Promoting sun safety among zoo visitors

A Review of the Impact of Sun Safety Interventions in Children

INTRODUCTION

In the United States, melanoma and non-melanoma skin cancers comprise the largest proportion of new cancer diagnoses every year. The prevalence of skin cancer can be largely reduced if proper preventative behaviors are adopted at an early age.

OBJECTIVES

We assessed the impact of various informational, economic, and environmental interventions on sun-protective behaviors, knowledge, attitudes, and sun exposure in the pediatric population reported in previous studies.

METHODS

A systematic search for relevant articles was conducted using three databases. Studies were included if they met the following three criteria: study subjects less than 18 years old, clear, measurable interventions and outcomes, and publication in the English language.

RESULTS

A total of 66 studies were included, of which 48 resulted in positive behavioral changes (i.e. increases in sunscreen application, use of hats and sun-protective clothing, shade-seeking, and avoidance of outdoor activities during peak UV radiation), 28 resulted in increased knowledge, 2 resulted in changes in attitudes towards tanning, and 10 resulted in decreased sun exposure effects (i.e. new sunburns, number of new nevi, and change in pigmentation of the skin).

CONCLUSIONS

It is crucial that children be educated on the importance and benefits of sun protection. Although a variety of interventions showed promise in achieving this goal, the challenges associated with adopting change were evident. This review provides direction for future interventions aimed at improving sun safety in children and illustrates the potential impact that early intervention can have on the incidence of skin cancer in future generations.

Golfers' Interest in Multilevel Sun-Protection Strategies

Active adults accumulate more ultraviolet (UV) radiation exposure and are at greater risk of skin cancer than inactive adults. Golf is a popular sport that increases UV exposure because it is played outdoors in daylight. This study evaluated adult golfers’ interest in multilevel sun-protection strategies and characterized differences in interest as a function of golfer characteristics. Adult golfers (N = 347) completed a web survey to rate their interest in 20 sun-protection strategies. We estimated descriptive statistics and evaluated differences in interest as a function of demographics, perceived risk, sun-protective behavior, and golf exposure. Golfers reported the greatest interest in environmental supports for sun protection, but these ratings were driven by golfers who already perceived golf as a risk behavior and used sunscreen diligently. Vulnerable golfers—those with a golf-related sunburn in the past year or who spend more time golfing—expressed interest in a broader range of intervention components, including education, family support, and text messages. Multilevel skin cancer prevention interventions are needed for golfers. Intervention components of interest involved support and reminders, which suggests they are open to sun-safety behaviors but need help executing them.

Skin cancer interventions across the cancer control continuum: Review of technology, environment, and theory

The National Cancer Institute's Skin Cancer Intervention across the Cancer Control Continuum model was developed to summarize research and identify gaps concerning skin cancer interventions. We conducted a mapping review to characterize whether behavioral interventions addressing skin cancer prevention and control from 2000 to 2015 included (1) technology, (2) environmental manipulations (policy and/or built environment), and (3) a theoretical basis. We included 86 studies with a randomized controlled or quasi-experimental design that targeted behavioral intervention in skin cancer for children and/or adults; seven of these were dissemination or implementation studies. Of the interventions described in the remaining 79 articles, 57 promoted only prevention behaviors (e.g., ultraviolet radiation protection), five promoted only detection (e.g., skin examinations), 10 promoted both prevention and detection, and seven focused on survivorship. Of the 79 non-dissemination studies, two-thirds used some type of technology (n=52; 65.8%). Technology specific to skin cancer was infrequently used: UVR photography was used in 15.2% of studies (n=12), reflectance spectroscopy was used in 12.7% (n=10), and dermatoscopes (n=1) and dosimeters (n=2) were each used in less than 3%. Ten studies (12.7%) targeted the built environment. Fifty-two (65.8%) of the studies included theory-based interventions. The most common theories were Social Cognitive Theory (n=20; 25.3%), Health Belief Model (n=17; 21.5%), and the Theory of Planned Behavior/Reasoned Action (n=12; 15.2%). Results suggest that skin cancer specific technology and environmental manipulations are underutilized in skin cancer behavioral interventions. We discuss implications of these results for researchers developing skin cancer behavioral interventions.

