WHO USES SUNSCREEN? A COMPARISON OF THE USE OF SUNSCREEN WITH THE USE OF PRESCRIBED PHARMACEUTICALS. Deborah Schofield

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1 WHO USES SUNSCREEN? A COMPARISON OF THE USE OF SUNSCREEN WITH THE USE OF PRESCRIBED PHARMACEUTICALS Deborah Schofield Discussion Paper No. 14 September 1998

2 National Centre for Social and Economic Modelling Faculty of Management University of Canberra The National Centre for Social and Economic Modelling was established on 1 January 1993, following a contract between the University of Canberra and the then federal Department of Health, Housing, Local Government and Community Services (now Health and Family Services). NATSEM aims to enhance social and economic policy debate and analysis by developing high quality models, applying them in relevant research and supplying consultancy services. NATSEM s key area of expertise lies in developing and using microdata and microsimulation models for a range of purposes, including analysing the distributional impact of social and economic policy. The NATSEM models are usually based on individual records of real (but unidentifiable) Australians. This base produces great flexibility, as results can be derived for small subgroups of the population or for all of Australia. NATSEM ensures that the results of its work are made widely available by publishing details of its products and research findings. Its technical and discussion papers are produced by NATSEM s research staff or visitors to the centre, are the product of collaborative efforts with other organisations and individuals, or arise from commissioned research (such as conferences). Discussion papers present preliminary research findings and are only lightly refereed. It must be emphasised that NATSEM does not have views on policy and that all opinions are the authors own. Director: Ann Harding

3 National Centre for Social and Economic Modelling Faculty of Management University of Canberra WHO USES SUNSCREEN? A COMPARISON OF THE USE OF SUNSCREEN WITH THE USE OF PRESCRIBED PHARMACEUTICALS Deborah Schofield Discussion Paper No. 14 September 1998

4 ISSN ISBN NATSEM, University of Canberra 1998 National Centre for Social and Economic Modelling GPO Box 563 Canberra ACT 2601 Australia Phone: Fax: Client services hotline@natsem.canberra.edu.au General natsem@natsem.canberra.edu.au Core funding for NATSEM is provided by the federal Department of Health and Family Services.

5 iii Abstract The Pharmaceutical Benefits Scheme provides substantial subsidies for prescribed pharmaceuticals for all Australians, but particularly for health benefit card holders. There are, however, a number of nonprescription items, including sunscreen, that are used to prevent illness, but are not subsidised by the scheme. This study analyses data from the national health survey to determine whether there is a difference in the pattern of use of prescribed medication and the use of sunscreen. It examines whether the lack of subsidy for sunscreen may be related to its low use within low income groups. In addition, it also examines which groups are least likely to protect themselves from the sun, and whether groups that might expect to have the greatest sun exposure are more or less likely to use sunscreen or some other form of sun protection.

6 iv Author note Deborah Schofield is a Research Fellow at the National Centre for Social and Economic Modelling, Faculty of Management, University of Canberra. Acknowledgments The author would like to thank Dr Amaya Gillespie from the Centre for Health Promotion and Cancer Prevention Research, University of Queensland, and Dr Ron Borland from the Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, for providing referees comments. Thanks also go to Dr David Pederson of the University of Canberra for his advice on the statistical methods used in this study. The author would also like to thank Richard Percival and Anthony King for providing helpful comments on an earlier draft. General caveat NATSEM research findings are generally based on estimated characteristics of the population. Such estimates are usually derived from the application of microsimulation modelling techniques to microdata based on sample surveys. These estimates may be different from the actual characteristics of the population because of sampling and non-sampling errors in the microdata and because of the assumptions underlying the modelling techniques. The microdata do not contain any information that enables identification of the individuals or families to which they refer.

7 v Contents Abstract Author note Acknowledgments General caveat...iii... iv... iv... iv 1. Introduction The Pharmaceutical Benefits Scheme Methodology Comparing of the use of subsidised pharmaceuticals with the use of sunscreen The use of pharmaceuticals and sunscreen by health card status The use of pharmaceuticals and sunscreen by income The use of pharmaceuticals and sunscreen by occupation The use of pharmaceuticals and sunscreen by sex The use of pharmaceuticals and sunscreen by state A multivariate analysis of the use of sunscreen Summary and conclusions...20 References...23

