Brief report: an empirically derived educational program for detecting and preventing skin cancer

Evaluating the Impact of a Virtual Skin Cancer Awareness Workshop for 16-19-Year-Olds

Introduction  The incidence of malignant melanoma (MM) in the United Kingdom (UK) has significantly increased in recent years and is expected to continue to rise over the next decade. Despite the preventable nature of most MM cases, existing evidence suggests that public health education around skin cancer and sun safety is often suboptimal, particularly for secondary school populations. Unlike primary school curricula, there is no national guidance to mandate the teaching of this topic in secondary school. Early intervention through education can encourage sun-safe practices, and therefore potentially reduce the risk of MM developing. The primary aim of this study was to improve awareness of skin cancer, including its risk factors and preventive measures, amongst sixth-form students.  Methods  An online workshop was organised by In2MedSchool, a national widening access charitable scheme for aspiring medical students, in collaboration with the Karen Clifford Skin Cancer Charity. Plan-Do-Study-Act methodology was utilised to design and evaluate a skin cancer awareness and sun safety workshop. It addressed key topics such as MM risk factors, preventive measures, and the widely used 'ABCDE' assessment of MM. A total of 73 students from across the UK attended the virtual workshop. To maximise engagement, visual aids, low-stakes quizzing, and an interactive chat function were utilised.  Participants completed anonymous pre- and post-intervention questionnaires, assessing their confidence and knowledge in understanding skin cancer risk factors and sun-safe behaviours. Confidence levels were measured using a seven-point Likert scale, and knowledge was evaluated through a ten-question assessment. Statistical analyses, including averages, medians, interquartile ranges (IQR), and Wilcoxon signed-rank tests were performed to assess the changes in participants' knowledge and confidence.  Results  Before the intervention, participants reported an average confidence score of 4.07 in understanding skin cancer risk factors, which significantly improved to 6.39 after the workshop, representing a 57.09% increase (p < 0.00001). Confidence in applying protective measures increased by 45.67%, from 4.51 to 6.57 (p < 0.00001). In addition, most students expressed feeling underprepared by existing sun safety programs at both primary and secondary school levels.  Knowledge assessments demonstrated significant improvement, with average scores increasing from 7.49 pre-intervention to 9.10 post-intervention (21.46% improvement, p < 0.00001). The median score increased from 8 (IQR: 3) to 9 (IQR: 1) following the workshop, demonstrating a notable increase in understanding of skin cancer risk factors, protective behaviours, and early detection methods.  Conclusion  Our findings indicate that many secondary school students feel unprepared regarding existing skin cancer awareness and sun safety programs in school. This study provides evidence to suggest that targeted, interactive workshops have the potential to improve awareness and knowledge of this important topic in the short term. However, participants in this cohort are likely to have an established interest in medicine and healthcare, beyond that of their wider peer group. This limits the broader application of our findings. Further research that explores the longer-term impact of such interventions, including changes in attitudes and behaviours, is recommended.

A Systematic Review of Evidence-Based High School Melanoma Prevention Curricula

Incorporation of melanoma prevention behaviors into daily lifestyles is difficult. Data suggest that high school educational programs on skin cancer prevention can be successful and should incorporate evidence-based teaching and learning strategies to achieve greatest impact. The goal of this systematic review is to describe evidence-based educational practices for a high-school melanoma curriculum through a comprehensive review of the literature. Ovid MEDLINE, Embase, CINAHL, and PyscINFO were searched in June 2020 for all original articles published between June 18, 1946 and June 17, 2020. All studies that used an educational curriculum to promote sun safety, skin exams, and early detection to high school students were included. A total of 25 studies with 22,683 adolescent participants were analyzed. Sixteen studies showed a significant increase in knowledge, twenty-one studies showed changes in behavior, and fifteen studies showed significant changes in attitudes. Limitations of this review include the heterogeneity of implementation and outcome reporting of educational curricula. These findings support incorporating active learning strategies as key aspects of creating an effective curriculum aimed at the prevention and early detection of melanoma.

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.

