SunSmart: evaluation of a pilot school-based sun protection intervention in Hispanic early adolescents

Reinforcing Photoprotection for Skin of Color: A Narrative Review

Skin of color (SOC) is characterized by increased tendency for tanning and decreased likelihood of sunburns due to the attenuation of sunlight by epidermal melanin. Although this contributes to the decreased incidence of skin cancer among SOC populations, individuals with SOC remain susceptible to various health consequences associated with sun exposure, including non-melanoma skin cancer, photoaging, pigmentary disorders, and photodermatoses - many of which not only present differently, but also disproportionately affect SOC. Prior epidemiological studies have found lower prevalence of sun protection behaviors among individuals with SOC, particularly in sunscreen use, signifying an unmet area for improvement in the prevention of sun-induced dermatologic conditions in these populations. The objective of this narrative review was to summarize the biology and health consequences of sun exposure in SOC, as well as cognitive and behavioral factors that affect the practice of photoprotection behaviors in SOC populations. We also review prior interventions that have been used to enhance photoprotection knowledge and behaviors among individuals with SOC, either in racially and ethnically diverse communities or within specific SOC populations.

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.

Encouraging sun protection early in life: from a successful prevention programme in children to the identification of psychological barriers in adolescents

Children and adolescents have high rates of sunburn and high levels of ultraviolet radiation (UVR) exposure and are therefore at risk of developing skin cancer in later life. Minimizing UVR exposure in childhood and adolescence may be the most important component of skin cancer prevention efforts. Thus, age-adapted prevention campaigns, targeting children, adolescents and caregivers, are needed to change sun protection behaviour among individuals in these age groups. In the first part of this review, we describe the 'SunPass' programme, which was initiated in Germany in 2010 as the first nationwide educational intervention for sun safety designed to teach kindergarten children and their caregivers how to protect themselves from overexposure to the sun. Implemented in 55 kindergartens, this programme has been shown to be effective at improving sun protection behaviour (P < 0.001) and hat use (P = 0.029) among kindergarten children, as well as at improving shade practices and increasing demand for protective clothing (P < 0.001). Up to 40 000 children, 50 000 parents/grandparents and 2500 kindergarten caregivers took part in the SunPass programme in Germany from 2019 to June 2021. The programme has also been adapted and implemented in several other European countries and could be readily adapted for use elsewhere. In the second part of this review, we discuss the specific challenges faced by adolescents and consider how these issues may impact their sun protection behaviour. Adolescents have difficulties suppressing responses to reward-related cues and projecting themselves into the future. They also place a lot of importance on social acceptance and cosmetic appearance, and their higher risk of depression, addiction and impulsivity make them vulnerable to tanning addiction. These specificities need to be acknowledged by dermatologists, so they can adapt their therapeutic relationship and develop effective sun protection interventions for this generation.

Skin Cancer Knowledge, Attitudes and Sun Protection Practices in the Hispanic Population: A Cross-Sectional Survey

Hispanics are more likely to be diagnosed with skin cancer at a later stage and experience worse overall survival than Whites. The objective of this cross-sectional study was to assess the skin cancer knowledge, attitudes, perceived risk, and sun protection practices among an underserved population in the Phoenix area. We recruited participants from the greater Phoenix area to undergo skin examination and complete a questionnaire. 208 participants were included. The majority were Hispanic (64.9%). Of this Hispanic group, most were from Mexico (87.9%). The Hispanic cohort had an overall mean skin cancer knowledge score of 3.68/6, the lowest of any other racial/ethnic group, but had the highest desire to learn more about skin cancer (64.6%, "strongly agree"). They were the most concerned about developing skin cancer (50.4%, "very concerned") but had relatively lower rates of sun protection practices (7.9% "always use" sunscreen, 22.0% "always use" sun-protective clothing). Limitations of this study include a small sample size, lack of validation for the skin cancer knowledge score, lack of season as a covariate in the multivariate analysis, lack of follow-up, and lack of robust skin cancer risk assessment. In conclusion, despite poorer skin cancer knowledge and sun protection practices, the Hispanic population had the highest concern for developing skin cancer and desire to learn more about skin cancer. Targeted and culturally relevant skin cancer and sun protection education for this group is needed.