8 1 1. Introduction In the past decade the use of sunscreen has emerged as one of the key issues for health education and disease prevention in Australia. Sun protection issues are particularly important in Australia where the level of exposure to the sun is high. According to information from the most recent national health survey (ABS 1990), only 5 per cent of Australians reported that they were not exposed to the sun, most of these being elderly people. In the past decade there has been an increasing awareness of the risks of sun exposure, and there has been a growing body of research both in Australia and other nations linking sun exposure with solar keratosis, basal cell and squamous cell carcinoma and malignant melanoma (Cambell and Bridsell 1994; Hicks 1980, p. 31; Holman et al. 1984; Jansen 1995; Thompson, Jolley and Marks 1993). In Australia there has been a focus on education and prevention of skin cancer, particularly because skin cancer can be fatal and yet it is preventable. In 1993 it was the cause of 854 deaths and was responsible for about 1 per cent of the total number of deaths in Australia (ABS 1994). In an attempt to reduce the level of unprotected sun exposure in Australia, a number of organisations (including the Australian Cancer Society and the cancer councils in the Australian states) have undertaken sun protection campaigns the Slip, Slop, Slap campaign, Skin Cancer Awareness Week, and the Sunsmart Campaign (Hill, White, Marks and Borland 1993; Sinclair et al. 1994). The purpose of the study reported in this paper was to compare the use of subsidised pharmaceuticals with the use of sunscreen. Currently, the federal government subsidises the majority of prescribed pharmaceuticals, primarily through the Pharmaceutical Benefits Scheme (PBS), but does not subsidise sunscreen. Sunscreen is, however, subsidised for war veterans through the Repatriation Pharmaceutical Benefits Scheme (RPBS) (Department of Human Services and Health 1995b, s.1, p. 6). Comparing sunscreen use with the use of other medications may indicate whether people who use little sunscreen simply use little medication or whether sunscreen use is inhibited by price barriers. Further, if high users of medications are found to be low users of

9 2 Discussion Paper No. 14 sunscreen, particularly in low income groups whose prescribed medications are subsidised, it is may be possible to infer that there is a price barrier to sunscreen use. The study compares the use of pharmaceuticals with the use of sunscreen across a number of socioeconomic variables including income, occupation, health concession card status, age, sex and state of residence. The study also explores the pattern of use of sunscreen by groups most likely to have the highest sun exposure. Previous Australian studies have found that sun related skin damage and the use of sun protection varies across a number of demographic groups, including age, sex, sensitive skin type, outdoor occupation and location of residence (Hill et al. 1992; Holman et al. 1984). However, these were based on relatively small sample surveys ( respondents), with the population selected from a small number of locations. This study builds on this previous work by including analysis across additional socioeconomic groups (based on income and health card status) and by using a relatively large national data source, the national health survey. In chapter 2 the Pharmaceutical Benefits Scheme and its purpose and scope are introduced. Chapter 3 describes the methodology used in this study. In chapter 4 the distribution of the use of subsidised pharmaceuticals is compared with the incidence of the use of sunscreen. Chapter 5 provides a multivariate analysis of the use of sunscreen. Finally, the key findings of the paper are summarised and some conclusions are suggested.

10 Who Uses Sunscreen? 3 2. The Pharmaceutical Benefits Scheme The Pharmaceutical Benefits Scheme was established under the National Health Act 1953 to provide Australians with affordable pharmaceuticals (Department of Human Services and Health 1994a). It began by supplying drugs listed in the British Pharmacopoeia to pensioners and 139 life saving drugs to non-pensioners. By the early 1990s it had been extended to cover 1600 items representing about 537 drug substances. It claims to provide suitable medications for most medical conditions, where medication is an accepted form of treatment (Department of Human Services and Health 1994b). Prescriptions for war veterans are subsidised through the Repatriation Pharmaceutical Benefits Scheme, which, like the PBS, is administered by the Department of Health and Family Services (formerly Human Services and Health). In the PBS dealt with approximately 165 million prescriptions, with the federal government contributing about $1.5 billion by way of PBS subsidies (Department of Human Services and Health 1993, statistical supplement, p. 38). For the same period the RPBS dealt with about 5.9 million scripts at a cost of approximately $81.7 million (Repatriation Commission and Department of Veteran s Affairs 1993, p. 110). Most prescriptions not dealt with by the PBS are delivered in public hospitals. These are subsidised by state or territory governments (Department of Human Services and Health 1994b). The main purpose of the PBS is to provide all Australians (while not attending public hospitals) with access to effective and necessary prescribed medications at a reasonable cost, mainly by subsidising the cost of pharmaceuticals when they exceed a cost threshold. These thresholds are determined in accordance with the ability of the patient class to pay (patient class being defined by income and receipt of government pension or benefit). To be subsidised, the pharmaceuticals must satisfy three conditions. First, they must be listed on the Schedule of Pharmaceutical Benefits. Second, they must have been prescribed by a registered medical practitioner or, for certain drugs, a registered dental practitioner. And, third, they must be dispensed by an approved pharmacist (or, in limited cases, by a medical practitioner).

