An Internet-based programme to promote adequate UV exposure behaviour in adolescents in Spain

Cancer Education Interventions in Adolescents: A Systematic Review of Scope and Content

Given the long induction time of many cancers and the fact that modifiable risk factors (e.g., cigarette smoking) including preventive factors (e.g., human papillomavirus [HPV] vaccination, healthy dietary and physical activity patterns) are influenced in adolescence, educating adolescents about cancer causation and risk reduction may have a large impact on reducing the cancer burden. We conducted a systematic review of literature evaluating the impact of cancer education interventions on adolescent knowledge of cancer risk reduction. We searched for articles published from 2000 to 2019 and identified 33 studies meeting our criteria. Given the methodological heterogeneity across studies, we briefly assessed effectiveness but focused on examining the design of the intervention and study. The majority of studies took place outside of the United States (67%). Most studies solely addressed skin or cervical cancer (67%) with only 18% (n = 6) discussing multiple cancers. The majority of interventions were a single-session (55%), did not involve a control or comparison group (67%), and were evaluated using a pre-test and a single post-test (61%); some studies administered multiple post-tests. Few studies (12%) investigated adolescents' knowledge of lifestyle and environmental risk factors at both the individual and community level. Most studies (94%) reported improvement in knowledge following an intervention. Our review revealed wide methodological variation and a deficit in research evaluating interventions that address multiple cancer types and risk factors. Future research should robustly test whether comprehensive cancer education for adolescents can reduce the cancer burden, particularly in communities with major cancer health disparities.

Digital interventions for promoting sun protection and skin self-examination behaviors: A systematic review

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A considerable number of digital interventions for skin cancer prevention have been evaluated.

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Most skin cancer digital interventions focus on sun protection-related outcomes.

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Most interventions use web-based digital technology (websites, webpages, mobile apps) rather than videos, emails or text messages alone as the delivery platform.

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Multi-component digital interventions are effective in promoting sun protection and skin self-examination.

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Almost all studies found digital interventions to be equally or more effective compared to non-digital interventions.

The skin cancer incidence rate has been rising, and digital health interventions can promote skin cancer prevention and detection behaviors. A systematic review was conducted to investigate the outcomes of digital interventions that promote sun protection and skin self-examination (SSE). This review examined studies that utilized randomized controlled designs or quasi-experiments, included outcomes related to sun safety or SSE, employed at least one digital platform, and were published in English from January 2000 to October 2020. A total of 62 studies were included in the review. Digital modalities included web-based (e.g., websites) alone (n = 29), mobile-based (e.g., mobile apps) alone (n = 12), game-based (n = 1), emails or text messages alone (n = 8), videos alone (n = 6), social media (n = 3), both text messages and mobile apps (n = 2), or both text messages and video (n = 1). Most studies (n = 44) only evaluated sun protection-related outcomes, seven studies assessed SSE outcomes only, nine studies examined both, and two assessed other related outcomes. Digital interventions are effective compared to non-intervention control conditions in promoting sun safety or SSE. Almost all studies found digital interventions to be equally or more effective compared to non-digital interventions. This review suggests that although the digital interventions varied, they showed promising effects on improving sun protection or SSE outcomes. Future research should include more sophisticated phase-based and rigorous longitudinal research designs, additional investigation of social media and other newer technologies, as well as more detailed reporting of methods and results.

Digital Health Promotion and Prevention in Settings: Scoping Review

BACKGROUND

Digital technologies are increasingly integrating into people's daily living environments such as schools, sport clubs, and health care facilities. These settings play a crucial role for health promotion and prevention because they affect the health of their members, as the World Health Organization has declared. Implementing digital health promotion and prevention in settings offers the opportunity to reach specific target groups, lower the costs of implementation, and improve the health of the population. Currently, there is a lack of scientific evidence that reviews the research on digital health promotion and prevention in settings.