Effect of an interactive educational activity using handheld ultraviolet radiation dosimeters on sun protection knowledge among Australian primary school students

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This interactive educational activity incorporated handheld UV dosimeters.

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The intervention improved UV-related knowledge among primary school students.

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Knowledge about the UV Index improved the most.

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Knowledge about UV harms, sun protective clothing and behaviours also improved.

Ultraviolet radiation (UV) is the main cause of skin cancer, and children are a priority group for reducing UV exposure. We evaluated whether an interactive educational activity using handheld dosimeters improved UV-related knowledge among primary (elementary) school students. We conducted an uncontrolled before-after study among 427 students in grades 3–6 (ages 8–12 years) at five schools in the Greater Sydney region, Australia. Students used UV dosimeters to measure UV exposure, using the UV index scale, at different locations on their school grounds with and without different forms of sun protection, followed by an indoor classroom presentation and discussion. A 10-point anonymous questionnaire was completed by each student before and after the entire session (60–90 min). Before-after responses were compared using a generalised linear mixed model, adjusted for school, grade and gender. Overall, the mean raw scores increased from 6.3 (out of 10) before the intervention to 8.9 after the intervention, and the adjusted difference in scores was 2.6 points (95% confidence interval 2.4–2.8; p < 0.0001). Knowledge improved for all questions, with the greatest improvement for questions related to the UV Index (p < 0.05). The effect of the intervention was similar across different school, grade and gender groups. School and grade had no significant effect on mean survey scores, but girls scored an average 0.2 points higher than boys (95% confidence interval 0.1–0.4; p = 0.01). In conclusion, Australian primary school students had moderate knowledge about UV and sun protection, and knowledge improved significantly after a short interactive educational activity using handheld UV dosimeters.

Intent to Change Sun-Protective Behaviors Among Hispanic People After a UV Photoaging Intervention: Cohort Study

Background

Mortality rates from melanoma are higher among Hispanic populations than non-Hispanic White (NHW) populations. Interventions to improve sun safety are needed. The Reveal Imager is a camera that uses standard cross-polarized flash photography to record surface and subsurface skin conditions.

Objective

This study aims to determine the intervention’s effectiveness in increasing awareness of sun damage and exposure reduction between Hispanic and NHW populations.

Methods

A cohort of 322 participants, aged ≥18 years, were recruited from community events in 2018. Baseline information was collected on demographics, sun exposure, and perception of risk factors. A facial image was then captured using the Reveal Imager. The results were explained and counseling on sun safety was given, followed by filling out an immediate postimage survey. Chi-square tests, analysis of variance, Wilcoxon signed-rank test, McNemar tests, and multivariable logistic regression were used.

Results

At follow-up, 125 of 141 (89%) Hispanic participants reported that viewing the UV photoaged image influenced intent-to-change sun protection behaviors, compared to 88 of 121 (73%) NHW participants (odds ratio 2.9, 95% CI 1.5-5.6). Of 141 Hispanic participants, 96 (68%) reported that they intended to increase sunscreen use, compared to only 41 of 121 (34%) NHW participants (P<.001).

Conclusions

We demonstrated an application of Reveal Imager for education and risk assessment. The Reveal Imager was especially helpful in motivating intention to change sun exposure among Hispanic populations.

Skin tone preferences and their influence on skin care behaviors

Knowledge regarding skin tone preferences and their influence on skincare behaviors among people of color is limited. The objective of this study was to determine whether there is a difference between ideal and actual skin tone among people of color and whether this difference is associated with tanning and sunscreen use. This was a one-time, voluntary, anonymous, electronic survey designed in REDCap and delivered through ResearchMatch, a national electronic, recruitment tool. Eligible participants were at least 18 years old and self-identified as Black, Asian, Latinx, American Indian/Alaskan Native or Mixed Race. In total, 548 completed survey results were analyzed using SAS. Only the Latinx population was found to have a significant preference for tanner skin (p < 0.05). The Latinx population had significantly more subjects that participated in outdoor tanning than both the Black (p < 0.0001) and Asian population (p < 0.05). Latinx participants who indicated a preference for tanner skin were 2.8 times more likely to never use sunscreen than those without this preference (OR = 2.821, CI = 1.029-7.732, p < 0.05). Our findings have implications for how dermatologists screen, treat, and educate Latinx and skin of color populations.