Food availability and food access in rural agricultural communities: use of mixed methods

Background

Hispanics bear some of the highest burden of the obesity epidemic and the disparities gap is bigger among Hispanics in rural communities. This mixed methods study examined the objective and subjective assessment of food availability and food access in four rural, agricultural, and predominantly Hispanic communities.

Methods

In this convergent parallel mixed methods study, we used the Nutrition Environment Measures Survey (NEMS) of Food Stores and Restaurants to objectively assess 57 food stores and 69 restaurants in four rural agricultural communities in Washington State. To complement the objective assessment findings, we conducted semi-structured interviews with 32 community residents. The data were collected from 2013 to 2014. Frequencies and means were calculated for quantitative data and content analysis conducted for interview data.

Results

Participants (n = 32) had a mean age of 35.6 (SD 6.2) years, were mostly women, uninsured, low income, and had less than a high school education. Grocery and convenience stores had low NEMS composite scores indicating low overall availability of food items, low quality, and high food prices. Composite scores for sit-down restaurants, fast casual restaurants, and fast-food restaurants were similarly low in all four towns indicating limited availability of healthier options. Semi-structured interviews revealed participants perceived high availability and accessibility of quality fresh produce. Most participants reported eating out regularly several times a week, frequenting restaurant chains that serve buffets or fast foods, and allowing children to make decisions regarding their own food choices.

Conclusions

Community members’ perception of food availability and food access may be different from the objective assessment of food environment. This information can be used to inform community-wide interventions to address food environment in these rural communities.

Signage as a tool for behavioral change: Direct and indirect routes to understanding the meaning of a sign

Signs, prompts, and symbols are a common means to change behavior in our society. Understanding the psychological mechanisms by which signage influences behavior is a critical first step to achieve the desired outcome. In the current research, we propose a theoretical model of sign-to-behavior process. The model suggests that when one encounters a sign, it is encoded to construct an action representation (comprehension process), which is then acted on unless its enactment is inhibited (decision process). We test the implications of the model in two studies. In support of our hypothesis, for unfamiliar signs, clarity of purpose predicts perceived effectiveness of a sign; however, for familiar signs, clarity of purpose does not matter. Insights gained from the studies will help to design effective signs. Practical implications of the model are discussed, and future research directions are outlined.

Measuring Cues for Healthy Choices on Restaurant Menus: Development and Testing of a Measurement Instrument

Purpose.

To develop and test the Menu Checklist, an instrument to be used by community members to assess cues for healthy choices in restaurants.

Design.

Menus from 14 restaurants were coded independently by two trained community reviewers to test the interrater reliability of the instrument.

Setting.

A low-income, urban, African-American community in Los Angeles, California.

Subjects.

Restaurants were selected based on community perceptions of their potential to be included in a nutrition education and advocacy program to improve the availability of healthy foods.

Measures.

The Menu Checklist was adapted from previously tested measurement tools developed by the Prevention Research Center at Saint Louis University. Intraclass correlation coefficients (ICCs), κ statistics, and percent agreements were calculated to assess interrater reliability. Descriptive statistics were calculated to show the availability of cues for healthy foods.

Results.

The interrater reliability coefficients for the majority of items were high (.93–1.0). Labeling on restaurant menus was rare, as were low-fat choices. Fruits and vegetables were readily available: 31% of all entrees included one serving and 39% of all appetizers were primarily fruits and vegetables.

Conclusions.

The Menu Checklist is a reliable, low-cost means for community members to collect data on influences on food choices in restaurants.

