Evaluation of the Sunny Days, Healthy Ways sun safety curriculum for children in kindergarten through fifth grade

Protocol for a cluster-randomized trial of a school-based skin cancer preventive intervention for adolescents

BACKGROUND

Adolescents infrequently use sun protection and engage in intentional tanning more frequently compared to other age groups, leading to increased ultraviolet radiation (UVR) exposure that heightens skin cancer risk across the lifespan. High schools are therefore an ideal setting for offering skin cancer preventive interventions. Yet, there are limited UVR protection interventions for high school students, especially those that are personalized, tested using randomized designs, and include long-term outcome assessment to determine the durability of intervention effects.

METHOD

The Sun-safe Habits Intervention and Education (SHINE) cluster-randomized trial will test a novel, personalized intervention that targets high school adolescents' sun protection and tanning behaviors, and tracks their outcomes for up to one year following intervention. Enrolled high schools will be randomized to receive either the personalized SHINE intervention, which includes facial UVR photographs and sun protection action planning, or standard education using publicly available materials. Students in both conditions will receive information about skin cancer, sun protection, and skin self-examination. Outcome variables will include students' sun protection and tanning behaviors and sunburn occurrence. Potential moderators (e.g., race/ethnicity) and mediators (e.g., self-efficacy) will also be assessed and tested.

CONCLUSIONS

This trial examines the efficacy of a personalized intervention targeting sun protection and tanning of high school students. The project will lead to new scientific understanding of the theoretical mechanisms underlying outcomes and moderators of the intervention effects, which will inform future intervention tailoring to meet the needs of vulnerable subgroups.

Efficacy of a facial-aging web app on sun protection behaviors among primary school students in Iran: a randomized controlled trial

BACKGROUND

Skin cancers resulting from excessive exposure to solar ultraviolet (UV) radiation are on the rise. This study aims to investigate the impact of facial-aging app intervention on promoting safe and healthy behaviors and its influence on reducing students' UV exposure.

METHOD

Utilizing a Pretest-Posttest repeated-measures design, we developed a theory-guided web app on the WhatsApp platform, named the Sunshine and Skin Health app. This app allows users to visualize their altered faces in three stages of adolescence, middle age, and old age based on sun protection behavior. The intervention continued within WhatsApp, incorporating 27 health messages grounded in the PMT theory, eight educational files, and a skin cancer video clip. The primary outcome is the change in sun protection behavior between the two groups (intervention and control) immediately after the intervention (T2) and the secondary outcome is the change in sun protection behavior between the two groups at 3 months follow-up (T3). The data are analyzed in SPSS 22 and a significance level of 0.05 is considered.

RESULTS

The results revealed no significant difference between the two groups before the intervention. However, in the intervention group, there were significant differences in the utilization of sunglasses, hats, and sunscreen in the last month, as well as sunscreen reapplication after washing their hands and face, both immediately after the intervention and at the 3-month follow-up, compared to the control group (P = 0.001). Furthermore, a significant intervention effect, time effect, and interaction effect between group and time were observed in behaviors related to using sunscreen in the last month and sunscreen reapplication after washing hands and face (P = 0.001). Specifically, the intervention group exhibited a significant difference from Time 1 to 2 and from Time 1 to 3 (p = 0.001), but no significant difference from Time 2 to 3. In contrast, the control group did not show any significant differences over time.

CONCLUSIONS

This study indicated that the Facial-Aging web app can effectively encourage safe behaviors in sunlight. To ensure the maintenance and sustainability of these behaviors over the long term, it is crucial to consider implementing booster sessions.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20200924048825N1. Registered prospectively on 8 February 2021.

Photoaging and theory-based intervention to improve sun protection behaviors in students in Zahedan: study protocol for a randomized controlled trial

BACKGROUND

Excessive exposure to solar ultraviolet (UV) radiation can cause skin cancer. Implementing new technologies and computational algorithms can potentially change the outlook for cancer prevention and facilitate early detection of melanoma, thereby reducing mortality. Mobile technology as a potential provider of health services in delivering health information and conducting interventions, especially in skin fields, where a significant part of diagnosis is based on visual examination, can be important. Evidence showed that constructs of protection motivation theory (PMT) were good predictors of practicing sun protection behaviors in students. This study will investigate whether mobile applications improve safe and healthy behaviors and affect students' reduced UV exposure.