The Effect of a School-Based Sun Protection Program on Students' Sun Protection Behavior in Turkey

PURPOSE

The aim of this study was to discover whether a school-based sun protection program (SPP) developed in line with the transtheoretical model (TTM) had an impact on students in an intervention group in the stages of change of developing sun protection behavior, reducing the number of sunburns adolescents sustain, and in terms of their perceptions of pros and cons and self-efficacy, as compared to the control group.

DESIGN AND METHODS

This study was designed as pre-/posttest control group semi-experimental research. The research was carried out with 376 adolescents in two schools. One of the schools was randomly designated as the intervention group of students and the other represented the control group. The chi-square test and the two-way repeated measures analysis of variance were used in the analysis of the data. The SPP formed the basis for the program.

RESULTS

The control group's sunscreen use and sun avoidance stages were behind and their self-efficacy mean scores significantly lower than the intervention group after the implementation of the SPP (p < .05).

CONCLUSIONS

The study showed that a SPP was effective in achieving progress in the TTM for sun protection. It can be suggested that school nurses will find it useful to make use of the sun protection program.

APPLICATION TO PRACTICE

School nurses who provide protective healthcare services can play an effective role in reducing the exposure of children and adolescents to the sun and promoting the development of sun protection behavior in schools.

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.

Making of Mobile SunSmart: Co-designing a Just-in-Time Sun Protection Intervention for Children and Parents

Background

In this study, we describe a participatory design process to develop a technology-based intervention for sun protection for children and their parents. Our methodology embraces and leverages the expert knowledge of the target users, children and their parents, about their sun protection practices to directly influence the design of our mobile just-in-time adaptive intervention (JITAI). The objectives of this paper are to describe our research procedures and summarize primary findings incorporated into developing our JITAI modules.

Methods

We conducted 3 rounds of iterative co-design workshops with design expert KidsTeam UW children (N: 11–12) and subject expert children and their parents from local communities in California (N: 22–48). Iteratively, we thematically coded the qualitative data generated by participants in the co-design sessions to directly inform design specifications.

Results

Three themes emerged: (1) preference for non-linear educational format with less structure,; (2) situations not conducive for prioritizing sun protection; and (3) challenges, barriers, and ambiguity relating to sun protection to protect oneself and one’s family. Based on the design ideas and iterative participant feedback, three categories of modules were developed: personalized and interactive data intake module, narrative-education module with augmented reality experiment, person/real-time tailored JITAI, and assessment modules.

Conclusions

This is one of the first projects that maximally engage children and parents as co-designers to build a technology to improve sun protection with iterative and intentional design principles. Our scalable approach to design a mobile JITAI to improve sun protection will lay the foundation for future public health investigators with similar endeavors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12529-021-09987-9.

A Sun Safety Pilot Program Using a Tanning Myths–Focused Video Contest for Utah Adolescents: Cross-sectional Analysis

Background

Adolescents are susceptible to excessive ultraviolet exposure due to intentional tanning, outdoor lifestyles, and poor sunscreen adherence. As skin cancer incidence continues to rise in the United States, effective and focused interventions are needed to encourage photoprotective behaviors.

Objective

This study seeks to determine poor photoprotective behavior risk factors in adolescents residing in Utah and whether video contest participants have increased sun-protective knowledge and intentions.

Methods

In this cross-sectional study, we surveyed Utah high school students (n=20) who participated in a tanning myths-themed public service announcement video contest. A control cohort of students who did not participate in the video contest were also surveyed (n=89). Demographics, sun exposure history, intentions to tan, and intentions to use sunscreen were documented. Knowledge of tanning myths was assessed with a 7-question sun safety quiz.

Results

The survey response rate was 93.2% (109/117). Two-thirds reported at least one sunburn, and 47.7% (52/109) reported intentional tanning within the past 2 years. Higher tanning intentions were associated with a personal (P<.001), family (P=.001), and peer (P<.001) history of tanning. Video contest participants had higher sun safety quiz scores (P<.001) and higher sunscreen use intentions (P=.01), but did not have decreased tanning intentions (P=.47) compared to non–video contest participants. Hispanic and Black students were less likely to participate in the video contest (P<.001 and P=.04, respectively). In a comparison of White students to students of color, there were no differences in sun exposure history, but students of color had lower sun safety knowledge (P=.01) and lower sunscreen use intention (P=.02).