Dissemination of go sun smart in outdoor recreation: effect of program exposure on sun protection of guests at high-altitude ski areas

Go Sun Smart is a theory-based health communication program designed to influence sun-protection behaviors of employees and guests at high-altitude ski areas to reduce skin cancer risk. The effects of Go Sun Smart, in a Phase IV dissemination randomized posttest-only trial, on sun-protection behaviors of ski area guests are reported. Program use was assessed by on-site observation and guest message exposure, and sun protection was measured in intercept surveys at ski areas. Dissemination strategy-enhanced versus basic-was not significantly related to sun safety practices. Additional analyses examined the relation between message exposure and guests' sun safety practices. Ski areas displaying at least 6 Go Sun Smart materials in guest-only areas and 9 Go Sun Smart materials throughout the area increased guests' message exposure. Higher message exposure within the high-use ski areas was associated with improved sun protection by guests but not within the low-use ski areas. The authors underscore the importance of program implementation and message exposure on the success of evidence-based health communication efforts applied industrywide.

Are interventions to promote sun-protective behaviors in recreational and tourist settings effective? A systematic review with meta-analysis and moderator analysis

BACKGROUND

Intermittent sun exposure and sunburn are risk factors for skin cancer that mostly occur in recreational/tourist settings. This review assesses the efficacy of skin cancer prevention interventions designed to promote sun-protective behaviors in recreational/tourist settings.

METHODS

Systematic review with meta-analyses of controlled trials with outcome measures of sun-protective behaviors and/or sunburn published until January 2011.

RESULTS

Twenty-three studies were included. We found no evidence for the efficacy of current interventions in reducing tanning or promoting protective clothing and seeking shade. Meta-analyses show a small heterogeneous effect for interventions on sun-protective behavior indices. Larger but heterogeneous effects were observed for self-reported sun exposure and sunburns. Modest methodological quality suggests risk of bias. Effective interventions were more likely to stimulate social norms supporting sun-protective behaviors and provide appearance-based information about photoaging illustrated with ultraviolet photographs.

CONCLUSION

There is weak and inconclusive evidence for the efficacy of interventions in promoting sun-protective behaviors.

Mailed intervention to promote sun protection of children: a randomized controlled trial

BACKGROUND

Sun exposure, especially during childhood, is the most important preventable risk factor for skin cancer, yet few effective interventions to reduce exposure exist.

PURPOSE

To test the effectiveness of a partially tailored mailed intervention based on the Precaution Adoption Process Model, delivered in the spring over 3 years to parents and children.

DESIGN

RCT, with data collection through telephone interviews of parents and skin exams of children at baseline (Summer 2004) and annually (Summer 2005-2007). The control group received no intervention.

SETTING/PARTICIPANTS

Families recruited in the Denver CO area, through private pediatric clinics, a large MCO, and community settings. Children born in 1998 were approximately 6 years of age at baseline; 867 children met inclusion criteria; analysis is reported for 677 white, non-Hispanic participants at highest risk for skin cancer.

MAIN OUTCOME MEASURES

Primary outcomes were parent-reported child sun protection behaviors. Secondary outcomes included parents' risk perception, perceived effectiveness of and barriers to prevention behaviors, stage of change, reported sunburns, and observed tanning and nevus development. The longitudinal mixed-model analysis was conducted between 2008 and 2011.

RESULTS

The intervention group reported more use of sunscreen, protective clothing, hats, shade-seeking, and midday sun avoidance; fewer sunburns; more awareness of the risk of skin cancer; higher perceived effectiveness of sun protection; higher stage of change; and lower perception of barriers to sun protection (all p<0.05). The intervention group had fewer nevi ≥2 mm in 1 year of the study, 2006 (p=0.03). No differences were found in tanning or nevi <2 mm.

CONCLUSIONS

The level of behavior change associated with this single-modality intervention is not likely sufficient to reduce skin cancer risk. However, the intervention shows promise for inclusion in longer-term, multicomponent interventions that have sufficient intensity to affect skin cancer incidence.

Please turn off the lights: the effectiveness of visual prompts

Two early studies showed that visual prompts can be effectively used to encourage people to turn off the lights in unoccupied classrooms, but they were methodologically limited. The current study used an ABAB-B design with an 11-week follow-up to investigate whether two different visual prompts (large and small signs) could be employed to increase "lights off" behaviour in 17 unoccupied washrooms. The odds were eight times higher that lights would be turned off in washrooms with signs than washrooms without, and large signs trended toward being more effective than small signs. Signs in washrooms with windows appeared to be the most effective, but this finding merits further research. Behaviour change persisted throughout the follow-up period, but reactance by a single washroom user resulted in some signs being removed. Compared to previous research, the current study used an improved methodology with a larger number of study sites. This study demonstrated that a simple, well-designed sign can effectively encourage energy conservation.