Systematic Review of Interventions to Increase Awareness of Ultraviolet Radiation-Induced Harm and Protective Behaviors in Post-Secondary School Adults

College and university students are a group known for excessive sun exposure and indoor tanning. Health education campaigns for avoidance of ultraviolet (UV) radiation have been relatively unsuccessful in this population. This systematic review examines interventions aimed at post-secondary school young adults on college and university campuses for skin cancer awareness, photoprotection, and change in UV-exposure-related behavior. Fifty-nine studies were identified for inclusion according to predetermined criteria. Study heterogeneity was high; methods of intervention were individual or group-based, and were mostly visually delivered and/or passive learning. Most interventions occurred at a single time point. Intervention success was assessed by evaluating subject behavior, intention, attitudes, knowledge, and emotion. Multicomponent interventions, generally consisting of UV photography and a passively delivered educational component, may be more effective than a single component alone. Overall, study quality was poor. Sample size of the majority of studies was <150 subjects. Most studies used self-report of behavior and had a short follow-up time. Generalizability of findings may be impacted as women, particularly white/Caucasian women, were overrepresented in the studies identified by this systematic review. For this specific target population, themes arising from the review include the importance of self-relevance and message framing. Self-affirmation was identified as a potential challenge in designing interventions for this target group, which can lead to defensiveness and a negative reaction to the health message. The findings of this systematic review may inform future research in this field, as well as guide planning of effective interventions in this target population.

Sensitivity to change of the Beach Questionnaire to behaviour, attitudes and knowledge related to sun exposure: quasi-experimental before-after study

Background

Health questionnaires must present accredited measurement properties such as validity, reliability and sensitivity to change, the latter being essential for interventions to be planned and for evaluating their effectiveness. The aim of this study was to evaluate the sensitivity to change of a Beach Questionnaire.

Methods

Quasi-experimental before-after study carried out in 2011, for a study population of adolescents attending schools in the Costa del Sol. First, the questionnaire was administered to the adolescents, after which a multicomponent educational intervention was carried out; finally, three months later, the same questionnaire was re-administered to the same adolescents. Changes were assessed in the categories of each item, using the McNemar test, and the changes in the scores, standardised to a range of 0–100, using the Student t test for paired samples, and including the mean of the differences and the 95% confidence interval. The level of statistical significance was set at p < 0.05.

Results

228 adolescents, aged 14–17 years, and 55.3% were girls. Statistically significant changes were observed in sunburn experiences, exposure to the sun at mid-day and attitudes to sun exposure and suncreams. For the seven items related to knowledge about sun exposure, a higher rate of correct answers was observed. The analysis of changes, within the standardised range, revealed a significant improvement in the scores for sun exposure habits (MD 4.33; CI 95% 2.2-6.5), attitudes to sun exposure (MD 2.22; CI 95% 1.2-3.2) and knowledge (MD 9.10; CI 95% 7.1-11.1), but not in those for sun-protection practices (MD 0.23; CI 95% -1.2-1.7).

Conclusions

The Beach Questionnaire on behaviour, attitudes and knowledge related to sun exposure is the first such instrument in Spanish language to provide sufficient sensitivity to change. It constitutes a useful tool for epidemiologic research into photoprotection and for skin cancer prevention programmes.

Reducing skin cancer risk: an intervention based on protection motivation theory

Caucasian college students who intentionally tanned participated in a brief skin cancer intervention based on protection motivation theory (PMT). This intervention targeted skin appearance and consisted of brief lectures, a comprehensive essay, video clips about a young man who died of melanoma, and short discussions. Compared to a waitlist control group, the intervention group showed increases on PMT variables and intentions at post-test. The waitlist group later received the intervention and showed similar increases. Additionally, all but one PMT variable maintained post-test levels at a one-month follow-up. Photographs taken at post-test and at the one-month follow-up were judged by raters blind to the hypothesis. Seventy-two percent of participants were judged to have lighter skin whereas only 16 percent had darker skin. These results provide additional support for theory-based methods for changing maladaptive attitudes and behaviors associated with skin cancer risk.