OBJECTIVE

This scoping review aims to provide an overview of research targeting digital health promotion and primary prevention in settings. It assesses the range of scientific literature regarding outcomes such as applied technology, targeted setting, and area of health promotion or prevention, as well as identifies research gaps.

METHODS

The scoping review was conducted following the Levac, Colquhoun, and O'Brien framework. We searched scientific databases and gray literature for articles on digital setting-based health promotion and prevention published from 2010 to January 2020. We included empirical and nonempirical publications in English or German and excluded secondary or tertiary prevention and health promotion at the workplace.

RESULTS

From 8888 records, the search resulted in 200 (2.25%) included publications. We identified a huge diversity of literature regarding digital setting-based health promotion and prevention. The variety of technology types extends from computer- and web-based programs to mobile devices (eg, smartphone apps) and telemonitoring devices (sensors). We found analog, digital, and blended settings in which digital health promotion and prevention takes place. The most frequent analog settings were schools (39/200, 19.5%) and neighborhoods or communities (24/200, 12%). Social media apps were also included because in some studies they were defined as a (digital) setting. They accounted for 31.5% (63/200) of the identified settings. The most commonly focused areas of health promotion and prevention were physical activity (81/200, 40.5%), nutrition (45/200, 22.5%), and sexual health (34/200, 17%). Most of the interventions combined several health promotion or prevention methods, including environmental change; providing information, social support, training, or incentives; and monitoring. Finally, we found that the articles mostly reported on behavioral rather than structural health promotion and prevention.

CONCLUSIONS

The research field of digital health promotion and prevention in settings is heterogeneous. At the same time, we identified research gaps regarding the absence of valid definitions of relevant terms (eg, digital settings) and the lack of literature on structural health promotion and prevention in settings. Therefore, it remains unclear how digital technologies can contribute to structural (or organizational) changes in settings. More research is needed to successfully implement digital technologies to achieve health promotion and prevention in settings.

Developing an Online Tool to Promote Safe Sun Behaviors With Young Teenagers as Co-researchers

Despite education about the risks of excessive sun exposure, teenagers in Australia are sun-seeking, with sunburn common in summer. Conversely, some regular (time-limited) exposure to sunlight (that avoids sunburn) is necessary for vitamin D and healthy bones and other molecules important for immune and metabolic health. New interventions are thus required to better support teenagers to make healthy and balanced decisions about their sun behaviors. This paper describes the development of a prototype online tool—a smartphone app—that aimed to foster safe sun practices in teenagers. We recruited young adolescents (aged 12–13 years, n = 24) as “co-researchers” to provide ongoing input into the nature and design of the online tool. This age group was selected, as it is a critical time when young people transition from primary education, where “SunSmart” behaviors are entrenched in Australian schools, to high school, where risky behaviors emerge. Through a series of interviews and workshops, we codesigned an Apple iOS smartphone app with the co-researchers, leading health promotion professionals, researchers, and app designers. The developed app, Sun Safe, contains educational content relevant to teenagers about safe sun behaviors, complemented by other features requested by co-researchers and stakeholders to help engage young people, including gamified quizzes to test their sun health knowledge, real-time weather data on the UV Index and temperature, a sunscreen application timer, and reminders to check the UV Index. The developed prototype app was rated well by co-researchers, suggesting it is suitable for further feasibility and efficacy testing as an intervention tool to improve knowledge and promote safe sun behaviors by young adolescents.

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.

Effectiveness of Sun Protection Interventions Delivered to Adolescents in a Secondary School Setting: A Systematic Review

Aim

The aim of this systematic review is to summarise the evidence of the effectiveness of interventions targeted to adolescents (13 to 18 years inclusive) and delivered in a secondary school setting with the purpose of improving sun protection behaviour, reducing ultraviolet radiation (UVR) exposure, and/or improving physiological outcomes related to UVR exposure (such as erythema or naevi development).

