III The Recommended Core Content for Sun Safety Messages in Canada
--Submitted by Maria Chu, Senior Policy Specialist, Population Health and Prevention, Prevention and Cancer Control, Cancer Care Ontario
From 2014 to 2015, representatives from 28 organizations from across Canada took part in a process to renew consensus on what Canadians should know and do to reduce their risk of skin cancer and eye diseases. The results of this process are a set of statements to be adapted for use in public education materials. A report on this work was recently published as a commentary in the Canadian Journal of Public Health (CJPH).  The following provides a summary of the commentary.
Exposure to the sun and other sources of ultraviolet radiation (UVR), such as tanning equipment, without sufficient protection are established causes of skin cancer and can increase the risk of eye diseases. [2,3] Past national surveys have suggested that an increasing number of Canadians spent more time in the sun without ensuring that they are protected against harmful UVR exposure.  The annual number of new cases of melanoma, the most deadly form of skin cancer, has also been increasing. 
Consensus on sun safety information for public education among organizations across Canada was last attempted and achieved in 1994.  The science on UVR protection has since evolved and updates by organizations have taken place inconsistently. A 2010 review by the Ontario Sun Safety Working Group (OSSWG) found a number of differences, including differences in the time of day for when protection is needed and the minimum sun protection factor (SPF) recommended for sunscreens. In some cases, a minimum SPF of 15 was recommended, while other organizations began recommending a minimum SPF of 30. Research on cancer prevention practices suggests that when people are presented with ambiguous information, the likelihood of adopting these prevention practices decreases.  Therefore, as a first step to addressing increased UVR exposure among Canadians, work to achieve consensus on recommended protection practices was undertaken.
Following the review of existing messages, the OSSWG worked with a scientific panel made up of experts across fields relevant to UVR protection. The panel advised on the current science and the preparation of a draft of new sun safety recommendation statements. The draft underwent external review by experts internationally and was focus tested for usability among public health professionals in Ontario.
Beginning in June 2014, member organizations with the OSSWG convened the national consensus process using the draft statements. The consensus process involved establishing a National Steering Committee and engaging a health communications expert to further develop and implement the consensus process. The process comprised identifying 28 organizations with a mandate to promote sun safety; inviting representatives from these organizations to attend a workshop held in Toronto in March 2015; conducting pre-workshop surveys to identify areas of disagreement on the draft statements; the workshop, and a post-workshop confirmation survey. Further details on the process are described in the (CJPH) commentary.
National dermatology, eye health, public health, family medicine and pediatric organizations; Environment Canada, the Public Health Agency of Canada, provincial cancer agencies and Canadian Cancer Society national and provincial divisions participated in the process. Many teleconferences with the Steering Committee, individual representatives, and a group of representatives took place for planning, introducing prospective representatives to the process and discussing specific topics in detail.
III The Recommended Core Content for Sun Safety Messages in Canada
The result of the consensus process is the new Recommended Core Content for Sun Safety Messages in Canada, which comprises four groups of statements:
- Key Facts. These statements highlight the potential harms of UVR rays and are core statements for describing why skin and eye protection is needed.
- Primary Recommended Protective Action Statements. These statements provide information on the specific actions that Canadians should take to reduce harmful UVR exposure. They make recommendations for situations where protection is required.
- Additional Recommended Protective Action Statements. These statements provide additional actions for individuals to consider when planning daily activities, prior to UVR exposure.
- Tips for Implementing Primary Protective Actions. These statements provide further details on how to implement personal protective actions, as outlined in the primary protective action statements. The tips are a secondary level of information to include in materials where space is available.
Organizations are encouraged to adopt, at a minimum, the Primary Recommended Protective Action Statements where practical. By doing so, sun protective actions will be communicated more consistently with the goal of improving knowledge and increasing the likelihood that the public will adopt these practices.
The Primary Recommended Protective Action Statements are as follows:
Enjoy the sun safely: Protect your skin, protect your eyes
Protect your skin
- When the UV Index is 3 or higher, protect your skin as much as possible. In general, the UV Index in Canada can be 3 or higher from 11 a.m. to 3 p.m. between April and September, even when it’s cloudy.
- Seek shade or bring your own (e.g., an umbrella).
- Wear clothing and a wide-brimmed hat that cover as much skin as possible, as appropriate to the activity and weather.