Skin cancer education and early detection at the beach: a randomized trial of dermatologist examination and biometric feedback

BACKGROUND

There are limited data on the effectiveness of skin cancer prevention education and early detection programs at beaches.

OBJECTIVES

We evaluate 4 strategies for addressing skin cancer prevention in beach settings.

METHODS

This prospective study at 4 beaches included 4 intervention conditions: (1) education only; (2) education plus biometric feedback; (3) education plus dermatologist skin examination; or (4) education plus biometric feedback and dermatologist skin examination. Outcomes included sun protection behaviors, sunburns, and skin self-examinations.

RESULTS

There was a significant increase in hat wearing, sunscreen use, and a reduction in sunburns in the education plus biometric feedback group (odds ratio = 1.97, 1.94, and 1.07, respectively), and greater improvements in knowing what to look for in skin-self examinations (odds ratio = 1.13); there were no differences in frequency of self-examinations. Skin examinations plus biometric feedback led to greater reductions in sunburns. The dermatologist examinations identified atypical moles in 28% of participants.

LIMITATIONS

Inclusion of only one beach per condition, use of self-report data, and a limited intervention period are limitations.

CONCLUSIONS

Education and biometric feedback may be more effective than education alone for impacting sun protective attitudes and behaviors in beachgoing, high-risk populations.

Qualitative methods to ensure acceptability of behavioral and social interventions to the target population

OBJECTIVES

This paper introduces qualitative methods for assessing the acceptability of an intervention.

METHODS

Acceptability refers to determining how well an intervention will be received by the target population and the extent to which the new intervention or its might meet the needs of the target population an d organizational setting. In this paper, we focus on two common qualitative methods for conducting acceptability research and their advantages and disadvantages: focus groups and interviews.

RESULTS

We provide examples from our own research and other studies to demonstrate the use of these methods for conducting acceptability research and how one might adapt this approach for oral health research.

DISCUSSION

We present emerging methods for conducting acceptability research, including the use of community-based participatory research, as well as the utility of conducting acceptability research for assessing the appropriateness of measures in intervention research.

Testing a theory-based health communication program: a replication of Go Sun Smart in outdoor winter recreation

The epidemic of preventable skin cancer in the United States creates an urgent need for health communication campaigns to improve sun protection. Go Sun Smart (GSS), a theory-driven multichannel health communication campaign showed positive effects on sun safety behaviors of employees and guests in a randomized trial at high-altitude ski areas. In this article we report findings from the North American GSS campaign for guests at ski areas that comprosed the original control-group resorts, replicating the results of the original guest intervention. Results showed that after GSS was deployed, guests at the original control group ski areas increased sun protection and reported greater recall of sun safety messages. Conversely, GSS had no effect on sunburning attitudes or self-efficacy beliefs. Like the original GSS guest intervention, the present study found that greater exposure to GSS messages was associated with greater use of sunscreen, sunscreen lip balm, and face covering, but not gloves or overall sun protection. There was no evidence that GSS decreased sunburning or attitudes and self-efficacy beliefs regarding sun safety.

Melanoma epidemiology and public health

This article reviews the research on, and examines the epidemiology and prevention of melanoma. Despite the great quantity of research into environmental and genetic causes, and the ease of diagnosis, incidence and mortality have risen in all developed countries during the last half century. Patient and physician education, and public health programs aimed at prevention, have had varied success. The authors conclude that, until we have better data on how to prevent skin cancer of all types, the best solutions are education of high-risk populations about skin self-evaluation in combination with physician examination to practice; and sun protection.