Adolescents' use of purpose built shade in secondary schools: cluster randomised controlled trial

OBJECTIVE

To examine whether students use or avoid newly shaded areas created by shade sails installed at schools.

DESIGN

Cluster randomised controlled trial with secondary schools as the unit of randomisation.

SETTING

51 secondary schools with limited available shade, in Australia, assessed over two spring and summer terms.

PARTICIPANTS

Students outside at lunch times.

INTERVENTION

Purpose built shade sails were installed in winter 2005 at full sun study sites to increase available shade for students in the school grounds.

MAIN OUTCOME MEASURE

Mean number of students using the primary study sites during weekly observations at lunch time.

RESULTS

Over the study period the mean change in students using the primary study site from pre-test to post-test was 2.63 (95% confidence interval 0.87 to 4.39) students in intervention schools and -0.03 (-1.16 to 1.09) students in control schools. The difference in mean change between groups was 2.67 (0.65 to 4.68) students (P=0.011).

CONCLUSIONS

Students used rather than avoided newly shaded areas provided by purpose built shade sails at secondary schools in this trial, suggesting a practical means of reducing adolescents' exposure to ultraviolet radiation.

TRIAL REGISTRATION

Exempt.

Evaluation of a multicomponent appearance-based sun-protective intervention for young women: Uncovering the mechanisms of program efficacy

An appearance-based sun-protection intervention program was developed, implemented, and evaluated in a sample of 211 Caucasian women (ages 18-25) randomly assigned to the sun-protection program or to a stress management (control) program. The sun-protection program incorporated a novel construct of image norms of aspirational peers (i.e., female media figures, fashion models) approving paleness. The authors targeted these image norms as well as the advantages of tanning, health beliefs about photoaging and skin cancer, and self-efficacy for sun protection. The intervention produced significant differences across conditions favoring sun protection on all constructs but severity of skin cancer and barriers to sun protection. At follow-up, treatment participants exceeded controls both in intention to sun protect and sun-protective behavior and reported lower intention to sunbathe and fewer hours of sunbathing. A mediational model of intervention outcomes revealed distinct mediators for sun protection versus sunbathing.

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

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

Sun exposure and sun protection behaviours among Australian adolescents: trends over time

BACKGROUND

This study compared the sun exposure and sun protection behaviours of adolescent students between 1993 and 1999.

METHODS

Schools from all Australian states and the two territories participated in each of the 1993, 1996, and 1999 surveys and a sample of students from years 7 to 12 were surveyed. In each of the states and territories a random sample of schools was selected within each education sector (government, Catholic, independent). The questionnaire was a self-completed booklet with questions about sunburn history during the previous summer, tan preferences, skin-type, and usual reported behaviour. Data from a total of 78,032 students were available for analysis.

RESULTS

From 1993 to 1999 there was a significant increase in the number of students reporting sunburn during the previous summer (chi(2) = 225.77, df = 2, P < 0.01). However, the percentage of students who preferred no tan at all increased over the same period (chi(2) = 184.47, df = 2, P < 0.01). The percentage of students who usually or always wore clothing that covered most of their body decreased between 1993 and 1999 (chi(2) = 20.46, df = 2, P < 0.01); the percentage of students usually or always wearing maximum protection sunscreen decreased over time (chi(2) = 27.71, df = 2, P < 0.01). Staying in the shade increased from 1993 (26%) to 1996 (32%) but decreased slightly in 1999 (30%). Across all survey years, only 11% of students routinely followed all three protective behaviours of wearing a hat, sunscreen, and clothes that cover the body.

CONCLUSIONS

Sun protection practices among adolescents are still below optimal levels. Future educational programs require innovative approaches that aims to change attitudes toward tanning as being healthy and attractive and modify adolescent behaviours in relation to sun exposure.

