The impact of the kidskin sun protection intervention on summer suntan and reported sun exposure: was it sustained?

School-based interventions to improve sun-safe knowledge, attitudes and behaviors in childhood and adolescence: A systematic review

Ultraviolet radiation exposure is the leading cause of skin cancer, and childhood and adolescence is a particularly susceptible life period for exposure. This systematic review assessed whether interventions in elementary and secondary school settings reduced sun exposure, sunburns, and development of melanocytic nevi, and improved sun-safe knowledge, attitudes and sun protection behaviors in childhood and adolescence. A systematic search up to June 2020 of MEDLINE, Embase, CINAHL, Cochrane and ProQuest databases was undertaken, for studies conducted among students in an elementary or secondary school setting that compared an intervention group with a pre-intervention or separate control group. Data were summarized using qualitative synthesis. Pooled effects from meta-analysis with random effects were also reported where appropriate. Sixty-five studies were included (22 randomized, 43 non-randomized). Most studies assessed measures of sun-safe behaviors, knowledge and attitudes (57, 48 and 33 studies, respectively), and observed improved sun protection behaviors and sun-safe knowledge, whereas few studies reduced time in the sun. About half improved participants' attitudes towards tanning desirability. Sunburns and nevus counts were less frequently assessed, but about half of these studies observed a reduction. There was substantial heterogeneity for outcomes except attitudes towards the desirability of tanning (pooled odds ratio from 6 studies: 0.81, 95% confidence interval 0.70-0.94). Key positive intervention features included: elementary school settings, interactive features or multiple components, and incorporating social norm influences. Most studies were classified at high risk of bias. In conclusion, school-based sun-related interventions had positive impacts on behaviors and attitudes among elementary and secondary school children.

Time spent outdoors in childhood is associated with reduced risk of myopia as an adult

Myopia (near-sightedness) is an important public health issue. Spending more time outdoors can prevent myopia but the long-term association between this exposure and myopia has not been well characterised. We investigated the relationship between time spent outdoors in childhood, adolescence and young adulthood and risk of myopia in young adulthood. The Kidskin Young Adult Myopia Study (KYAMS) was a follow-up of the Kidskin Study, a sun exposure-intervention study of 1776 children aged 6–12 years. Myopia status was assessed in 303 (17.6%) KYAMS participants (aged 25–30 years) and several subjective and objective measures of time spent outdoors were collected in childhood (8–12 years) and adulthood. Index measures of total, childhood and recent time spent outdoors were developed using confirmatory factor analysis. Logistic regression was used to assess the association between a 0.1-unit change in the time outdoor indices and risk of myopia after adjusting for sex, education, outdoor occupation, parental myopia, parental education, ancestry and Kidskin Study intervention group. Spending more time outdoors during childhood was associated with reduced risk of myopia in young adulthood (multivariable odds ratio [OR] 0.82, 95% confidence interval [CI] 0.69, 0.98). Spending more time outdoors in later adolescence and young adulthood was associated with reduced risk of late-onset myopia (≥ 15 years of age, multivariable OR 0.79, 95% CI 0.64, 0.98). Spending more time outdoors in both childhood and adolescence was associated with less myopia in young adulthood.

Understanding sunscreen and photoprotection misinformation on parenting blogs: A mixed-method study

BACKGROUND/OBJECTIVES

Sun exposure during childhood is a modifiable risk factor for skin cancer. Social media (including parenting blogs) represent promising platforms for understanding misinformation about pediatric photoprotection. This study's objective was to qualitatively and quantitatively evaluate the digital social context of parenting blogs that shape parents' decisions about children's photoprotection.

METHODS

Mixed-method analysis was conducted of the 25 most popular parenting blogs in the USA, including 56 blog posts addressing photoprotection and 2661 comments. An inductive method was used to code and identify key themes associated with blog post categorization as sunscreen-encouraging, -discouraging, and -ambivalent. The qualitative analysis program NVivo was used to calculate descriptive statistics for comment codes based on co-occurrence with blog post category.

RESULTS

Sunscreen-discouraging posts addressed natural remedies, sunscreen recipes, and vitamin D. Sunscreen-encouraging posts focused on skin cancer and protective clothing. Sunscreen-ambivalent posts were associated with scientific studies. Sunscreen-discouraging posts received more comments (mean 124) than encouraging (31) or ambivalent posts (8). Discouraging (65%) and ambivalent posts (75%) cited scientific literature more often than encouraging posts (14%). Comments were twice as likely to discourage photoprotection as to encourage it (1340 vs 447 comments).