Design and methods for a cluster randomized trial of the Sunless Study: a skin cancer prevention intervention promoting sunless tanning among beach visitors

Background

Skin cancer is the most prevalent yet most preventable cancer in the US. While protecting oneself from ultraviolet radiation (UVR) can largely reduce risk, rates of unprotected sun exposure remain high. Because the desire to be tan often outweighs health concerns among sunbathers, very few interventions have been successful at reducing sunbathing behavior. Sunless tanning (self-tanners and spray tans), a method of achieving the suntanned look without UVR exposure, might be an effective supplement to prevention interventions.

Methods and Design

This cluster randomized trial will examine whether a beach-based intervention that promotes sunless tanning as a substitute for sunbathing and includes sun damage imaging and sun safety recommendations is superior to a questionnaire only control group in reducing sunbathing frequency. Female beach visitors (N = 250) will be recruited from 2 public beaches in eastern Massachusetts. Beach site will be the unit of randomization. Follow-up assessment will occur at the end of the summer (1-month following intervention) and 1 year later. The primary outcome is average sunbathing time per week. The study was designed to provide 90% power for detecting a difference of .70 hours between conditions (standard deviation of 2.0) at 1-year with an intra-cluster correlation coefficient of 0.01 and assuming a 25% rate of loss to follow-up. Secondary outcomes include frequency of sunburns, use of sunless tanning products, and sun protection behavior.

Discussion

Interventions might be improved by promoting behavioral substitutes for sun exposure, such as sunless tanners, that create a tanned look without exposure to UVR.

Trial registration

NCT00403377

Increasing sun protection in winter outdoor recreation a theory-based health communication program

BACKGROUND

Unprotected and excessive exposure to ultraviolet radiation (UVR) is the primary risk factor for skin cancer.

DESIGN

A pair-matched, group-randomized, pre-test/post-test, quasi-experimental design, with ski resorts as the unit of randomization, tested the effectiveness of Go Sun Smart, a multi-channel skin cancer prevention program. Independent samples of guests were taken at baseline (2001) and follow-up (2002); data were analyzed in 2006.

SETTING AND PARTICIPANTS

A total of 6516 adult guests at 26 ski areas in the western U.S. and Canada were recruited, consented, and interviewed on chairlifts. This study was nested within an occupational intervention for ski area workers.

INTERVENTION

Ski areas were pair-matched and randomized to receive Go Sun Smart, which consisted of print, electronic, visual, and interpersonal skin cancer prevention messages.

MAIN OUTCOME MEASURES

Sun-protection behaviors, sunburning, recall of sun-protection messages, and the association of message exposure to sun protection.

RESULTS

The difference in recall of all sun-protection messages, messages on signs and posters, and the Go Sun Smart logo was significant between the intervention and control resorts. Reported use of sun-protection practices was higher by guests at intervention ski areas using more (a higher dose of) Go Sun Smart materials. Intervention-group guests who recalled a sun-safety message were more likely to practice sun safety than intervention-group guests who did not recall a message and control-group guests.

CONCLUSIONS

While the mere implementation of Go Sun Smart did not produce sun-safety improvements, Go Sun Smart appeared to be effective for guests who encountered and remembered it. Many factors can work against message exposure. Signage seemed to produce the greatest increase in exposure to sun-safety messages.

Primary Prevention of Skin Cancer in Children and Adolescents: A Review of the Literature

Although skin cancer is an easily preventable disease, self-directed prevention behaviors in children are difficult to achieve. The purpose of this article is to evaluate the status of primary prevention interventions and identify gaps in national and international research in order to make suggestions for further intervention design. A comprehensive search of MEDLINE, CINAHL, and PSYCHinfo databases was conducted to collect published research used in this review. The most effective interventions used multicomponent curricula administered over an extended period of time. Younger children were more receptive to interventions than were older children, who had stronger attitudes against sun-protective behaviors. Interventions in Australia have been more successful than interventions in North America and Europe. Further research needs to be conducted to create primary prevention interventions that address informational gaps. Specifically testing the dose and effect of individual educational components and bundling of components with reliable and valid outcome measures would help health care researchers define and measure the most effective way to battle social norms and attitudes of children and sun exposure.