Methods

Peer-reviewed journal articles were identified from seven database searches (Cochrane, Embase, CINAHL, Scopus, Medline, PsycInfo, and Web of Science) to January 2020, forward citation searches of relevant articles, and monitoring of WHO INTERSUN UVR list server for recent publications. Relevant articles were collected and critically analysed using the Effective Public Health Practice framework. Two reviewers independently reviewed, and when deemed eligible, extracted data and performed quality appraisals for each study.

Results

Thirteen studies met the criteria for inclusion in the review. There were no studies that met a “strong” quality rating, five received a “moderate” quality rating, and eight studies a “weak” quality rating. Three of those with a moderate rating found evidence for effectiveness. The most promising interventions overall (including the pilot/uncontrolled studies) were those that moved beyond a pure health education approach and used innovative approaches such as the provision of shade, or use of technology (e.g., appearance-based apps or real-time ultraviolet index (UVI) monitors).

Conclusions

There is a lack of high-quality published studies investigating the interventions delivered in a secondary school setting to protect students from UVR. The evidence could be strengthened if researchers used consistent, standardised outcome measures for sun protection exposure and behaviour. Other factors limiting the strength of evidence were short follow-up times (largely less than 6 months) and/or nonrobust study design.

Sun protection education for adolescents: a feasibility study of a wait-list controlled trial of an intervention involving a presentation, action planning, and SMS messages and using objective measurement of sun exposure

BACKGROUND

People increase their risk of melanoma unless they are protected from the harmful effects of sun exposure during childhood and adolescence. We aimed to assess the feasibility of a three-component sun protection intervention- presentation, action planning, and SMS messages - and trial parameters.

METHODS

This feasibility wait-list trial was conducted in the United Kingdom in 2018. Students aged 13-15 years were eligible. Feasibility outcomes were collected for recruitment rates; data availability rates for objective measurements of melanin and erythema using a Mexameter and self-reported sunburn occurrences, severity and body location, tanning, sun protection behaviours and Skin Self-Examination (SSE) collected before (baseline) and after the school summer holidays (follow-up); intervention reach, adherence, perceived impact and acceptability. Quantitative data were analysed using descriptive statistics; qualitative data were analysed thematically.

RESULTS

Five out of eight schools expressing an interest in participating with four allocated to act as intervention and one control. Four parents/carers opted their child out of the study. Four hundred and eighty-seven out of 724 students on the school register consented to the study at baseline (67%). Three hundred and eighty-five were in intervention group schools. Objective skin measurements were available for 255 (66%) of the intervention group at baseline and 237 (61%) of the group at follow up. Melanin increased; erythema decreased. Complete self-report data were available for 247 (64%) students in the intervention group. The number of students on the school register who attended the presentation and given the booklet was 379 (98%) and gave their mobile phone number was 155 (40%). No intervention component was perceived as more impactful on sun protection behaviours. Adolescents did not see the relevance of sun protection in the UK or for their age group.

CONCLUSIONS

This is the first study to use a Mexameter to measure skin colour in adolescents. Erythema (visible redness) lasts no more than three days and its measurement before and after a six week summer holiday may not yield relevant or meaningful data. A major challenge is that adolescents do not see the relevance of sun protection and SSE.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN11141528. Date registered 0/2/03/2018; last edited 31/05/2018. Retrospectively registered.

Creation Of The «Soludable» Sun Protection Accreditation Program For Schools

INTRODUCTION

Sun exposure during childhood is the main risk factor for skin cancer in later life. School-based sun protection policies and practices have proven to be the most effective and cost-effective strategies for preventing skin cancer.

OBJECTIVE

To develop a sun protection accreditation program known as «Soludable» (a play on the Spanish words sol [sun] and saludable [healthy]) to objectively identify schools that actively promote sun protection behaviors among students.

METHODS

The consensus method used was a 2-round Delphi technique with input from a panel of experts. We then calculated the median scores for the importance and feasibility of each of the recommendations proposed and the level of complexity assigned to each recommendation by counting the percentage of experts who chose each difficulty category.