CONCLUSIONS

Parenting blogs are a substantial resource of both information and misinformation on pediatric photoprotection. However, misinformation receives substantially more engagement. The themes revealed in this study may help physicians and public health officials in developing interventions to target misinformation around pediatric photoprotection.

Re-engaging an inactive cohort of young adults: evaluating recruitment for the Kidskin Young Adult Myopia Study

BACKGROUND

Recent changes in communication technologies, including increased reliance on mobile phones and the internet, may present challenges and/or opportunities to re-engaging inactive study cohorts. We evaluate our ability to recruit participants for the Kidskin Young Adult Myopia Study (KYAMS), a follow-up of the Kidskin Study.

METHODS

KYAMS participants were recruited from the Kidskin Study, a sun exposure-intervention study for 5-6 year-olds running from 1995 to 1999 with most recent follow-up in 2005. From 2015 to 2019, the KYAMS used mail-outs, phone calls and social media to contact Kidskin Study participants. Multivariable logistic regression was used to identify variables associated with successful contact of a Kidskin Study participant or family member and KYAMS participation.

RESULTS

Of 1695 eligible participants, 599 (35.5%) participants (or a family member) were contacted and 303 (17.9%) participated in the KYAMS. KYAMS participation was more likely in those who participated in the 2005 follow-up (odds ratio [OR] = 5.09, 95% confidence interval [CI]: 3.67-7.06) and had a mobile phone number on record (OR = 2.25, CI: 1.57-3.23). Of those contacted, participants who were the first point of contact (OR = 4.84, CI: 2.89-8.10) and who were contacted by letter in the first (OR = 6.53, CI: 3.35-12.75) or second (OR = 5.77, CI: 2.85-11.67) round were more likely to participate in the KYAMS, compared to contact by landline phone.

CONCLUSIONS

We recruited approximately one-fifth of Kidskin Study participants for the KYAMS. Participants were more likely to participate in the KYAMS if they were contacted directly, rather than through a family member, and if they were contacted by invitation letter.

TRIAL REGISTRATION

ACTRN12617000812392.

Investigating the long-term impact of a childhood sun-exposure intervention, with a focus on eye health: protocol for the Kidskin-Young Adult Myopia Study

INTRODUCTION

Excessive and insufficient sun exposure during childhood have been linked to serious diseases in later life; for example, insufficient sun exposure during childhood may increase the risk of developing myopia. The Kidskin-Young Adult Myopia Study (K-YAMS) is a follow-up of participants in the Kidskin Study, a non-randomised controlled trial that evaluated the effect of a 4-year educational intervention on sun-protection behaviours among primary school children in the late 1990s. Children who received the Kidskin intervention had lower levels of sun exposure compared with peers in the control group after 2 and 4 years of the intervention, but this was not maintained 2  years after the intervention had ceased. Thus, a follow-up of Kidskin Study participants provides a novel opportunity to investigate the associations between a childhood sun-exposure intervention and potentially related conditions in adulthood.

METHODS AND ANALYSIS

The K-YAMS contacts Kidskin Study participants and invites them to participate using a variety of methods, such as prior contact details, the Australian Electoral Roll and social media. Self-reported and objective measures of sun-exposure and sun-protection behaviours are collected as well as a number of eye measurements including cycloplegic autorefraction and ocular biometry. Data will be analysed to investigate a possible association between myopic refractive error and Kidskin intervention group or measured sun exposure.

ETHICS AND DISSEMINATION

The K-YAMS is approved by the Human Research Ethics Committee of the University of Western Australia (RA/4/1/6807). Findings will be disseminated via scientific journals and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12616000812392; Pre-results.

Treatment integrity in school-wide programs: a review of the literature (1993-2012)

We assessed the reporting of treatment integrity in school-wide prevention programs in K-12 schools. This review was designed to determine (a) the extent to which treatment integrity was reported in school-wide prevention and intervention programs and how the reporting varied by research design, year, and journal; and (b) the procedures (e.g., method, frequency, informant) used to collect treatment integrity data. Results indicated that fewer than half of the studies in the review (n = 36, 45.6 %) measured and reported treatment integrity. Those studies reporting treatment integrity often used multiple methods and informants. Reporting treatment integrity in this body of literature has increased steadily over time.