11 4 Discussion Paper No. 14 The PBS provides greatest assistance to people in financial need (by providing a higher subsidy for low income families who are issued a health card) and patients needing treatment for chronic conditions (by providing a safety net whereby families spending more than a threshold amount on prescribed pharmaceuticals get further prescription drugs at a reduced cost or free). The benefits of a pensioner health care card or a concessional health care card extend to all members of the immediate family. In 1995 there were two cost thresholds for pharmaceutical subsidies. Concessional health card holders were supplied pharmaceuticals with a copayment of $2.60, while general patients paid $16.20, with any remaining cost being subsidised by the PBS (Health Insurance Commission 1995). A safety net scheme protected families and, in particular, the chronically ill, by setting an upper limit to expenditure on pharmaceuticals each calendar year. For concessional card holders, the safety net was $135.20, with further pharmaceuticals provided free of charge. For general patients, the safety net was $407.60, with further pharmaceuticals provided at the concessional rate of $2.60 per prescription. Copayments for pharmaceuticals are not refundable from private health insurance or discountable by dispensers (Department of Human Services and Health 1994b). The PBS subsidises medication for treatment of existing illness such as antibiotics for bacterial infections and some medication for the prevention of illness such as cholesterol and triglyceride reducers (Department of Human Services and Health 1995b, s. 2, pp. 28 9). 3. Methodology This study is based primarily on an analysis of the national health survey, which was conducted by the Australian Bureau of Statistics (ABS 1990). The survey provides data on a number of important demographic, economic, health service and health status variables, including information on the use of pharmaceuticals and sunscreen. It is comparatively large for a sample survey, containing records for about persons who were interviewed.

12 Who Uses Sunscreen? 5 Information was obtained from residents of private dwellings (houses, flats, etc.) and non-private dwellings (hotels, motels, caravan parks, etc.). Households were selected so that persons in each state and territory had, in the main, an equal chance of selection in the survey. Non-Australian diplomatic personnel and members of non-australian defence forces, persons holidaying in Australia, students at boarding schools and institutionalised persons were excluded from the survey (ABS 1993, p. 125). The survey data are available as a unit record tape that is, it provides a single record of information about each respondent to the survey. (Strict privacy requirements mean that it is not possible to identify any particular individual participating in the survey.) Each record has a weight attached, indicating how many similar Australians (of the same age and sex and state of residence) the record represents. The data include a large number of variables describing the use of pharmaceuticals in the two weeks prior to the survey. Information is recorded on the use of sleeping medications, pain killers, tranquillisers, heart medications, laxatives, skin preparations, allergy treatments, cough medicines, vitamins, oral contraceptives and other medications. The multiple use of only three medications tranquillisers, pain killers and sleeping medications was recorded. Therefore, the multiple use of medications was not included in this study. For the purposes of this study, only pharmaceuticals that were indicated as prescribed (and, therefore, mostly eligible for subsidy through the PBS) were included. The survey data also include a variable that records the use of sunscreen by the respondent. The variable is based on the response to the question: When you are out in the hot sun do you usually use sunscreen on areas of your skin which are not protected? The response categories indicated whether sunscreen was used, whether the person was otherwise fully protected, whether the individual was not exposed to the sun, or whether the individual was exposed but unprotected. For the purposes of this study, the use of sunscreen and being otherwise fully protected and not exposed to the sun were combined to form the basic sunscreen analysis variable. This choice was made because only 2.9 per cent of respondents reported being fully protected and 5.2 per cent reported not being exposed (most of these being the elderly). It was also considered inappropriate to classify respondents who were fully protected or not

13 6 Discussion Paper No. 14 exposed with those who did not use sunscreen, as they had been protected from the sun. The use of sunscreen variable from the national health survey presented some difficulties in that respondents were not asked about their use of sunscreen over a specific period, nor whether sunscreen was regularly or irregularly used. In addition, it provides little information on alternative or complementary sun protection such as wearing hats, sunglasses and protective clothing and the use of shade. However, the sunscreen variable was considered to provide enough information to allow a comparison to be made of the reported usual use of sunscreen across a broad subpopulation. Another difficulty was presented by the lack of information from the survey on the hours of exposure to the sun. As a result, sun exposure had to be inferred from other information from the survey, such as location or occupation (which might suggest high sun exposure) and age (the elderly were more likely to report not being exposed to the sun than young people were). 4. Comparing of the use of subsidised pharmaceuticals with the use of sunscreen The following analysis compares the use of sunscreen to the use of subsidised pharmaceuticals, to explore whether the cost of sunscreen is a barrier to sun protection, particularly for low income groups. The analysis also considers the variation in the use of sunscreen by particular socioeconomic and demographic subpopulations. These were chosen using a univariate regression model which determined those characteristics that were significant predictors of sun protection. 4.1 The use of pharmaceuticals and sunscreen by health card status In this study individuals were identified as having a health concession card if they were covered by a Social Security health concession card and/or a Veteran s Affairs health concession card. As they apply in

14 Who Uses Sunscreen? 7 practice, a health concession card reported by one member of the family in the survey was considered to apply to all family members (that is, parents and dependent children). The analysis indicated that individuals covered by a health concession card used more prescribed pharmaceuticals but were less likely to be protected from the sun than general patients (see figure 1). Individuals with a health card, whose prescription medications are heavily subsidised, used almost twice the number of prescribed medicines per fortnight that general patients used (2.03 compared with 1.14 scripts per fortnight), and yet they were about 40 per cent more likely to have been unprotected from the sun (42 per cent compared with 30 per cent respectively). While the majority of young children whether covered or not by a health card were protected from the sun, children aged 0 4 years covered by a health card were about 65 per cent more likely to have been unprotected from the sun than were those not covered by a health card (16 per cent compared with 10 per cent respectively). Adolescents aged years with a health card were about 33 per cent more likely to have been unprotected from the sun than were those without a health card (40 per cent compared with 30 per cent respectively). Across the working age population, people with a health card remained about 25 per cent more Figure 1 The use of pharmaceuticals and sunscreen by health card, Australia, Protected from the sun (%) Prescriptions per fortnight Protected from the sun (%) Yes Health care card No 0.0 Data source: ABS (1990).