Conclusions

Sun safety educational disparities exist, and targeted efforts are needed to encourage photoprotective behaviors in high-risk populations. Our findings suggest that video contest participation may encourage sunscreen use and sun protection awareness.

Effect of a Face-Aging Mobile App-Based Intervention on Skin Cancer Protection Behavior in Secondary Schools in Brazil: A Cluster-Randomized Clinical Trial

Question

Can a face-aging mobile app improve the skin cancer protection behavior of secondary school students?

Findings

In this cluster-randomized clinical trial of 52 school classes with 1573 Brazilian pupils, meaningful improvements were observed in sunscreen use, tanning behavior, and skin self-examinations 3 to 6 months after an intervention using a face-aging app compared with the nonintervention group.

Meaning

Face-aging apps may be useful tools to increase skin cancer protection in adolescents and thereby decrease skin cancer risk.

Importance

Because exposure to UV radiation early in life is an important risk factor for melanoma development, reducing UV exposure in children and adolescents is of paramount importance. New interventions are urgently required.

Objective

To determine the effect of the free face-aging mobile app Sunface on the skin cancer protection behavior of adolescents.

Design, Setting, and Participants

This cluster-randomized clinical trial included a single intervention and a 6-month follow-up from February 1 to November 30, 2018. Randomization was performed on the class level in 52 school classes within 8 public secondary schools (grades 9-12) in Itauna, Southeast Brazil. Data were analyzed from May 1 to October 10, 2019.

Interventions

In a classroom seminar delivered by medical students, adolescents’ selfies were altered by the app to show UV effects on their future faces and were shown in front of their class, accompanied by information about UV protection. Information about relevant parameters was collected via anonymous questionnaires before and 3 and 6 months after the intervention.

Main Outcomes and Measures

The primary end point of the study was the difference in daily sunscreen use at 6 months of follow-up. Secondary end points included the difference in daily sunscreen use at 3 months of follow-up, at least 1 skin self-examination within 6 months, and at least 1 tanning session in the preceding 30 days. All analyses were predefined and based on intention to treat. Cluster effects were taken into account.

Results

Participants included 1573 pupils (812 girls [51.6%] and 761 boys [48.4%]; mean [SD] age, 15.9 [1.3] years) from 52 school classes. Daily sunscreen use increased from 110 of 734 pupils (15.0%) to 139 of 607 (22.9%; P < .001) at the 6-month follow-up in the intervention group. The proportion of pupils performing at least 1 skin self-examination in the intervention group rose from 184 of 734 (25.1%) to 300 of 607 (49.4%; P < .001). Use of tanning decreased from 138 of 734 pupils (18.8%) to 92 of 607 (15.2%; P = .04). No significant changes were observed in the control group. The intervention was more effective for female students (number needed to treat for the primary end point: 8 for girls and 31 for boys).

Conclusions and Relevance

These findings suggest that interventions based on face-aging apps may increase skin cancer protection behavior in Brazilian adolescents. Further studies are required to maximize the effect and to investigate the generalizability of the effects.

Trial Registration

ClinicalTrials.gov Identifier: NCT03178240

Are Environmental Interventions Targeting Skin Cancer Prevention among Children and Adolescents Effective? A Systematic Review

Skin cancer, which is increasing exceedingly worldwide, is substantially preventable by reducing unprotected exposure to ultraviolet radiation (UVR). Several comprehensive interventions targeting sun protection behaviors among children and adolescents in various outdoor settings have been developed; however, there is a lack of insight on stand-alone effectiveness of environmental elements. To compose future skin cancer prevention interventions optimally, identification of effective environmental components is necessary. Hence, an extensive systematic literature search was conducted, using four scientific databases and one academic search engine. Seven relevant studies were evaluated based on stand-alone effects of various types of environmental sun safety interventions on socio-cognitive determinants, sun protection behaviors, UVR exposure, and incidence of sunburns and nevi. Free provision of sunscreen was most often the environmental component of interest, however showing inconsistent results in terms of effectiveness. Evidence regarding shade provision on shade-seeking behavior was most apparent. Even though more research is necessary to consolidate the findings, this review accentuates the promising role of environmental components in skin cancer prevention interventions and provides directions for future multi-component sun safety interventions targeted at children and adolescents in various outdoor settings.