METHOD/DESIGN

This randomized controlled trial will be conducted on 320 students on 06/04/2022 in Zahedan. We created mobile applications (Sunshine and Skin Health and WhatsApp apps). Sunshine and Skin Health app allows users to see their changed faces in three stages of adolescence, middle age, and old age based on sun protection behavior. The WhatsApp app has 27 health messages based on PMT theory, eight educational files, and a skin cancer clip that will be sent through WhatsApp during a week. Randomization will be performed using a 1:1 (control: intervention) ratio. The primary endpoint is the group difference in sun-protective behaviors and PMT constructs immediately after the intervention. The secondary endpoint is the group difference in sun-protective behaviors and PMT constructs at a 3-month follow-up. The data will be analyzed in SPSS.22, and the significance level will be considered at 0.05.

DISCUSSION

The present study examines the effectiveness of mobile applications in improving sun-protective behaviors. If this intervention enhances sun protection behaviors, it can prevent students' skin damage.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20200924048825N1. Prospectively registered on 8 February 2021.

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.

Cluster Randomized Trial: Sun Protection Intervention 'Clever in Sun and Shade for Preschools'-Effectiveness and Dissemination

Skin cancer is one of the most common types of cancer and UV radiation is one of the main risk factors. Therefore, sun protection, especially in childhood, is strongly recommended. We examined the effectiveness of the ‘Clever in Sun and Shade for Preschools’ program (CLEVER) in promoting sun protection behavior among preschool staff (trial registration: DRKS00023468) and describe its dissemination. Within a cluster randomized trial with 24 preschools (n = 273 staff members) stating a high need for sun protection measures, an educational workshop for preschool staff and a project kit with materials applicable in preschool groups was provided. Staff members of preschools taking part in CLEVER report significantly stronger sun protection behavior to avoid the sun (effect size [ES] 0.70, 95% confidence interval [CI] 0.04 0.71, p < 0.05) and less perceived impediments to avoid the sun (ES −0.56, CI −0.82 −0.17, p < 0.01) after 12 months as well as higher self-efficacy to avoid the sun (ES 1.09, CI 0.39 1.07, p < 0.001) and to use sunscreen (ES 0.71, CI 0.03 0.88, p < 0.05) after 1 month. Compared to the control group, there was no significant effect on sunscreen use and further psychosocial outcomes. The effectiveness of CLEVER may be underrated due to a high drop-out rate. Within three years, an enhanced free-of-charge program kit, including a media-based workshop and materials, had reached over 4000 preschools, i.e., 7.1% of all daycare centers in Germany. The results show that CLEVER can strengthen sun protection, offer high-quality information at low cost, and is easily disseminable.

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.

Parent reports of sun safety communication and behaviour for students in a randomised trial on a school policy implementation intervention

OBJECTIVE

Schools are an important setting for skin cancer prevention. An intervention for implementation of school sun safety policy, Sun Safety Schools (SSS), was evaluated.

METHODS

Primary schools (n=118) in California school districts that had already adopted a sun safety policy were enrolled in a study with a randomised controlled design. Half of the schools were randomised to SSS intervention (N=58). Parents completed an online post-test.

RESULTS

More parents in intervention schools received information about sun safety (mean=26.3%, sd=3.1%, p=0.017) and children more frequently wore sun-protective clothing when not at school (mean=2.93, sd=0.03, p=0.033) than in control schools (mean=18.0%, sd=2.5%; mean=2.83, sd=0.03, respectively). In schools where principals reported implementing sun safety practices, parents reported that children spent less time outdoors at midday (mean=14.78 hours, sd=0.25, p=0.033) and fewer were sunburned (mean=12.7%, sd=1.1%, p=0.009) than in non-implementing schools (M=16.3 hours, sd=0.67; mean=21.2%, sd=3.8%, respectively). Parents who received sun safety information (mean=3.08, sd=0.04, p=0.008) reported more child sun protection than parents not receiving information (mean=2.96, sd=0.02).

CONCLUSIONS

A school district sun protection policy and support for implementation increased dissemination of sun safety information to parents and student sun safety. Implications for public health: Technical assistance for sun safety policies may increase sun protection of children.