15 8 Discussion Paper No. 14 likely to have been unprotected from the sun than were those without a health card. However, for the elderly, there was little difference in the incidence of sun protection between the two groups, which tends to be uniformly low among the older population. 4.2 The use of pharmaceuticals and sunscreen by income The finances available to individuals to purchase sunscreen (and which determines their eligibly for a health concession card) are generally determined by family rather than individual income. Therefore, family rather than individual income was used in the analysis by income, with family income being defined as the sum of the income of both adults for couples with and without children. The national health survey incomes are in $5000 ranges. Personal income was taken as the mid-point of the income range. Children s incomes were not included. The survey definition of income is annual gross income. Gross income includes regular income from any source, including wages and earnings, investments, compensation payments and cash payments such as social security payments. The use of pharmaceuticals was the highest by those in the lowest income ranges (most of whom would have had a health concession card), but varied relatively little across the middle and top income groups. In contrast, the use of sunscreen increased steadily with income (see figure 2). Only 53 per cent of persons in the lowest income range were protected from the sun, compared with 84 per cent in the top family income range. These results suggest that low income might present a barrier to sun protection, while prescribed pharmaceuticals appear to be more accessible to low income earners. The explanation that the cost of sunscreen may present a barrier to the use of sunscreen is supported by the findings from research undertaken as part of the Sunsmart campaign. Murphy (1995, p. 73) reported that some of the young people reported that the prices of sunscreens were somewhat prohibitive to their liberal use. There is additional support for the notion that unsubsidised pharmaceuticals such as sunscreen may be inaccessible to low income earners from a study commissioned by the Department of Human Services and Health (1995a), which reported that the copayment of $2.50 (for concessional card holders) for subsidised

16 Who Uses Sunscreen? 9 Figure 2 The use of pharmaceuticals and sunscreen by family income, Australia, Protected from the sun (%) Prescriptions per fortnight Annual family income ($'000) 0.0 Data source: ABS (1990). pharmaceuticals was not a deterrent to having prescriptions filled, but cost was a deterrent to purchasing private (non-subsidised) pharmaceuticals. This explanation is also indirectly supported by other authors (for example, McClelland 1991, p. 20, and Whitehead 1992, p. 27), who found that the cost of services can be a deterrent to their use by lower socioeconomic groups. Apart from the possible income barrier to sun protection, there is another reason that may help to explain the lower use of sunscreen by people on low incomes. This is the lower average health status of individuals from low income families. Individuals from families on the lowest incomes reported an average health status of fair, while individuals from families on the highest incomes reported an average health status of good (see figure 3). There is evidence to suggest that families on low incomes focus their time and expenditure on the treatment of existing illness rather than preventing ill health in the future. Mathers (1994) found that working age adults from low income families were significantly more likely than those from high income families to suffer from mental disorders, ulcers, bronchitis and emphysema, insomnia, arthritis and asthma. Most importantly, he found that while people in lower socioeconomic groups use more health services such as medical and hospital services, they use fewer preventative services and early intervention and screening

17 10 Discussion Paper No. 14 Figure 3 Health status by income, Australia, Annual family income ($'000) Note: Health status: 1 = poor; 2 = fair; 3 = good; 4 = excellent. Source: ABS (1990). services. For example, Mathers found on the basis of the national health survey that low income women were significantly less likely to have had a mammogram or Pap smear in the last three years than high income women. 4.3 The use of pharmaceuticals and sunscreen by occupation The definition of occupation for this study was generally based on occupation as used in the national health survey. However, one of the occupation categories combined a number of groups (not applicable/ member of the armed forces) that would have been better identified separately. Accordingly, information on labour force status was used to disaggregate this group into the unemployed and those in the armed forces. Children, those not in the labour force and those not seeking to be in the labour force were excluded from the analysis by occupation. The analysis of the distribution of pharmaceuticals and sunscreen by occupation suggests that individuals in occupations where the use of pharmaceuticals is high also tended to be high users of sun protection (see figure 4). Clerks, sales people and professionals reported the highest average use of pharmaceuticals (1.55, 1.41 and 1.37 prescriptions per fortnight respectively) while also reporting the highest incidence of sunscreen use (77 per cent, 75 per cent and 72 per cent respectively). The