Melanoma Epidemiology and Prevention

The epidemiology of melanoma is complex, and individual risk depends on sun exposure, host factors, and genetic factors, and in their interactions as well. Sun exposure can be classified as intermittent, chronic, or cumulative (overall) exposure, and each appears to have a different effect on type of melanoma. Other environmental factors, such as chemical exposures-either through occupation, atmosphere, or food-may increase risk for melanoma, and this area warrants further study. Host factors that are well known to be important are the numbers and types of nevi and the skin phenotype. Genetic factors are classified as high-penetrant genes, moderate-risk genes, or low-risk genetic polymorphisms. Subtypes of tumors, such as BRAF-mutated tumors, have different risk factors as well as different therapies. Prevention of melanoma has been attempted using various strategies in specific subpopulations, but to date optimal interventions to reduce incidence have not emerged.

Targeted melanoma prevention intervention: a cluster randomized controlled trial

PURPOSE

Targeted interventions to reduce the risk and increase the early detection of melanoma have the potential to save lives. We aimed to assess the effect of such an intervention on patient prevention behavior.

METHODS

We conducted a pilot clustered randomized controlled trial, comparing a targeted screening and education intervention with a conventional information-based campaign in 20 private surgeries in western France. In the intervention group, 10 general practitioners identified patients at elevated risk for melanoma with a validated assessment tool, the Self-Assessment Melanoma Risk Score (SAMScore), examined their skin, and counseled them using information leaflets. In the control group, 10 general practitioners displayed a poster and the leaflets in their waiting room and examined patients' skin at their own discretion. The main outcome measures were sunbathing and skin self-examinations among patients at elevated risk, assessed 5 months later with a questionnaire.

RESULTS

Analyses were based on 173 patients. Compared with control patients, intervention patients were more likely to remember the campaign (81.4% vs 50.0%, P = .0001) and to correctly identify their elevated risk of melanoma (71.1% vs 42.1%, P = .001). Furthermore, intervention patients had higher levels of prevention behaviors: they were less likely to sunbathe in the summer (24.7% vs 40.8%, P = .048) and more likely to have performed skin self-examinations in the past year (52.6% vs 36.8%, P = .029). The intervention was not associated with any clear adverse effects, although there were trends whereby intervention patients were more likely to worry about melanoma and to consult their general practitioner again about the disease.

CONCLUSIONS

The combination of use of the SAMScore and general practitioner examination and counseling during consultations is an efficient way to promote patient behaviors that may reduce melanoma risk. Extending the duration of follow-up and demonstrating an impact on morbidity and mortality remain major issues for further research.

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.

Sun-protection habits of primary students in a coastal area of Greece

Aim. The aim of the present study was to record habits and attitudes of primary school students in Greece regarding sun-protection measures. Materials and Methods. 2,163 students with an average age of 9.9 (±1.1) years, studying in 14 schools of a Greek region, constituted our sample. The SPSS 17.0 software was used for the statistical analysis and significance level was set to P ≤ 0.05. Results. Our sample had an equal gender distribution. 16% of the students belonged to the high-risk group, 70.2% of the participants lived 0–5 km away from the sea (urban area), 84.2% of the students were Greek, and 15.8% had non-Greek nationality. Half of the participants said they wear a hat when under the sun and 72% of them said they use sunscreen. 33.1% of the students said they had a sunburn last summer. Greek students as well as those who lived near the sea had better behaviour patterns regarding sun protection. Finally, children who did not use a sunscreen systematically had suffered sunburns more often than the rest. Conclusions. Health education programmes are necessary for students and parents/teachers alike, in order to raise awareness about everyday sun protection.

A cluster randomized trial of sun protection at elementary schools. Results from year 2

BACKGROUND

Elementary schools are one potential venue for sun protection interventions that reduce childhood sun exposure.

PURPOSE

To assess Year-2 results from a cluster randomized trial promoting hat use at schools.

DESIGN

Block randomization was used to assign intervention/control status to participating schools. Data were collected from 2006 to 2008 and analyzed in 2007-2010.

SETTING/PARTICIPANTS

Of the 24 schools in the School District of Hillsborough County, Florida enrolled, 4th-graders were targeted in the first year and followed through their 5th-grade year.