Sun-related knowledge and attitudes of primary and secondary schoolchildren in western Switzerland

Switzerland, particularly its western region, has the highest incidence of melanoma in Europe. Although the risk of melanoma increases with sun overexposure during childhood, sun-related knowledge and attitudes of Swiss children are scarcely documented. We report the first investigation of the knowledge of the danger of ultraviolet radiation, attitudes towards a suntan and parental influence of schoolchildren in western Switzerland. All fifth, eighth and eleventh graders (average ages of 9, 12 and 15, respectively) in the 18 primary (fifth grade, n=431) and secondary (eighth and eleventh grades, n=837) public schools of La Chaux-de-Fonds were surveyed during regular school classes. The response rate was 91% (1154/1268). Sun-related knowledge was high overall. Eight out of 10 children knew about the risk of skin cancer and recognized the most susceptible phototype. Knowledge increased significantly with age. Girls, older children, fair-skinned participants and those who preferred a tanned skin obtained the highest knowledge score. The main source of information on ultraviolet radiation and sun protection was their parents (76%), followed by the school (11%) and the media (9%). Multivariate logistic regression analyses identified higher sun-related knowledge, lower familial socioprofessional status and skin phototypes III-IV to be associated with a tan-seeking attitude. Parental sensitization (56%) and encouragement (61%) towards sun protection were more common among fair-skinned children and those of higher familial socioprofessional status. The high awareness of the risk of skin cancer among Swiss schoolchildren does not translate into appropriate attitudes. Community-wide intervention programmes involving parents, teachers, peers and primary care clinicians could be considered for Swiss prevention campaigns to improve children's sun behaviour and change their current pro-tan attitude.

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.

Correlates of sun protection behaviors among Hispanic children residing in a high UVR environment

BACKGROUND/PURPOSE

Rates of melanoma are rising in Hispanics in the United States. Excessive sun exposure in childhood increases the risk of melanoma in adulthood, and little is known about the factors motivating sun protection behaviors among Hispanic youth.

METHODS

Correlates of sun protection were examined among Hispanic children residing in Los Angeles, California (N = 1891). Associations between multiple constructs (psychosocial, familial, and cultural) and sun protection outcomes (use of sunscreen, protective clothing, and shade seeking/sun avoidance) were examined.

RESULTS

Family variables were associated with more frequent sun protection among Hispanic children across outcomes, as were perceived peer norms, perceived self-efficacy, and fewer sun protection barriers. Skin cancer risk factors such as lighter skin and sunburn experience, and level of acculturation were not associated with greater sun protection.

CONCLUSION

Family sun protection habits are instrumental to Hispanic children's sun safe behaviors, and interventions that engage the family may be most effective. Increasing risk communication to high-risk subgroups of Hispanic children (those with lighter, more sun reactive skin) is important when developing intervention strategies. However, there is overlap between Hispanic children's sun protection correlates and those observed among non-Hispanic white children, suggesting that interventions to improve sun protection may generalize across cultural contexts.

A School-Based Intervention to Increase Lyme Disease Preventive Measures Among Elementary School-Aged Children

Purpose: Educational interventions to reduce Lyme disease (LD) among at-risk school children have had little study. The purpose of this study was to evaluate whether a short in-class LD education program based on social learning theory and the Health Belief Model (HBM) impacted a child's knowledge, attitude, and preventive behavior.

Methods: Students in grades 2–5 in 19 elementary schools were selected in an area that was highly endemic for LD. The children received an educational intervention or were on a wait list as controls. Their knowledge, attitudes, and self-reported preventive behaviors were surveyed before implementing the program and 1 year later. General linear regression analyses adjusting for age, gender, and baseline variables were used to measure the impact of the intervention.

Results: There were 3570 participants in the study: 1562 received the intervention, and 2008 were controls. The mean age for both groups was 9.1 years, with 53% women in the intervention group and 50% women in the control group. The children in the intervention group increased their overall knowledge of LD more than the children in the control group (overall knowledge score improvement, mean difference (SD) 1.38 (1.3) vs. 0.36 (1.3) p < 0.0001). All children in classes receiving the intervention reported an increase in precautionary behavior, positive attitude toward taking precautions, and self-efficacy compared with the wait list controls. Two LD cases were confirmed during the follow-up period, one in the intervention group and one in the controls.

Conclusions: These findings demonstrate that a short in-class educational program that includes elements of the HBM, including: (1) awareness and knowledge about the disease, (2) benefits of preventive behavior, and (3) confidence in ability to perform preventive behaviors can improve knowledge, attitude, and self-reported precautionary behavior among at-risk children. www.clinicaltrials.gov: NCT00594997

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.