18 Who Uses Sunscreen? 11 high incidence of sunscreen use among clerks probably reflects the high proportion of women in this profession in 1991, 31.7 per cent of working women compared with 6.9 per cent of working men (ABS 1992, p. 174). The most significant finding was that tradespeople, labourers and plant and machine operators and drivers, who would experience much greater sun exposure than would professionals and clerks in the course of their work, had the lowest incidence of sun protection. However, professionals were almost twice as likely to be protected from the sun than were plant and machine operators and drivers (77 per cent compared with 42 per cent respectively). Interestingly, the unemployed were more likely to be protected from the sun than tradespeople, labourers and plant and machine operators and drivers. The low use of sun protection by people in outdoor occupations is of particular concern. Holman et al. (1984), for example, found that outdoor occupations had a positive association with actinic (sun related) skin damage. It may be that individuals in occupations where they are frequently exposed to the sun become accustomed to the risk and consequently treat it more lightly. This paradoxical response to familiarity with a particular hazard was noted by the Royal Society Study Group (1983, p. 123). The analysis by occupation was further broken down to determine Figure 4 The use of pharmaceuticals and sunscreen by occupation, Australia, Protected from the sun (%) Prescriptions per fortnigh Protected from the sun (%) Professional al Clerk Armed forces Sales Para- Manager professional al Occupation Tradesperson Unemploy Unemployed ed Labourer Plant operator & driver 0.0 Data source: ABS (1990).

19 12 Discussion Paper No. 14 Figure 5 The use of sunscreen by occupation and sex, Australia, Female Male Protected from the sun (%) Professional l Clerk Sales Manager Unemployed d Occupation Paraprofessional Tradesperson Labourer Plant operator & driver Data source: ABS (1990). whether the pattern of sunscreen use by occupation varied between the sexes. The results indicate that, within all professions, more women than men protect themselves from the sun (see figure 5). Furthermore, the finding of a lower incidence of sun protection among tradespeople, labourers and plant operators and drivers than among other professions was consistent across men and women. (Gender differences in the use of sunscreen are examined further in section 4.4.) The lower incidence of the use of sunscreen by the unemployed, tradespersons, labourers and plant operators and drivers may be associated with low income. This group reported lower income than the professionals, people in the armed forces, managers and paraprofessionals, who reported both higher incomes (see table 1) and higher incidences of sun protection. This finding is important for two reasons. First, each unit of sunscreen would represent a higher proportion of the incomes of the unemployed, tradespersons, labourers, and plant operators and drivers than it would of the incomes of other workers and, second, workers employed mainly outdoors would require a much greater amount of sunscreen than would people with indoor occupations, increasing the cost barrier considerably.

20 Who Uses Sunscreen? 13 Table 1 Average gross annual income by occupation, Australia, Occupation Average gross annual income Unemployed Labourer Clerk Sales and personal service Trades person Plant and machine operator and driver Paraprofessional Manager and administrator Armed forces Professional Source: ABS (1990). $ 4.4 The use of pharmaceuticals and sunscreen by sex The use of pharmaceuticals and sunscreen by sex was undertaken for people of all ages. It was found that females used about 30 per cent more pharmaceuticals than men did and that almost 75 per cent of women were protected from the sun compared with about 60 per cent of men (see figure 6). This finding is consistent with research undertaken by Figure 6 The use of pharmaceuticals and sunscreen by sex, Australia, Protected from the sun (%) Prescriptions per fortnight Protected from the sun (%) Male Female 0.0 Data source: ABS (1990).

21 14 Discussion Paper No. 14 Holman et al. (1984) and Hill et al. (1992), who found that males had a significant predictive value for the presence of sun related skin damage and a negative relationship with the use of sunscreen. Holman et al. suggested that the lower prevalence of sunscreen use among males compared with females may have been because males regard the application of a cream or lotion to the skin as being unmanly (p. 421). Generally, the finding of considerable variation in the use of sunscreen by males and females was consistent across most ages (see figure 7). There was little difference in sun protection between girls and boys under the age of 10 years. However, by the age of years, boys were almost twice as likely to be unprotected from the sun as girls were (40 per cent compared with 22 per cent respectively). The finding that the use of sun protection by males is much lower in adolescence than in childhood is of particular concern as this lower use is shown to persist throughout adulthood. By the age of years, almost half of the men reported being unprotected when exposed to the sun compared with only about a quarter of the women (48 per cent compared with 26 per cent respectively). Both older men and women were less inclined to protect themselves from the sun than younger people were. However, men were still much more likely not to protect themselves from the sun than women were Figure 7 The use of sunscreen by age and sex, Australia, Females Males Age Data source: ABS (1990).