- Use sunscreen labelled "broad spectrum" and "water-resistant" with a sun protection factor (SPF) of at least 30, on skin not covered by clothing. Apply sunscreen generously and reapply when required.
- Don’t use UV tanning equipment or deliberately try to get a suntan, and avoid getting a sunburn.
Protect your eyes
- Wear sunglasses or prescription eyeglasses with UV-protective lenses.
- Wear a wide-brimmed hat for added eye protection.
The core content fulfills a standard step in planning for health communications campaigns by establishing agreement on what should be communicated, helping organizations with a role in promoting sun safety in Canada to form a common understanding of what is needed for effective sun protection. This information is not expected to improve protection among individuals on its own. Organizations are expected to determine how the information conveyed by the statements should be communicated, and then tailor their wording, the order in which the information appears and the amount of detail provided according to the needs of different audiences.
Developing tailored messages should be based on focus testing among target audiences and on the evidence for communications strategies to achieve behaviour change. In addition, some audiences may require information beyond the recommended core content. Integrating further evidence-based information for reducing UVR exposure as needed is encouraged. Similarly, reducing UVR exposure among the public will also require structural changes such as policies to increase shade. Consensus on personal UVR protection recommendations could support policy development.
The consensus process was well received and a high level of agreement on the resulting core content was achieved. The process benefited from interdisciplinary discussions and an interactive and iterative approach to developing the content.
Since the completion of the national consensus process, several participating organizations have updated, or have committed to updating, their information for public education on their websites and have used the results of the consensus process in developing new materials. In addition to the publication in the Canadian Journal of Public Health  and presentations at conferences and through webinars, the Canadian Cancer Society, the Canadian Dermatology Association and Cancer Care Ontario issued news releases disseminating the results of the consensus process and received coverage through a number of outlets across the country.
A webinar is scheduled for April 27, 2017 from 12:00 to 1:00 p.m. through Public Health Ontario. The webinar will provide an opportunity for discussion and to understand the evidence behind the consensus statements in greater detail.
The OSSWG has also developed a toolkit on the national consensus statements. The toolkit consists of presentations and factsheets for children and outdoor workers, sun safety in outdoor sports and recreation settings, on tanning and on sunscreen. The materials are co-brandable, allowing organizations to insert their logo alongside the OSSWG’s.
The full-text report (https://journal.cpha.ca/index.php/cjph/article/view/5556 ) providing more details summarized in this article has been published in the Canadian Journal of Public Health.
The Ontario Sun Safety Working Group’s public education toolkit may be found here https://www.dropbox.com/sh/1i2f7oe48jyxw6f/AACgwt0gHoKH4eh_IElFxocDa?dl=0.
For information on the April 27, 2017 webinar and to register please visit Public Health Ontario’s events page at https://www.publichealthontario.ca/en/LearningAndDevelopment/Events/Page....
Funding support for the consensus process was received from the Canadian Institutes of Health Research (FRN 137214), Cancer Care Ontario, Canadian Cancer Society (National and Ontario Divisions), Canadian Dermatology Association, and Saskatchewan Cancer Agency/Sun Smart Saskatchewan. Advice throughout the entire process was provided by the Ontario Sun Safety Working Group; Ontario public health sun safety leads focus tested an earlier version of the draft statements with their stakeholders; staff at Cancer Care Ontario, Prevention and Cancer Control and Canadian Cancer Society, Ontario Division provided extensive support; and the following individuals provided a review of an earlier version of the draft statements: Marianne Berwick, David Broadhurst, David Buller, B. Ralph Chou, Richard Gallagher, DeAnn Lazovich, Robyn Lucas and Craig Sinclair. Additional acknowledgements of consensus process participants, committee members, and scientific panel members may be found in the Supplementary Appendix to the Canadian Journal of Public Health commentary (see ARTICLE TOOLS section on the journal site https://journal.cpha.ca/index.php/cjph/article/view/5556).
- Marrett LD, Chu MB, Atkinson J, Nuttall R, Bromfield G, Hershfield L, et al. An update to the recommended core content for sun safety messages for public education in Canada: a consensus report. Can J Public Health. 2016 Dec 27;107(4-5):e473-e479.
- International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans. Volume 100D. A review of human carcinogens. Part D: Radiation. Lyon, FR: IARC Press; 2012.
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- Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2015. Special topic: predictions of the future burden of cancer in Canada. Toronto: Canadian Cancer Society; 2015.
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