Randomized trial on sun safety education at ski and snowboard schools in western North America

The purpose of this study was to evaluate the effectiveness of Go Sun Smart, a sun safety education program, directed to parents and children enrolled in ski and snowboard schools at high altitude resorts in western North America. Twenty-six ski resorts were paired and then randomly assigned to the intervention or control condition. Three hundred fifty-seven parents were interviewed about their children's sun safety behavior and exposure to the Go Sun Smart program. More parents at the intervention resorts reported that their child was wearing sunscreen than at the control resorts (OR 2.37, 95% CI 0.93, 5.99) but this result was significant only at resorts in the Northwest region (OR 2.72, 95% CI 1.24, 5.95). Parents at intervention resorts had significantly increased odds of having seen a Go Sun Smart poster than those at the control resorts (OR=8.53, 95% CI 2.17, 33.54). No significant differences were identified between the intervention and control groups for verbal messages from ski resort employees about sun protection. Outdoor wintertime recreation venues are a potentially effective site from which to implement sun safety education programs for children and parents.

An intervention for parents to promote preschool children's sun protection: effects of Sun Protection is Fun!

BACKGROUND

Young children are an important focus of sun-protection efforts, but there has been relatively little study of sun-protection interventions developed for preschool-aged children and their parents. This paper reports on the evaluation of Sun Protection is Fun! (S.P.F.), designed to improve parents' practices and psychosocial outcomes related to protecting preschool children from sun exposure.

METHODS

A group-randomized trial was conducted in 20 preschools to evaluate the S.P.F. parent intervention that included a video, newsletters, and handbooks. A separate, on-site intervention for preschool staff aimed to create a preschool climate that encouraged parents' sun protection for their children. Cross-sectional samples of parents completed surveys at baseline (n = 384), 12 months (n = 640), and 24 months (n = 694).

RESULTS

S.P.F. demonstrated significant effects on parents' sun-avoidance strategies at 12 months (P < .05) and sunscreen use at 24 months (P < .05). There were significant intervention effects on parents' sun-protection knowledge (P < .001), perceived norms of teachers' sunscreen use (P < .001), sunscreen impediments (P < .05), and sunscreen expectancies (P < .05) at 12 months. Parents' perceived norms of teacher sunscreen use were significantly improved at 24 months (P < .001).

CONCLUSIONS

More intense intervention strategies may need to complement take-home materials to result in greater effects on parents' sun protection for their children.

Reducing ultraviolet radiation exposure to prevent skin cancer methodology and measurement

Skin cancer is the most common type of cancer, and is also one of the most preventable. This paper builds on an evidence review of skin cancer prevention interventions that was conducted for the Guide to Community Preventive Services (n=85 studies), and summarizes the state of knowledge about research methodology and measurement in studies of the effectiveness of interventions to reduce ultraviolet radiation (UVR) exposure. As this field advances, researchers should strive to minimize threats to validity in their study designs, as well as to consider the balance between internal and external validity. There is a need for more longer-duration interventions, and follow-up periods that make possible conclusions about the potential of these interventions to affect intermediate markers of skin cancer or at least sustained behavior change. Also, more work is needed to minimize attrition and characterize nonresponders and study dropouts. Verbal report measures of behavior are the most widely used measures of solar protection behavior. Given their limitations, investigators should routinely collect data about reliability and validity of those measures. They should also increase efforts to complement verbal data with objective measures including observations, skin reflectance, personal dosimetry, skin swabbing, and inspection of moles. Measures of environments and policies should incorporate observations, documentation, and direct measures of ambient UVR and shade. This article places the data derived from the evidence review in the context of needs and recommendations for future research in skin cancer prevention.

Ethnoracial differences among outdoor workers in key sun-safety behaviors

BACKGROUND

Few sun-safety studies have included ethnoracially diverse groups. Comparison across such groups of sun-safety behaviors was the main objective of this analysis.