22 Who Uses Sunscreen? 15 (for years olds, 60 per cent of men were unprotected compared with 46 per cent of women). Interestingly, older men also reported less than half the incidence of not being exposed to the sun that women did (for years olds, 6 per cent of men were unexposed compared with 17 per cent of women). The lower incidence of the use of sunscreen by men is particularly alarming as a study undertaken by the Australian Bureau of Statistics (ABS 1994, p. 18) found that in Australia in 1993 about twice as many men as women died from a melanoma of the skin (575 men compared with 279 women). This result is not surprising as, in addition to reporting a lower incidence of sun protection, men more often spent their working lives in occupations with high sun exposure. For example, in 1991, the ratio of men to women was about 11 to 1 in mining, 9 to 1 in the trades, 6 to 1 in construction, and 2 to 1 in labouring and agriculture (ABS 1992, p. 175). 4.5 The use of pharmaceuticals and sunscreen by state The analysis suggests little apparent relationship between the use of pharmaceuticals and sunscreen when analysed by state of residence (see figure 8). It was noticeable, however, that the two states with the highest Figure 8 The use of pharmaceuticals and sunscreen by state, Australia, Protected from the sun (%) Prescriptions per fortnight Protected from the sun (%) Tas. SA WA Vic. ACT NSW Qld NT 0.0 Data source: ABS (1990).

23 16 Discussion Paper No. 14 and lowest levels of sun protection were also the two lowest users of pharmaceuticals. This low use of pharmaceuticals probably had more to do with factors such as access to pharmacies in rural communities and a lower average age in the Northern Territory (in 1994 about 3 per cent of the population were over 65 years in the Northern Territory compared with about 12.5 per cent in New South Wales (ABS 1995, p. 18) than with the impact of subsidies for low income earners, or sex and occupational differences. Analysis of the use of sunscreen by state did, however, reveal some apparently paradoxical findings that are cause for concern. Similar to the findings on the use of sunscreen by occupation, analysis by state indicates that Australians who are most exposed to the sun, and thus to the highest risk of skin cancer (Hicks 1980, p. 29), are also the least likely to protect themselves from sun exposure. This may be an example of the tendency for people to underestimate the risk of a hazard to which they are frequently exposed (Royal Society Study Group 1983, p. 123). Australians in the southern most state, Tasmania, reported the highest incidence of sun protection (71 per cent), while people in the two northern most states, Queensland and the Northern Territory, reported the lowest incidence (63 per cent and 56 per cent, respectively). 5. A multivariate analysis of the use of sunscreen The analysis of the use of sunscreen in chapter 4 identified groups who reported relatively low use of sunscreen on the basis of a univariate regression model. The multivariate regression model discussed in this chapter provides some indication of which variables have the most effect on the use of sunscreen when the effect of other variables in the model are taken into account. To identify the variables with the greatest effect on the use of sunscreen, a multivariate regression model was developed in a stepwise fashion. To calculate the value of R 2 and the contribution of each of the predictors to the variability in the use of sunscreen the procedure GLM in SAS was used.the cumulative contribution of each of the variables to R 2 is presented in table 2.

24 Who Uses Sunscreen? 17 Table 2 Predictors of the use of sunscreen Variables Cumulative contribution to R 2 Additional contribution to R 2 p value % % Age Occupation Sex Family income State Health card n Source: ABS (1990). Age was identified as the most important explanatory variable of the use of sunscreen. When added in a stepwise manner to the model, occupation, sex and family income were the three next most important explanatory variables. Finally, while state and health card were both significant at the 0.01 level, they had the least impact on the ability of the model to explain the variance in the use of sunscreen when the effects of other variables were taken into account. Although this study is limited mainly to an analysis of economic variables and the principle demographic variables (age, sex and state of residence), there is scope for further research on the impact of a number of additional demographic variables on the use of sunscreen. In particular, the effect of variables that might indicate access to care due to location of residence, ethnicity, education and family type would be worth considering. It was found in preliminary analysis that the addition of a variable identifying region of residence in more detail (47 regions), three variables related to ethnicity (country of birth, whether a language other than English was spoken at home and the year of arrival in Australia), level of education (high school through to post-graduate) and a description of family type (sole parent, couple with children, couple without children, and single) increased the predictive ability of the existing model from an R 2 value of to While the analysis of the contribution of each variable to R 2 provides information on the importance of each predictor in the model, the comparison of least squares means provides information on the effect of

25 18 Discussion Paper No. 14 each predictor. The least squares means were derived from a model that included all of the predictors listed in table 3, and so were adjusted means. For example, the estimate of 53.9 per cent of males using sunscreen is standardised to take into account the effect of the other five variables. The results from the multivariate analysis of the use of sunscreen by age and sex are very similar to those of the univariate analysis, with the use of sunscreen declining with age and with men less likely to use sunscreen than women are. However, the ranking of the states by the proportion of the population using sunscreen varied from the univariate results. The ACT moved from the fourth lowest position to the second lowest and Queensland and New South Wales moved from the third and second lowest positions to the fourth and third lowest respectively. Even so, the main conclusion remained relatively unchanged (after controlling for the effect of the other variables in the model). Residents of Tasmania and South Australia still reported the highest incidence of sunscreen use, while residents of Queensland and the Northern Territory remained some of the least likely to use sunscreen (at the third lowest and lowest position respectively). There are also some differences in the ranking of the use of sunscreen by occupation in the multivariate analysis. The unemployed move down in the ranking, swapping places with tradespeople. Members of the armed forces and paraprofessionals move up two places in the order, while clerks and salespersons moved down the order. This is probably the result of standardising for the varying proportions of males in some professions, which is particularly high for the armed forces. Again, however, the major findings remain unchanged outdoor workers continue to report the lowest incidence of sunscreen use even when the results are standardised to take into account the effect of other factors. The trend for the use of sunscreen to increase with income remained in the multivariate model, although the difference in the proportion of high income earners using sunscreen compared with the proportion of users among low income earners was not as great as in the univariate model. (The same pattern was observed for health concession card and non-card holders.)