RESULTS

The resulting accreditation model consists of 14 recommendations with corresponding evaluation criteria divided into 7 domains: 1) organizational leadership (5 recommendations), 2) effective communication (2 recommendations), 3) structural elements (2 recommendations), 4) training of professionals (1 recommendation), 5) school curriculum (1 recommendation), 6) behavioral models (2 recommendations), and 7) student habits (1 recommendation). A high level of agreement among experts was observed for all recommendations, in terms of both their perceived importance and feasibility and their categorization by levels of complexity.

CONCLUSIONS

This is the first sun protection accreditation program developed for Spanish schools. Studies are needed to evaluate how this program is received and how it affects students' sun protection behaviors.

Promoting sunscreen use and skin self-examination to improve early detection and prevent skin cancer: quasi-experimental trial of an adolescent psycho-educational intervention

Background

Skin cancer rates are increasing. Interventions to increase adolescent sunscreen use and skin self-examination (SSE) are required.

Methods

Quasi-experimental design; 1 control and 4 intervention group schools in Scotland, UK. Participants were 15–16 year old students on the school register. The intervention was a theoretically-informed (Common-Sense Model and Health Action Process Approach) 50-min presentation, delivered by a skin cancer specialist nurse and young adult skin cancer survivor, to students in a classroom, supplemented by a home-based assignment. Outcome variables were sunscreen use intention, SSE intention/behaviour, planning, illness perceptions and skin cancer communication behaviour, measured 2 weeks pre- and 4 weeks post- intervention using self-completed pen and paper survey. School attendance records were used to record intervention up-take; students self-reported completion of the home-based assignment. Pearson’s chi-square test, analysis of variance, and non-parametric Wilcoxon Signed Ranks Test were used to measure outcomes and associations between variables. Focus groups elicited students’ (n = 29) views on the intervention. Qualitative data were analysed thematically.

Results

Five of 37 invited schools participated. 639 (81%) students in intervention schools received the intervention; 33.8% completed the home-based assignment. 627 (69.6%) of students on the school register in intervention and control schools completed a questionnaire at baseline; data for 455 (72.6%) students were available at baseline and follow-up. Focus groups identified four themes – personal experiences of skin cancer, distaste for sunscreen, relevance of SSE in adolescence, and skin cancer conversations. Statistically significant (p < 0.05) changes were observed for sunscreen use, SSE, planning, and talk about skin cancer in intervention schools but not the control. Significant associations were found between sunscreen use, planning and 2 illness perceptions (identity and consequence) and between SSE, planning and 3 illness perceptions (timeline, causes, control).

Conclusions

It is feasible to promote sunscreen use and SSE in the context of an adolescent school-based psychoeducation intention. Further research is required to improve study uptake, intervention adherence and effectiveness.

Trial registration

ISRCTN11141528

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5570-y) contains supplementary material, which is available to authorized users.

Adolescents' Attitudes to Sun Exposure and Sun Protection

Adolescents are considered a risk group for the development of skin cancer in later life due to their high rates of sunburn. The aim of this study is to evaluate the association between attitudes to sun exposure and the sociodemographic characteristics of adolescents, their habits, practices and knowledge. As a secondary goal, we describe the magnitude and sign of the correlations between these attitudes. Cross-sectional study of adolescent students from 12 secondary schools in southern Spain, the subjects were asked to complete the 'Beach Questionnaire'. This instrument examines four dimensions of attitudes, with standardised scores of 0-100, related to the sun, sun tanning, sun protection and sun cream. The higher the score, the more positive the attitude. The study population was composed of 270 adolescents. The highest scores were obtained for attitudes towards sun protection practices (mean 66.2; SD 18.6) and towards sun tanning (mean 64.2; SD 21.1). The lowest scores were obtained for attitudes towards using sun cream (mean 50.1; SD 24.6). Significant differences were found for all four attitudes, with a positive sign for the relationship between the number of days of sun exposure and a higher score for attitudes towards sunbathing (27.3 points difference between response extremes) and for attitudes towards suntanning (20 points difference). Favourable attitudes towards sunbathing and sun tanning have most influence on inadequate habits of sun exposure and deficient measures of sun protection. Adolescents should be considered a priority group for targeted interventions to improve sun protection behaviour.