INTERVENTION

Classroom sessions were conducted to improve sun protection knowledge, foster more positive attitudes about hat use, and change the subjective norm of wearing hats when at school.

MAIN OUTCOME MEASURES

Year-2 outcomes assessed included hat use at school (measured by direct observation), hat use outside of school (measured by self-report) and skin pigmentation and nevi counts (measured for a subgroup of 439 students).

RESULTS

The percentage of students observed wearing hats at control schools remained unchanged during the 2-year period (range 0%-2%) but increased significantly at intervention schools (2% at baseline, 41% at end of Year 1, 19% at end of Year 2; p<0.001 for intervention effect). Measures of skin pigmentation, nevi counts, and self-reported use of hats outside of school did not change during the study period.

CONCLUSIONS

This intervention increased use of hats at school through Year 2 but had no measurable effect on skin pigmentation or nevi. Whether school-based interventions can ultimately prevent skin cancer is uncertain.

Sun protection advice mediated by the general practitioner: an effective way to achieve long-term change of behaviour and attitudes related to sun exposure?

OBJECTIVE

To investigate, in primary health care, differentiated levels of prevention directed at skin cancer, and how the propensity of the patients to change sun habits/sun protection behaviour and attitudes towards sunbathing were affected, three years after intervention. Additionally, the impact of the performance of a phototest as a complementary tool for prevention was evaluated.

DESIGN

Randomized controlled study. Setting and subjects. During three weeks in February, all patients ≥ 18 years of age registering at a primary health care centre in southern Sweden were asked to fill in a questionnaire mapping sun exposure habits, attitudes towards sunbathing, and readiness to increase sun protection according to the Transtheoretical Model of Behaviour Change (TTM) (n = 316). They were randomized into three intervention groups, for which sun protection advice was given, in Group 1 by means of a letter, and in Groups 2 and 3 orally during a personal GP consultation. Group 3 also underwent a phototest to demonstrate individual skin UV sensitivity.

MAIN OUTCOME MEASURES

Change of sun habits/sun protection behaviour and attitudes, measured by five-point Likert scale scores and readiness to increase sun protection according to the TTM, three years after intervention, by a repeated questionnaire.

RESULTS

In the letter group, almost no improvement in sun protection occurred. In the two doctor's consultation groups, significantly increased sun protection was demonstrated for several items, but the difference compared with the letter group was significant only for sunscreen use. The performance of a phototest did not appear to reinforce the impact of intervention.

CONCLUSION

Sun protection advice, mediated personally by the GP during a doctor's consultation, can lead to improvement in sun protection over a prolonged time period.

[Update on photoprotection in children]

Children are one of the population groups in which the photo-protection must be maximised. Firstly, because they take part in outdoor activities more often than adults. Secondly, because the principal risk factor for all types of skin cancer is ultraviolet radiation, and in particular, cumulative exposure during childhood. Hence, decreasing exposure to ultraviolet radiation in childhood has the potential to significantly lower the incidence of most forms of skin cancer. Photoprotection includes behavioural measures to protect the skin from sun exposure, e.g. sun protective clothes, hats, sunglasses, and sunscreens. It is necessary to provide information on aphotoprotection to parents, and, above all, to children, using educational campaigns to increase knowledge of photoprotection to help change attitudes towards sun exposure. Dermatologists and Paediatricians play a essential role in this educational work. In this article we review the latest information regarding paediatric sun protection, the new sunscreens, and the recent sun protection educational programs.

Child sun protection: sun-related attitudes mediate the association between children's knowledge and behaviours

AIM

To describe and investigate the relationship among the sun-related knowledge, attitudes and behaviours of New Zealand primary schoolchildren and consider the roles of sex and school year level.

METHODS

A randomly selected, two-stage cluster sample of 488 children from 27 primary schools in five regions of New Zealand was surveyed regarding their sun-related knowledge, attitudes and behaviours. A scoring system was used to assign a knowledge, attitude and behaviour score to each child.

RESULTS

Although knowledge increased with school year level, there was a decline in sun protective attitudes and behaviours. There was little variation in knowledge, attitudes and behaviour between boys and girls, but sex-year level interactions were found for knowledge and behaviour. When considering children's knowledge, attitudes and behaviours simultaneously, knowledge was only significantly associated with behaviours when mediated by attitudes.