26 Who Uses Sunscreen? 19 Table 3 The proportion of people who use sunscreen estimated within a multivariate model Means and standard deviations for economic and demographic variables Variables Mean Standard error Demographic Age (years) or more Sex Male Female State Tasmania South Australia Western Australia Victoria New South Wales Queensland Australian Capital Territory Northern Territory Economic Occupation Professional Armed services Paraprofessional Clerk Sales Manager Tradesperson Unemployed Labourer Plant operator and driver Family income ($ 000) or more Health card Yes No Note: Means and standard errors are based on a least squares estimation. Source: ABS (1990).

27 20 Discussion Paper No Summary and conclusions This study found that there is considerable variation in the use of sunscreen by different groups in the Australian community between men and women, between the states of residence and between occupations. Importantly, it was also found that there was an inverse relationship between the level of sun exposure and, by implication, the risk of sun cancer and the use of sunscreen. These findings suggest that targeted measures to improve sun protection awareness and behaviour must remain a priority health issue for Australia. In particular, it points to a continuing need for education about the use of sunscreen to target adolescent males, outdoor workers, and the residents of the northern states of Australia. In addition, there is a need for both education and government policy to ensure that sunscreen is accessible to low income families. The study confirmed that men have a lower incidence of sun protection than women have. This, combined with the finding that sun protection is often lowest in occupations that are male dominated and have high sun exposure, suggests that sun protection is a particular issue for men s health. While the lack of sun protection is a serious general health problem, it remains a particular problem for men in Australia because about twice as many men as women die each year as a result of skin cancer. These findings also suggest that sun exposure is an important occupational health and safety issue for workers in outdoor occupations. Strategies to address this might sensibly include further health education and safety programs directed at both workers and their employers. In addition, the taxation system could be used to encourage greater sun protection by recognising the cost of protection from the sun (in the form of hats and sunscreen) as a legitimate work expense. Currently the Australian Taxation Office allows workers in dangerous work environments to claim the cost of, for example, steel capped boots, protective clothing, gloves, safety helmets and ear and eye guards to provide protection from chemicals and physical injury (CCH Australia Limited 1995, pp ). However, the costs of protection from exposure to injury from nature in the form of hats, sunglasses and sunscreen cannot currently be claimed as deductible work expenses (CCH Australia Limited 1995, p. 580).

28 Who Uses Sunscreen? 21 The study also found that the people most likely to be exposed to the sun as a result of their geographic location are also the least likely to use sun protection. In particular, residents of the most northern states, the Northern Territory and Queensland, reported the lowest incidence of sun protection of all the states and territories. The apparent decrease in perceived risk among those most exposed to the sun through their location of residence or occupation presents particular challenges to health educators preparing sun safety campaigns. Finally, the study compared the use of sunscreen with the use of prescribed pharmaceuticals to explore whether there may be indications of cost barriers that are reducing the use of sunscreen, particularly among low income groups. The findings in this study show that people with the lowest incomes are the least likely to use sunscreen, its use steadily increasing as income increases. It was also found that the use of prescribed pharmaceuticals was higher for health concession card holders (low income families) than for general patients and that the use of sunscreen was considerably lower for health card holders than for general patients. While these results might suggest that the cost of sunscreen makes it less accessible to families on low incomes, further research is needed to specifically determine whether cost is a primary barrier to sunscreen use or whether other factors are involved, such as a lack of awareness of the potential dangers of sun exposure or a preoccupation with existing illness rather than preventing future illness. If the cost of sunscreen is a significant barrier to the use of sunscreen among low income groups, it clearly conflicts with the frequently made assertion that affordable access to health care is an important part of an equitable social welfare system (see, for example, McClelland 1991 and Whitehead 1992). Access to sunscreen is particularly important for Australian residents as they face a higher risk of skin cancer than residents of any other country (Hicks 1980, p. 29; Hill et al. 1993). One such avenue of support for affordable health care is provided by the federal government through the PBS, where it undertakes to provide access to medications for most medical conditions where medication is an accepted form of treatment. In particular, it seeks to ensure affordable access to prescribed pharmaceuticals through pharmaceutical subsidies, with greater assistance given to people in the greatest financial need.