Patterns of sun protective behaviors among Hispanic children in a skin cancer prevention intervention

BACKGROUND

Invasive melanoma is becoming more common in U.S. Hispanics, yet little is known about the sun protection behaviors in this population, particularly children and adolescents who incur high ultraviolet (UV) exposures.

METHODS

We used latent class analysis to examine patterns of sun protective behaviors in a cross-sectional survey of Hispanic elementary students participating in a sun safety intervention in Los Angeles from 2013- to 2014 (N=972). Five behavior indicators in two environments (school and home) representing multiple methods of sun protection were selected for the model.

RESULTS

Results suggested a four-class model best fit the data. Classes were labeled in order of increasing risk as multiple protective behaviors (28%), clothing and shade (32%), pants only (15%), and low/inconsistent protective behaviors (25%). Children who reported high parental engagement with sun protection were significantly more likely to be classified in high overall protective categories (odds ratio (OR)=4.77). Girls were more likely than boys to be classified in the highest protecting class (OR=3.46), but were also more likely to be in the "pants only" class (OR=2.65). Sensitivity to sunburn was associated with less likelihood of being in the "clothing and shade" class (OR=0.53).

CONCLUSION

The differences among these classes and their predictors reveal the heterogeneity and complexity of Hispanic children's sun protective behaviors. These findings have implications for the design and delivery of future sun protection interventions targeting Hispanic children, as strategies tailored to specific subgroups may be more effective in achieving meaningful behavioral changes.

Translation of a Ski School Sun Safety Program to North American Ski and Snowboard Schools

Health promotion programs that develop and implement strategies to promote sun safety practices to children have the potential to reduce skin cancer occurrence later in life. Go Sun Smart (GSS), a sun safety program for employees and guests of ski areas, was distributed to determine if an enhanced dissemination strategy was more effective than a basic dissemination strategy at reaching parents at ski and snowboard schools. On-site observations of GSS use and surveys of 909 parents/caregivers with children enrolled in ski and snowboard schools at 63 ski areas were conducted and analyzed using techniques for clustered designs. No differences were identified by dissemination strategy. Greater implementation of GSS (>5 messages posted) was associated with greater parental recall, 36.6% versus 16.7%, of materials, but not greater sun protection practices. Greater recall of messages, regardless of level of implementation, resulted in greater sun protection practices including applying sunscreen (p < .05), providing sunglasses and goggles (p < .01), and more use of all sun protection practices (p < .01). Ski areas with more program materials appeared to reach parents with sun safety advice and thus convinced them to take more precautions for their children. Sun safety need not be at odds with children's outdoor recreation activities.

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

The incidence of melanoma is rising among Hispanic populations in the United States. The purpose of this study is to evaluate the impact of a pilot sun safety educational intervention conducted from 2006 to 2012 on Hispanic early adolescents in a high ultraviolet environment. Nineteen schools with high Hispanic enrollment were recruited from urban neighborhoods in Los Angeles. The analytic sample was restricted to students identifying as Hispanic or Latino (n = 777). A mixed effects linear model was used to test mean changes from pre- to posttest on students' sun protection knowledge, attitudes and behaviors. Significant improvements were observed across several cognitive outcomes related to sun protection, including knowledge of and attitudes toward sun protection and self-efficacy to wear sunscreen. However, changes in sun protective behaviors were not achieved. Although some improvements were observed, future studies should identify the factors that motivate sun protection in this population and develop tailored prevention strategies, as improving the sun safe behaviors of Hispanic youths may aid in reducing the risk of melanoma in adulthood in this population.

Sun protection training based on a theater play for preschoolers: an effective method for imparting knowledge on sun protection?

Sun protection in childhood is important to reduce the risk of developing skin cancer later in life. The "Periods-of-Life-Program" for primary prevention of skin cancer introduces a combination of individual and environmental interventions for the preschool period. Within this pilot study, an intervention group received cognitive-behavioral and environmental interventions. A control group had solely received the environmental intervention, and a wait-control group received no intervention. Nursery school children (n = 80, 3 to 6 years of age) of four nursery schools were randomly assigned to these groups on school level. The ability of the cognitive-behavioral intervention (a theater play) to enhance sun protection knowledge was examined. The theater play improved knowledge over all age groups (p < .05 η(2) = .06). Age-specific analyses showed better results for children aged 5 to 6 (p < .05 η(2) = .20) compared to children aged 3 to 4 years (p = .17 η(2) = .04). In combining cognitive-behavioral and environmental interventions, the "Periods-of-Life-Program" is a promising strategy for primary prevention of skin cancer.