Randomised controlled trial to evaluate the influence of mHealth and eHealth skin cancer prevention education among young organ transplant recipients: the HIPPOlino intervention study

OBJECTIVES

To determine whether a multicomponent sun protection intervention programme (mHealth) for young organ transplant recipients (OTR) leads to a higher increase of preventive knowledge and behavioural change than an e-learning education programme (eHealth).

DESIGN

Randomised controlled trial with one preintervention baseline survey and three follow-up surveys after 6 weeks, 6 and 12 months. Comparison of two different intervention schedules with a control group (CG).

SETTING

Multicomponent sun protection trainings in Germany, the Netherlands and Austria between June 2013 and September 2015.

PARTICIPANTS

137 OTRs (5-22 years of age, 61 females/76 males) participated in the study.

INTERVENTIONS

(A) Intervention group 1 (IG1): personal training with subsequent forwarding of individual ultraviolet index-dependent sun protection recommendations via short message service (SMS); (B) intervention group 2 (IG2): e-learning training without SMS; (C) CG: regular information letters, online training after 1 year.

OUTCOME MEASURES

Key questions were used to form a knowledge and a behavioural score. Behavioural strategies and knowledge were quantified through self-administered questionnaires.

RESULTS

Analyses 6 weeks after the intervention showed a higher knowledge increase in both IG compared with the CG (IG1 to CG: OR 12.64, 95% CI 4.20 to 38.20; IG2 to CG: OR 2.59, 95% CI 0.95 to 7.04). Sun protection behaviour improved slightly but not significantly in both IG (IG1 to CG: OR 2.56, 95% CI 0.93 to 7.00; IG2 to CG: OR 1.22, 95% CI 0.45 to 3.32). One year after the intervention, no behavioural changes were observed in either IG compared with the CG. IG1 but not IG2 still scored significantly higher in sun protection knowledge than the CG 1 year after intervention (IG1 to CG: OR 4.46, 95% CI 1.48 to 13.43; IG2 to CG: OR 1.41, 95% CI 0.51 to 3.93).

CONCLUSIONS

This multicomponent sun protection programme provides a promising strategy to increase sun protection knowledge and possibly also protective behaviour in young OTR.

TRIAL REGISTRATION NUMBER

DRKS00011393.

Implementation of Project Students Are Sun Safe (SASS) in Rural High Schools Along the Arizona-Mexico Border

The incidence of skin cancer is raising in Hispanics/Latinos, which is a concern for Hispanics/Latinos living in Arizona, a state with a high amount of ultraviolet radiation exposure. There is a dearth of research on skin cancer prevention education for Hispanic/Latino adolescents in high school. Using a community-based participatory research (CBPR) framework, academic and community partners conducted a project to adapt an existing efficacious skin cancer prevention program, Project Students are Sun Safe (SASS) and the current SASS online training model, for dissemination to predominantly Hispanic/Latino students attending high schools in rural southeastern Arizona, located along the Arizona-Mexico border. We assessed the feasibility of training some of these students as peer educators (n = 16) to implement the "Border SASS" lesson to their peers in high school classrooms (n = 198). Border SASS training and the classroom lesson were feasible for, and highly acceptable to, peer educators and classroom students. These students significantly improved skin cancer prevention knowledge scores and self-reported skin cancer prevention behaviors over a 3- to 4-month period post training and the intervention implementation. Here we report on the following: (1) academic-community partnership and adaptation of the SASS training model for rural Hispanic high school students, (2) training of the high school peer educators, (3) administration of the SASS lesson by the trained peer educators to high school students, and (4) further evaluation of peer educator training and classroom student outcomes.

