions (mean 2-67, SD 0-88). Of the schools that had addressed sun protection, the majority had done so after the release of the guidelines in 1995. The proportion of schools beginning to take action was greater in the second year of the study than in the first year. Teaching in the curriculum was the most frequent action and was information giving. Brimmed hats and long sleeves were rarely part of summer school wear. Most schools had less than 25% of their outside break in shade but action was being taken to increase this. Sports days were usually scheduled for the afternoon. Sunscreen was allowed in over 80% of schools but its application caused problems for teachers. Few staff manuals included sun awareness issues, few staff attended in-service training on the issue but

Does health policy lead to more effective community interventions to reduce the risk of skin cancer?

two-thirds of head teachers would support staff attending such training. The researchers concluded that more support, government guidelines, funding, materials and courses were required if sun awareness is to be improved.25

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