Sun-care product advertising in parenting magazines: what information does it provide about sun protection?

This study analyzed the content of sun-care product advertisements in five major U.S. parenting magazines with high circulation: Family Circle, Parents, Family Fun, Parenting (Early Years), and Parenting (School Years). The study examined what information sun-care product advertisements tell parents about skin cancer prevention and about sunscreen use for themselves or for their children based on the Health Belief Model concepts of perceived benefits and perceived barriers. Results showed that the most commonly mentioned benefit of the product was that it blocks ultraviolet A (UVA) and ultraviolet B (UVB) rays. One-third of the ads promoted the product's effectiveness in overcoming four of the barriers that prevent people from using sunscreens: eye irritation, skin irritation, an unpleasant smell, and the need to reapply sunscreen too often or after physical activity. However, only a few of the ads provided information about the consequences of unprotected sun exposure or mentioned methods of sun protection or skin cancer prevention other than sunscreen use. We discuss the implications of these messages for parents' ability to understand correctly how to protect their children from damaging sun exposure.

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.

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 at elementary schools: a cluster randomized trial

BACKGROUND

Elementary schools represent both a source of childhood sun exposure and a setting for educational interventions.

METHODS

Sun Protection of Florida's Children was a cluster randomized trial promoting hat use at (primary outcome) and outside of schools among fourth-grade students during August 8, 2006, through May 22, 2007. Twenty-two schools were randomly assigned to the intervention (1115 students) or control group (1376 students). Intervention schools received classroom sessions targeting sun protection attitudes and social norms. Each student attending an intervention school received two free wide-brimmed hats. Hat use at school was measured by direct observation and hat use outside of school was measured by self-report. A subgroup of 378 students (178 in the intervention group and 200 in the control group) underwent serial measurements of skin pigmentation to explore potential physiological effects of the intervention. Generalized linear mixed models were used to evaluate the intervention effect by accounting for the cluster randomized trial design. All P values were two-sided and were claimed as statistically significant at a level of .05.

RESULTS

The percentage of students observed wearing hats at control schools remained essentially unchanged during the school year (baseline = 2%, fall = 0%, and spring = 1%) but increased statistically significantly at intervention schools (baseline = 2%, fall = 30%, and spring = 41%) (P < .001 for intervention effect comparing the change in rate of hat use over time at intervention vs control schools). Self-reported use of hats outside of school did not change statistically significantly during the study (control: baseline = 14%, fall = 14%, and spring = 11%; intervention: baseline = 24%, fall = 24%, and spring = 23%) nor did measures of skin pigmentation.

CONCLUSIONS

The intervention increased use of hats among fourth-grade students at school but had no effect on self-reported wide-brimmed hat use outside of school or on measures of skin pigmentation.

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

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

Effects of the Sunny Days, Healthy Ways curriculum on students in grades 6 to 8

BACKGROUND

There are few effective sun-safety education programs for use in secondary schools. Project aims were to create a sun-safety curriculum for grades 6 to 8, and to test whether exposure to the curriculum would increase children's sun-protection behavior.

DESIGN

A pair-matched, group-randomized, pre--post test, controlled trial was performed with middle schools as the unit of randomization. Teachers implemented the six-unit sun-safety curriculum in 2001-2003, and analyses were performed in 2003-2004.

SETTING/PARTICIPANTS

A total of 2038 children from 30 middle schools in Colorado, New Mexico, and Arizona.

MAIN OUTCOME MEASURES

Self-reported sun-protection behavior using frequency ratings and diary.

RESULTS

Compared to control schools, children receiving the curriculum reported more frequent sun protection (p=0.0035), and a greater proportion wore long-sleeved shirts during recess (p<0.0001) and applied sunscreen (p<0.0001). Exposure to the curriculum improved knowledge (p<0.0001), decreased perceived barriers to using sunscreen (p=0.0046), enhanced self-efficacy expectations (p=0.0577) about sun safety, and reduced favorable attitudes toward sun tanning (p=0.0026 to <0.0001). In intent-to-treat analyses, the treatment effect was eliminated only under the most conservative assumptions about dropouts.

CONCLUSIONS

Educational approaches to sun safety in middle school may be effective for improving children's sun safety. Potential trial limitations include measuring short-term outcomes, focusing on young adolescents, using active parental consent, and testing in the American Southwest.