Barriers to Enacting Childhood Sun Safety Behavior: Findings from Focus Group Interviews Among Hispanic Parents in Miami

Hispanics are generally diagnosed at more advanced stages of melanoma than non-Hispanic Whites, leading to lower survival rates. As skin cancer incidence is attributable to lifetime exposure to ultraviolet light, encouraging the performance of sun safety behaviors in childhood is an important strategy to address this divide. Problematically, we know little about the barriers to sun safety among Hispanic youth, especially among the Hispanics living in South Florida. To address this gap, we conducted focus groups among parents of Hispanic children aged 4-10 to understand the unique barriers to sun protection among this audience. Results revealed four categories of barriers: child-based barriers, external barriers, parental enactment barriers, and parental proper adherence barriers. These results are discussed in terms of their implications for future intervention research among this audience.

A Skin Cancer Prevention Facial-Aging Mobile App for Secondary Schools in Brazil: Appearance-Focused Interventional Study

Background

The incidence of melanoma is increasing faster than any other major cancer both in Brazil and worldwide. Southeast Brazil has especially high incidences of melanoma, and early detection is low. Exposure to ultraviolet (UV) radiation is a primary risk factor for developing melanoma. Increasing attractiveness is a major motivation among adolescents for tanning. A medical student-delivered intervention that takes advantage of the broad availability of mobile phones and adolescents’ interest in their appearance indicated effectiveness in a recent study from Germany. However, the effect in a high-UV index country with a high melanoma prevalence and the capability of medical students to implement such an intervention remain unknown.

Objective

In this pilot study, our objective was to investigate the preliminary success and implementability of a photoaging intervention to prevent skin cancer in Brazilian adolescents.

Methods

We implemented a free photoaging mobile phone app (Sunface) in 15 secondary school classes in southeast Brazil. Medical students “mirrored” the pupils’ altered 3-dimensional (3D) selfies reacting to touch on tablets via a projector in front of their whole grade accompanied by a brief discussion of means of UV protection. An anonymous questionnaire capturing sociodemographic data and risk factors for melanoma measured the perceptions of the intervention on 5-point Likert scales among 356 pupils of both sexes (13-19 years old; median age 16 years) in grades 8 to 12 of 2 secondary schools in Brazil.

Results

We measured more than 90% agreement in both items that measured motivation to reduce UV exposure and only 5.6% disagreement: 322 (90.5%) agreed or strongly agreed that their 3D selfie motivated them to avoid using a tanning bed, and 321 (90.2%) that it motivated them to improve their sun protection; 20 pupils (5.6%) disagreed with both items. The perceived effect on motivation was higher in female pupils in both tanning bed avoidance (n=198, 92.6% agreement in females vs n=123, 87.2% agreement in males) and increased use of sun protection (n=197, 92.1% agreement in females vs n=123, 87.2% agreement in males) and independent of age or skin type. All medical students involved filled in a process evaluation revealing that they all perceived the intervention as effective and unproblematic, and that all pupils tried the app in their presence.

Conclusions

The photoaging intervention was effective in changing behavioral predictors for UV protection in Brazilian adolescents. The predictors measured indicated an even higher prospective effectiveness in southeast Brazil than in Germany (>90% agreement in Brazil vs >60% agreement in Germany to both items that measured motivation to reduce UV exposure) in accordance with the theory of planned behavior. Medical students are capable of complete implementation. A randomized controlled trial measuring prospective effects in Brazil is planned as a result of this study.

A skin cancer prevention photoageing intervention for secondary schools in Brazil delivered by medical students: protocol for a randomised controlled trial

INTRODUCTION

The incidence of melanoma is increasing faster than any other major cancer both in Brazil and worldwide. The Southeast of Brazil has especially high incidences of melanoma, and early detection is low. Exposure to UV radiation represents a primary risk factor for developing melanoma. Increasing attractiveness is a major motivation for adolescents for tanning. A medical student-delivered intervention that harnesses the broad availability of mobile phones as well as adolescents' interest in their appearance may represent a novel method to improve skin cancer prevention.