CONCLUSIONS

When targeting child sun protection and skin cancer prevention programmes, a focus on attitudes towards sun exposure and a suntan may prove beneficial in influencing sun-related behaviours.

Economic evaluation of the US Environmental Protection Agency's SunWise program: sun protection education for young children

OBJECTIVE

The SunWise School Program is a school-based sun safety education program that was developed by the US Environmental Protection Agency and aims to teach children how to protect themselves from overexposure to the sun. The objectives of this study were to assess the health benefits of the SunWise School Program and use economic analysis to determine the program's net benefits and cost-effectiveness.

METHODS

Standard cost/benefit and cost-effectiveness analysis methods were used. Intervention costs were measured as program costs estimated to be incurred by the US government, which funds SunWise, using 3 funding scenarios. Health outcomes were measured as skin cancer cases and premature mortalities averted and quality-adjusted life-years saved. These health outcomes were modeled using an effectiveness evaluation of SunWise based on pretest and posttest surveys administered to students who participated in the program and the Environmental Protection Agency's peer-reviewed Atmospheric and Health Effects Framework model. Costs averted were measured as direct medical costs and costs of productivity losses averted as a result of SunWise. Net benefits were measured as the difference between costs averted and program costs.

RESULTS

Economic analysis indicated that if the SunWise School Program continues through 2015 at current funding levels, then it should avert >50 premature deaths, nearly 11,000 skin cancer cases, and 960 quality-adjusted life-years (undiscounted) among its participants. For every dollar invested in SunWise, between approximately $2 and $4 in medical care costs and productivity losses are saved, depending on the funding scenario.

CONCLUSIONS

From a cost/benefit and cost-effectiveness perspective, it is worthwhile to educate children about sun safety; small to modest behavioral impacts may result in significant reductions in skin cancer incidence and mortality.

Solar UVR Exposure, Concurrent Activities and Sun-Protective Practices Among Primary Schoolchildren

Comprehensive measures of ultraviolet radiation (UVR) exposure, concurrent activities and sun-protective practices are needed to develop and evaluate skin cancer prevention and sun protection interventions. The UVR exposures of 345 primary schoolchildren at 23 schools around New Zealand were measured using electronic UVR monitors for 1-week periods over 12 weeks in 2004 and 2005. In addition, ambient UVR levels on a horizontal surface were measured on-site at each school. Children completed activity diaries during the period UVR measurements were made and provided information on their indoor and outdoor status and clothing and sun protection worn. Mean total daily UVR exposure (7:00-20:00 h NZST + 1) at the body location where the UVR monitors were worn was 0.9 SED (standard erythemal dose, 1 SED = 100 J m(-2)). This was 4.9% of the ambient UVR on a horizontal surface. Mean time spent outdoors was 2.3 h day(-1). Differences in children's UVR exposure could be explained in part by activity, where outdoor passive pursuits were associated with higher UVR exposure rates than outdoor active and outdoor travel pursuits. Compared with older children, the activities of younger children, although labeled the same, resulted in different UVR exposures, either as a result of reporting differences or a real difference in UVR exposure patterns. UVR exposure rates were generally higher on weekdays compared with the weekend, confirming the important role of school sun protection and skin cancer prevention programs. High UVR exposure activities included physical education, athletics and lunch break.

Time spent outdoors at midday and children's body mass index

OBJECTIVES

We investigated whether the Kidskin sun protection intervention increased children's body mass index by reducing the time spent outdoors at midday.

METHODS

The Kidskin sun protection intervention involved 1614 Australian school children assigned to 1 of 3 groups: a control group, a moderate-intervention group, or a high-intervention group. Schools in the control group received the standard health curriculum and schools in the intervention groups received a multicomponent intervention. Outcomes included time spent outdoors and nevus development (a marker of melanoma risk). Height and weight were measured at 3 time points. Body mass index was transformed into age- and gender-specific z scores; z scores at each age were modeled simultaneously. Time spent outdoors at ages 10 and 12 years was analyzed using a linear mixed effects modeling.

RESULTS

The proportion of children who were overweight or obese increased with age. The moderate-intervention and control groups had a minimal increase in z score over time, and the z score for the high-intervention group decreased over time. There were no differences among groups with respect to total time outdoors at any age.

CONCLUSIONS

It is possible to reduce the time children spend outdoors when ultraviolet radiation is high without producing an unfavorable effect on the children's body mass index.