Knowledge is not enough: Skin cancer prevention requires policy

Excessive childhood exposure to ultraviolet radiation (UVR) is strongly linked to lifetime skin cancer burden. Solar UVR has been declared a class 1 carcinogen by the International Agency for Research on Cancer.1 So why do sun protection knowledge, attitudes and behaviours in our schools remain inadequate? In this issue of JEADV, Vuichard-Bouvet et al. present the results of a cluster randomized controlled trial of skin cancer prevention initiatives within primary schools.2 The study takes place on the paradisical tropical island of Réunion, a location which combines major conditions for incubation of skin cancers: a beautiful natural environment and pleasant climate for outdoor activities, extremely high UVR (UV index up to 20) and a sizable population of European ancestry with corresponding fair phototype. In this well-designed trial, 1452 children from 100 classes in 20 schools of differing socioeconomic status were randomized to 4 additive interventions: (1) no intervention (2) UV protection education (3) as per (2) plus peer ambassador program or (4) as per (3) plus provision of free caps, sunglasses and sunscreen. At 1–3 months post intervention, there was a modest increase in sun protection knowledge scores in group 4 vs. group 1 (p < 0.0001). Knowledge scores did not improve in groups 2 or 3 (education without provision of UV protective equipment). Disappointingly, there was no change observed in behaviour as measured by objective assessment of hat wearing. The efficacy and cost-efficacy of skin cancer prevention is unequivocal3; however, this study demonstrates that knowledge-based sun protection interventions are not enough. Vuichard-Bouvet et al.'s additive interventions disentangle the role of education, peer influence and physical enablement of sun protection. In this study, physical provision of protective equipment was the only effective intervention, and underscores the importance of providing children with resources to enable a UVR-safe behaviour. It is time to move the rhetoric away from ‘knowledge’ and ‘personal responsibility’ to effective policy action. Children in this study had a median age of 9 years, well below the age of medical consent, and an age at which they are considered to lack the cognitive and developmental judgement to safely cross a road. School children have little or no control over their timetables or physical surrounds. Social media has intensified the role of peer pressure in shaping young people's attitudes and behaviour, as has the responsibility of government to redress harm with regulation.4 This study demonstrates that relying on implementation at the school or teacher level is inadequate, with 0%–8% of classes randomized to the education intervention completing all 10 modules. Health equity is an important consideration, as there are geographical and socioeconomic disparities in melanoma mortality.5 Students from ‘priority’ schools, indicating socioeconomic disadvantage, had lower knowledge scores both before and after the education interventions. These structural inequalities to health outcomes need to be addressed with practical legislation, support and infrastructure. A key challenge is nuanced policy, which considers biological differences in skin cancer risk, vitamin D requirements and UVR protection recommendations across the spectrum of skin types. Children with skin phototypes I-II in this study comfortingly demonstrated increased baseline knowledge of UVR risk. There is a need for culturally appropriate guidance on UVR exposure for differing ethnic groups. Sun safety is a structural and social issue, not just an educational one. The dangers of UVR exposure are widely understood, but knowledge has not transformed into action. There is a need for sustained policy intervention, not one-off awareness programs, which embed sun protection within our educational institutions. Public health should not be optional. It is time for ‘slip, slop, slap’ to be statutory. Open access publishing facilitated by University of New South Wales, as part of the Wiley - University of New South Wales agreement via the Council of Australasian University Librarians. LKM is supported by the Warwick L. Morison Professorship in Dermatology, UNSW Sydney. PG has participated in Advisory Boards for L'Oréal and received honoraria from Metaoptima PTY; none relevant for this article. LKM has nothing to declare. Not applicable. Not applicable. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.