Using UV photoaged photography to better understand Western Australian teenagers' attitudes towards adopting sun-protective behaviors

BACKGROUND

This study aimed to determine whether the viewing of a personal photoaged photograph had the capacity to alter Western Australian teenagers' pro-tanning attitudes.

METHOD

Semi-structured interviews were conducted with fifteen teenagers.

FINDINGS

The teenagers' pro-tanning attitudes prior to viewing their photoaged photograph are encapsulated in the study's central theme: 'You've got to look after your skin and use sunscreen, but I always forget!'. Post-viewing their photoaged facial image many teenagers reiterated their intentions to adopt (when they remembered) skin-protective measures. However, photoaged photography did not alter other teenagers' intention to tan. NEW KNOWLEDGE: Teenagers who choose to continue to tan were aware of the long-term health risks associated with ultra-violet over-exposure. However, their desire remained strong to emulate the media promoted image of bronzed youth being popular individuals. Indeed, the social benefits of being considered attractive to their peers became an attitudinal barrier to the teenagers' adoption of skin-protective behaviours. Those teenagers who changed their pro-tanning attitudes following their viewing of their ultra-violet photoaged photograph did so because of the shock they received when they saw their sun-damaged facial image. This suggests that photoageing photography can be effective with many adolescents because it reduces the cause-and-effect delay that exists between the occurrence of sun-damage and its visual presentation in later-life.

CONCLUSION

Greater effort needs to be focused on increasing teenagers' understanding of how sun-damage occurs, when it is appropriate to apply sunscreen, as well as in changing the prevailing media image of an attractive body being a tanned body.

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.

Brazilian consensus on photoprotection

Brazil is a country of continental dimensions with a large heterogeneity of climates and massive mixing of the population. Almost the entire national territory is located between the Equator and the Tropic of Capricorn, and the Earth axial tilt to the south certainly makes Brazil one of the countries of the world with greater extent of land in proximity to the sun. The Brazilian coastline, where most of its population lives, is more than 8,500 km long. Due to geographic characteristics and cultural trends, Brazilians are among the peoples with the highest annual exposure to the sun. Epidemiological data show a continuing increase in the incidence of non-melanoma and melanoma skin cancers. Photoprotection can be understood as a set of measures aimed at reducing sun exposure and at preventing the development of acute and chronic actinic damage. Due to the peculiarities of Brazilian territory and culture, it would not be advisable to replicate the concepts of photoprotection from other developed countries, places with completely different climates and populations. Thus the Brazilian Society of Dermatology has developed the Brazilian Consensus on Photoprotection, the first official document on photoprotection developed in Brazil for Brazilians, with recommendations on matters involving photoprotection.

Effects of a short messaging service-based skin cancer prevention campaign in adolescents

BACKGROUND

Skin cancer prevention emphasizes early adoption and practice of sun protection behaviors. Adolescence represents a high-risk period for ultraviolet radiation exposure, presenting an opportunity for intervention. The ubiquity of mobile phones among teens offers an engaging medium through which to communicate prevention messages.

PURPOSE

To evaluate a skin cancer prevention intervention using short messaging service (SMS, or text messages) to impact sun-related knowledge, beliefs, and behaviors among adolescents.

METHODS

The intervention was conducted in middle school youth (N=113) recruited in April or October 2012. Participants were English speakers, 11-14 years old, routinely carried a mobile phone, and completed a 55-minute sun safety education program. Participants were sent three sun safety-themed SMS messages each week for 12 weeks. Skin and sun protective knowledge, beliefs, behaviors, and post-intervention program satisfaction were collected and analyzed at baseline and end of intervention (April/June 2012; October 2012/January 2013). Paired responses were tested for equality using Wilcoxon signed-rank tests.