29 22 Discussion Paper No. 14 However, this is not the case with sunscreen, which is not currently subsidised through the PBS. If it were shown that the cost of sunscreen is a barrier to the use of sunscreen, then there would be a good case for subsidising it through the PBS. This would effectively reduce its unit cost to $2.60 for health concession card holders, who tend to be the most at risk of not using sunscreen. Such an approach would be consistent with the existing subsidy for sunscreen that is provided for war veterans though the RPBS. The inclusion of sunscreen in the PBS would also have the indirect benefit of reinforcing the status of sunscreen as a preventative medication rather than as a cosmetic. Such recognition is needed to help make its use more acceptable among groups such as male outdoor workers who are presently among its lowest users, despite experiencing some of the highest levels of sun exposure.

30 Who Uses Sunscreen? 23 References ABS (Australian Bureau of Statistics) 1990, 1989/90 National Health Survey, Unit Record Data, Canberra. 1992, Social Indicators, Canberra. 1993, State of Health in NSW, Canberra. 1994, Causes of Death: Australia, Canberra. 1995, Estimated Resident Population by Sex and Age States and Territories of Australia, Canberra. Cambell, H. and Bridsell, J. 1994, Knowledge, beliefs, and sun protection behaviours of Alberta adults, Preventative Medicine, vol. 23, no. 2, pp CCH Australia Limited 1995, 1995 Australian Master Tax Guide, North Ryde. Department of Human Services and Health 1993, Annual Report , AGPS, Canberra. 1994a, The Australian Pharmaceutical Benefits Scheme, Pharmaceutical Benefits Branch, Canberra, August. 1994b, The Australian Pharmaceutical Benefits Scheme, Pharmaceutical Benefits Branch, Canberra, November. 1995a, Prescription Drug Utilisation Following Change in the Level of Patient Copayment in Australia, Report to the Department of Human Services and Health from the Drug Utilisation Sub-Committee of the Pharmaceutical Benefits Advisory Committee, Canberra. 1995b, Schedule of Pharmaceutical Benefits, AGPS, Canberra. Health Insurance Commission 1995, Medicare: Your Questions Answered, Canberra. Hicks, R. 1980, Understanding Cancer, University of Queensland Press, St Lucia. Hill, D., White, V., Marks, R., Theobald, T., Borland, R. and Roy, C. 1992, Melanoma prevention: behavioural and nonbehavioural factors in sunburn among an Australian urban population, Preventative Medicine, vol. 21, no 5, pp

31 24 Discussion Paper No. 14 Hill, D., White, V., Marks, R. and Borland, R. 1993, Changes in sun-related attitudes and behaviours, and reduced sunburn prevalence in a population at high risk of melanoma, European Journal of Cancer Prevention, vol. 2, pp Holman, C., Evans, P., Lumsden, G. and Armstrong, B. 1984, The determinants of actinic skin damage: problems of confounding among environmental and constitutional variables, American Journal of Epidemiology, vol. 120, no. 3, pp Jansen, C. 1995, Effect of sunlight on the skin: what have we learned?, Nordic Medicine, vol. 110, no. 3, pp Mathers, C. 1994, Health Differentials Among Adult Australians Aged Years, Health Monitoring Series no. 1, Australian Institute of Health and Welfare, AGPS, Canberra. McClelland, A. 1991, In Fair Health, Background Paper no. 3, National Health Strategy, Canberra. Murphy, M. 1995, A bit of colour, young adults, tanning and sun protection: a report of focus group discussion, in Anti-Cancer Council of Victoria, Sunsmart, Sunsmart Evaluation Studies no. 4, Melbourne. Repatriation Commission and Department of Veteran s Affairs 1993, Annual Report , AGPS, Canberra. Sinclair, C., Borland, R., Davidson, M. and Noy, S. 1994, From Slip! Slop! Slap! to Sunsmart: a profile of a health education campaign, Cancer Forum, vol. 18, pp Royal Society Study Group 1983, Risk Assessment, London. Thompson, S., Jolley, D. and Marks, R. 1993, Reduction of solar keratoses by regular sunscreen use, New England Journal of Medicine, vol. 329, no. 16, pp Whitehead, M. 1992, The health divide, in Townsend, P. and Davidson, N., Inequalities in Health, Penguin Group, London.

32 NATSEM publications Copies of NATSEM publications and information about NATSEM may be obtained from: Ms Kirrilie Nordsvan Publications Officer National Centre for Social and Economic Modelling University of Canberra GPO Box 563 Canberra City ACT 2601 Australia Ph: Fax: natsem@natsem.canberra.edu.au Periodic publications NATSEM News keeps the general community up to date with the developments and activities at NATSEM, including product and publication releases, staffing and major events such as conferences. This newsletter is produced twice a year. The Income Distribution Report (IDR), which is also produced twice a year, provides information and comment on the average incomes of Australian families, covering the incidence of taxation for different family types, the income support provided by the government and how different family groups are faring. The IDR, which is available on subscription, presents this information in a simple, easy-to-follow format. NATSEM s Annual Report gives the reader an historical perspective of the centre and its achievements for the year. DYNAMOD Technical Paper series No. Authors Title 1 Antcliff, S. An Introduction to DYNAMOD: A Dynamic Microsimulation Model, September 1993