Nursing intervention to support behavioural change (prevention) in relation to sun exposure

Despite the significance of skin cancer as a growing health issue, evidence indicates limited knowledge and unsafe sun practices in the UK (Office of National Statistics, 1999). Further research is required to promote and evaluate behavioural change to prevent cancer and promote early detection (National Cancer Research Institute, 2005). The Cancer Research UK Sunsmart campaign aims to achieve this by ‘action … to inform and empower patients so that they can play an active role in decisions’, but there is limited discussion about delivery models, other than UV awareness campaigns (Department of Health, 2007). Review evidence of primary care prevention proposes caution when drawing from US and Australian strategies (Melia et al., 2000). The Royal College of Physicians’ (2007) guidelines on the prevention of skin melanoma highlight the need for sun avoidance and effective sunscreen and clothing use.

The International Cancer Research Portfolio (International Cancer Research Funding Organisations, 2008) highlights US research using an educational preventive intervention with young people. Although sun exposure in children is an important preventable factor since risk develops in childhood (Armstrong and Kricker, 2001) through genetic mutation and learnt risk behaviour, educational intervention with this group remains problematic since adolescents continue to report intentional sun exposure to get a tan (e.g. Melia et al., 2000; Cokkinides et al., 2002). The key risk factors for skin cancer are well established (Gandini et al., 2005; South West Public Health Observatory, 2008); this includes young adults’ frequent use of sun beds (Armstrong and Kricker, 2001). A review paper argues prevention is also valuable later in life, especially in people who have heavy exposure to solar radiation in childhood (Armstrong and Kricker, 2001). Also, achieving attitude and UV protective behavioural change in adults, many of whom will be parents, may result in good practice being passed to children (e.g. parental UV risk behaviour is a predictor of that by young people; Cokkinides et al., 2002). However, adults have received little focused attention in preventive studies.

Using evidence of theory related to effective behaviour change is likely to maximise the effectiveness and efficiency of lifestyle interventions (Berwick et al., 2000; National Institute for Health and Clinical Excellence, 2007). Relevant theories include Bandura’s Construct of Selfefficacy (Bandura, 1977, 1996) and Theory of Planned Behaviour (Ajzen, 1991, 2001). Selfefficacy is derived from Bandura’s (1977, 1996) social learning theory, highlighting a person’s belief and their capacity to undertake a health behaviour, such as to prevent skin cancer and engage in effective self-examination. A body of research highlights self-efficacy as an important predictor of engagement in healthy behaviours (Havas et al., 1998; Rosal et al., 1998; Clark and Dodge, 1999). The theory of planned behaviour is the most widely applied model of beliefs, attitudes and intentions that precede action (Ajzen 2001; Connor and Sparks, 2005). Both theories are likely to bolster intentions and sustain action.

Nurses are a substantial resource with a potential to deliver effective health education (Latter, 2000; Runciman et al., 2006). Evidence suggests primary care nurses could play an effective role in reducing the risks of cancer by promoting early detection and fast referral (Austoker, 1994; Oliveria et al., 2002). Studies of nurse-led interventions to increase awareness or change behaviour related to cancer have been successful (Koinberg et al., 2004; Sharp and Tischelman, 2005). However, most previous initiatives have been applied in cancer contexts other than skin cancer prevention, with many involving self-examination only (e.g. Oliveria et al., 2002) and limited theoretical underpinning. A nurse-led teaching intervention, using images, can enhance patient skin self-examination (Oliveria et al., 2004); however, this study did not incorporate the evaluation of education to reduce risk behaviours. A good example of a self-examination guide is that provided by the Wessex Cancer Trust (Hancock, 2007).

A key challenge for nurse-led prevention is to establish how best to raise awareness about skin cancer but in particular change behaviour. A systematic review by Saraiya et al. (2004) argues for research focused on health outcome, patient behaviour and examination of the ‘role of the non-physician provider to help identify if counselling skills to change behaviour might be better suited to providers with the time and skills, such as a nurse’ (p. 444); however, there is little evidence of such studies. Also, resource-efficient models of service delivery are required for primary care–based health promotion. One possibility for consideration is telephone consultation. Nurses have been found to increase patient self-efficacy in targeted telephone interventions with patients (Wong et al., 2005) with systematic review evidence finding them to be safe and acceptable to patients (Bunn et al., 2004).

Details of key health education messages related to skin cancer prevention are given in Skin cancer and its prevention.