RESULTS

Ninety-six students (85%) completed the study. At 12 weeks, significant positive changes were reported for sun avoidance during peak ultraviolet radiation, sunscreen application, wearing hats and sunglasses, and knowledge about skin cancer risk. Participants expressed moderately high satisfaction with the program, and 15% shared messages with family or friends.

CONCLUSIONS

A brief, SMS-based intervention affected youth skin cancer prevention behaviors and knowledge. Future research will determine whether program effects were sustained at 24 weeks and explore how sun safety parenting practices inform these effects.

Impact of a web-based intervention supplemented with text messages to improve cancer prevention behaviors among adolescents: results from a randomized controlled trial

OBJECTIVE

To assess the impact of a web-based intervention supplemented with text messages to reduce cancer risk linked with smoking, unhealthy diet, alcohol consumption, obesity, sedentary lifestyle and sun exposure.

METHODS

A total of 2001 voluntary adolescents from Spain and Mexico were recruited between 2009 and 2012 and randomly assigned to: one control group and two experimental groups, which received exclusively the online intervention (experimental group 1) or the intervention supplemented with encouraging text messages (experimental group 2). The educational intervention was based on both: successful psychosocial models (i.e. A.S.E. and Transtheoretical model) and the school curriculum.

RESULTS

After a 9-month follow-up, the prevalence of students who did not eat fruit was reduced significantly in all groups: experimental group 1 (-62.6%), experimental group 2 (-71.5%) and even the control group (-66.8%). Being overweight was only reduced in the experimental group 2 (-19.6%). The total cancer behavioral risk score, which ranged from 0 to 100 points (highest risk), was significantly reduced in the experimental group 1 (-3.5 points) and in the experimental group 2 (-5.3 points). The text-supplemented online intervention increased the probability of improving the post-test total cancer behavioral risk (OR=1.62).

CONCLUSION

The web-based intervention supplemented with text messages had a positive global impact, but it lead to only minimal changes in risky behaviors. This intervention appears useful in controlling overweight adolescents.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN27988779.

Study protocol of a randomized controlled trial to improve cancer prevention behaviors in adolescents and adults using a web-based intervention supplemented with SMS

Background

The overall number of cancer cases is increasing and, therefore, strengthening cancer prevention has become a priority. The institutions responsible for its control establish guidelines for primary prevention. These include recommendations, such as: not smoking, following a healthy diet, doing daily physical exercise or avoiding overweight. Adolescence is a period of adoption and/or consolidation of health behaviors, and both school- and family-based interventions have proven effective to improve them. Furthermore, online and mobile phone educational interventions are encouraging. Consequently, the main aim of this study is to assess the efficacy of an intervention in which these requirements (school, family, the Internet and SMS) are combined to prevent behavioral cancer risk.

Methods

This protocol describes the design and implementation of a complex online program that includes a randomized controlled trial put into practice in two countries: Spain and Mexico. Adolescents and adults of their environment (relatives and teachers) who voluntarily participate will be randomly assigned to the experimental group or to the control group once they have completed the online pre-test. The experimental group members will have free access to a tailor-made and interactive website (http://www.alertagrumete.com). During the academic year, this website will be periodically updated with different school and leisure activities related to the avoidance of risk behaviors. To encourage participation, the program includes a competition that gives rewards to the winners. SMS are also sent to students to stimulate the adoption of healthy behaviors and as a reminder of participation. Finished the intervention, an online post-test is performed in both groups and the impact on the risk behaviors is therefore assessed.

Discussion

The program is pioneer, since it combines many components which have already proven effective in previous researches. Moreover, it aims to compare efficacy in two countries with different socio-economic levels to find out if these approaches are equally effective in countries with a lower income level. However, the vertiginous evolution of the Internet and mobile phones may make this tool less attractive for adolescents, who may prefer social networks and other mobile phone applications which are nowadays massively used by their peers.

Trial registration

ISRCTN27988779