METHODS

Postal workers (n =2543) self-reported frequency of sunscreen, wide-brim hat, and sunglasses use during the last 5 workdays on 5-point Likert-type scales ranging from "never" to "always." Responses were dichotomized by "always" versus all other responses. Generalized estimating equations were used to assess the association between ethnicity/race and frequency of each sun safety behavior. The baseline data reported in this paper were collected in the summer of 2001, and the randomized trial was completed in the summer of 2004.

RESULTS

Ethnicity/race was significantly related to sunscreen and sunglasses use. For both sunscreen and sunglasses, the white group had significantly higher "always" rates than the other four groups (30% vs 14% to 23% and 63% vs 44% to 52%, respectively).

CONCLUSIONS

The results of this study indicated that although non-Latino white employees tended to have higher rates of sun-safety behaviors, the rates of adequate protection of all groups were low.

Raising sun protection and early detection awareness among Florida high schoolers

Changing adolescents' sun protection behaviors remains a challenge, and the need for effective interventions targeting this group is a priority, particularly in warmer climates where emphasis on appropriate sun protection remains a year-round concern. However, there has been little prospective research on the effect of school-based sun protection interventions, particularly on adolescents, especially teens aged 15 to 18. High school science students in Palm Beach County, Florida, received a seven-lesson sun protection and early detection curriculum preceded by pretests and followed with post-tests 6 months later. The main outcome measures were student knowledge and sun protection practices, including adherence to sunscreen recommendations. Of 344 students completing the baseline surveys, 184 students completed the postintervention questionnaire. Overall, there were significant improvements from baseline to follow-up for many of the knowledge questions. Greatest change scores were seen in the children's ability to correctly define the five rules of early detection of skin cancer (27-60%, p<0.001) with improved change scores by gender and race persisting after 6 months. No significant differences were found in reported use of sunscreen, hat wearing, or sunglasses, although there was a slight decrease in the reported use of always wearing sun protective clothing (p=0.03). In conclusion, in this study, a skin cancer prevention and detection curriculum integrated into high school biology, resulted in knowledge gains maintained at least 6 months after classroom teaching. For example, procedural knowledge (e.g., knowing ways to identify early malignant moles) obtained in this study improved in 6 months, and may lay the foundation for future behavioral change. Sun protection activities in the United States have met with many challenges and obstacles and thus, further work is needed to better understand what combination of knowledge-based information, activity-based education, school-wide changes, and community efforts, will create a long-term systemic improvement in sun protection habits in children.

Disseminating a Sun Safety Program to Zoological Parks: The Effects of Tailoring

Previous research found that a sun safety program for visitors at 1 zoo increased sun safety behaviors. This randomized study compared the effects of tailored dissemination materials plus 2 brief follow-up phone calls (tailored group) versus generic materials (basic group) on implementation by other zoos of the previously evaluated sun safety program. Education directors of 126 zoos completed surveys several months following initial dissemination and 1 year later. During Summer 1, 40% of tailored group zoos and 24% of basic group zoos offered visitors at least 1 sun safety activity (odds ratio=2.2, 95% confidence interval=1.0-4.8). During Summer 2, these rates were 34% and 44%, respectively (ns). The pattern of findings suggests that tailoring had no incremental long-term impact and that the generic materials produced a good level of dissemination.

Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review

The relationship between skin cancer and ultraviolet radiation is well established. Behaviors such as seeking shade, avoiding sun exposure during peak hours of radiation, wearing protective clothing, or some combination of these behaviors can provide protection. Sunscreen use alone is not considered an adequate protection against ultraviolet radiation. This report presents the results of systematic reviews of effectiveness, applicability, other harms or benefits, economic evaluations, and barriers to use of selected interventions to prevent skin cancer by reducing exposure to ultraviolet radiation. The Task Force on Community Preventive Services found that education and policy approaches to increasing sun-protective behaviors were effective when implemented in primary schools and in recreational or tourism settings, but found insufficient evidence to determine effectiveness when implemented in other settings, such as child care centers, secondary schools and colleges, and occupational settings. They also found insufficient evidence to determine the effectiveness of interventions oriented to healthcare settings and providers, media campaigns alone, interventions oriented to parents or caregivers of children, and community-wide multicomponent interventions. The report also provides suggestions for areas for future research.