METHODS AND ANALYSIS

We developed a free mobile app (Sunface), which will be implemented in at least 30 secondary school classes, each with 21 students (at least 30 classes with 21 students for control) in February 2018 in Southeast Brazil via a novel method called mirroring. In a 45 min classroom seminar, the students' altered three-dimensional selfies on tablets are 'mirrored' via a projector in front of their entire class, showing the effects of unprotected UV exposure on their future faces. External block randomisation via computer is performed on the class level with a 1:1 allocation. Sociodemographic data, as well as skin type, ancestry, UV protection behaviour and its predictors are measured via a paper-pencil questionnaire before as well as at 3 and 6 months postintervention. The primary end point is the group difference in the 30-day prevalence of daily sunscreen use at a 6-month follow-up. Secondary end points include (1) the difference in daily sunscreen use at a 3-month follow-up, (2) if a self-skin examination in accordance with the ABCDE rule was performed within the 6-month follow-up and (3) the number of tanning sessions.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the ethics committee of the University of Itauna. Results will be disseminated at conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03178240; Pre-results.

Photoaging Mobile Apps in School-Based Melanoma Prevention: Pilot Study

BACKGROUND

Around 90% of melanomas are caused by exposure to ultraviolet (UV) radiation and are therefore eminently preventable. Tanning behavior is mostly initiated in early adolescence, often with the belief that it increases attractiveness; the problems related to malignant melanoma and other skin cancers are too far in the future to fathom. Given the substantial amount of time children and adolescents spend in schools, as well as with their mobile phones, addressing melanoma prevention via both of these ways is crucial. However, no school-based intervention using mobile apps has been evaluated to date. We recently released a photoaging mobile app, in which a selfie is altered to predict future appearance dependent on UV protection behavior and skin type.

OBJECTIVE

In this pilot study, we aimed to use mobile phone technology to improve school-based melanoma prevention and measure its preliminary success in different subgroups of students with regard to their UV protection behavior, Fitzpatrick skin type and age.

METHODS

We implemented a free photoaging mobile phone app (Sunface) in 2 German secondary schools via a method called mirroring. We "mirrored" the students' altered 3-dimensional (3D) selfies reacting to touch on mobile phones or tablets via a projector in front of their whole grade. Using an anonymous questionnaire capturing sociodemographic data as well as risk factors for melanoma we then measured their perceptions of the intervention on a 5-point Likert scale among 205 students of both sexes aged 13-19 years (median 15 years).

RESULTS

We measured more than 60% agreement in both items that measured motivation to reduce UV exposure and only 12.5% disagreement: 126 (63.0%) agreed or strongly agreed that their 3D selfie motivated them to avoid using a tanning bed, and 124 (61.7%) to increase use of sun protection. However, only 25 (12.5%) disagreed with both items. The perceived effect on motivation was increased in participants with Fitzpatrick skin types 1-2 in both tanning bed avoidance (n=74, 71.8% agreement in skin types 1-2 vs n=50, 53.8% agreement in skin types 3-6) and increased use of sun protection (n=70, 68.0% agreement in skin types 1-2 vs n=52, 55.3% agreement in skin types 3-6), and also positively correlated with higher age.

CONCLUSIONS

We present a novel way of integrating photoaging in school-based melanoma prevention that affects the students' peer group, considers the predictors of UV exposure in accordance with the theory of planned behavior, and is particularly effective in changing behavioral predictors in fair-skinned adolescents (Fitzpatrick skin types 1-2). Further research is required to evaluate the intervention's prospective effects on adolescents of various cultural backgrounds.

A Trial Online Educational Melanoma Program Aimed at the Hispanic Population Improves Knowledge and Behaviors

BACKGROUND

Hispanic individuals who suffer from melanoma are diagnosed later and have a worse prognosis. Because the Hispanic population is one of the fastest growing in the United States, it is important to spread awareness of melanoma.

OBJECTIVE

The study aimed to evaluate whether an online educational video about skin cancer could improve knowledge about melanoma and encourage self-skin examinations (SSE).

METHODS

The authors directed Hispanic patients to an online survey, which assessed for knowledge about melanoma risk factors and prevention. This was followed by a 5-minute online video about melanoma. A second survey was sent immediately after the video, and a third survey was sent 1 month later. All project materials were in Spanish and available online.

RESULTS

Eighty-six participants completed the full experiment. After watching the online video, a significantly higher proportion of participants provided correct answers for melanoma risk factors and prevention techniques. A similar increase was seen in the number of individuals who reported performing SSEs.

CONCLUSION

This study provides evidence that an online educational video targeted at the Hispanic population has potential to improve melanoma awareness. This type of intervention may lead to earlier diagnosis and better prognosis for Hispanic individuals.