Effects of a multicomponent intervention on motivation and sun protection behaviors among midwestern beachgoers

Skin cancer is the most prevalent of all cancers in the United States. Although avoiding sun exposure and using sun protection reduces skin cancer risk, rates of such behaviors are moderate at best. The present study examined the impact of a multicomponent intervention that aimed to increase the saliency of skin cancer risk while promoting the use of sun protection. Midwestern beachgoers (n = 100) participated in an intervention or questionnaire-only control group. Sun protection, stage of change, and sun exposure were measured at baseline and 2-month follow-up. The intervention group significantly improved in sun protection use and stage of change, but not sun exposure, compared with the control group. Personalizing the risks of unprotected sun exposure combined with providing education about sun protection facilitated healthy changes in behavior and motivation.

A systematic review of the effectiveness of environmental awareness interventions

PURPOSE

To evaluate and summarize evidence on the effectiveness of interventions available to public health staff regarding the protection of the public from environmental risks.

METHOD

This systematic review involved a comprehensive literature search, screening for relevance, quality assessment of relevant studies, data extraction and synthesis.

RESULTS

Fourteen of 65 relevant studies were of 'moderate' or 'strong' quality. Intervention types in these 14 studies included: mass campaign, counselling, school curriculum, educational sessions, and distribution of printed materials. Short-term improvements in awareness or knowledge were observed in 13 of the 14 studies. Eight of 13 studies that examined behavioural outcomes observed short-term improvements in self-reported behavioural outcomes.

CONCLUSIONS

Positive short-term changes in health-protective awareness, knowledge and self-reported behaviour appear to be associated with relatively intensive interventions that use multiple methods and settings, and/or are delivered over multiple sessions.

Evaluation of a three-year school-based intervention to increase adolescent sun protection

The efficacy of a school-based intervention was evaluated using a randomized controlled trial in Australia. In consecutive grades (8, 9, and 10), students in the intervention group received components of a program that addressed issues related to the need to protect yourself from the sun, behavioral strategies related to using sun-protective measures, personal and social images of having a tan, the use of sun-safe clothing, and how to change their schools through forms of structural change. Pre- and postintervention measures among junior high school students showed greatest improvement in the intervention group's knowledge scores and minimal changes in sun protection behavior from Grade 8 to Grade 9, which were not maintained through Grade 10. Results of the study highlight some limitations of school-based interventions for changing sun protection behaviors.

Health psychology: mapping biobehavioral contributions to health and illness

Our evolving understanding of how psychosocial and behavioral factors affect health and disease processes has been marked by investigation of specific relationships and mechanisms underlying them. Stress and other emotional responses are components of complex interactions of genetic, physiological, behavioral, and environmental factors that affect the body's ability to remain or become healthy or to resist or overcome disease. Regulated by nervous, endocrine, and immune systems, and exerting powerful influence on other bodily systems and key health-relevant behaviors, stress and emotion appear to have important implications for the initiation or progression of cancer, HIV, cardiovascular disease, and other illnesses. Health-enhancing and health-impairing behaviors, including diet, exercise, tobacco use, and protection from the sun, can compromise or benefit health and are directed by a number of influences as well. Finally, health behaviors related to being ill or trying to avoid disease or its severest consequences are important. Seeking care and adhering to medical regimens and recommendations for disease surveillance allow for earlier identification of health threats and more effective treatment. Evidence that biobehavioral factors are linked to health in integrated, complex ways continues to mount, and knowledge of these influences has implications for medical outcomes and health care practice.

Public health interventions for melanoma. Prevention, early detection, and education

Worldwide melanoma control programs that include some combination of primary prevention, education, and screening activities have only recently begun to undergo an evaluation process. More studies with rigorous design and evaluation are needed. Until then, the proper public health policy guidelines for melanoma control, especially screening, are open to debate. Future studies must determine how screening, early detection, case finding, and education can best be used to reduce mortality and achieve optimal melanoma control.

The prevalence and predictors of solar protection use among adolescents

BACKGROUND

Adolescence has been identified as a critical period in the etiology of subsequent melanoma and nonmelanocytic skin cancer. This study examines the prevalence and predictors of solar protection use among adolescents.

METHODS

A total of 3,642 adolescents between the ages of 11 and 16 years were recruited from a random sample of 27 schools in an Australian state. The participants completed a validated survey that provided information on a range of demographic, knowledge, attitudinal, and behavioral factors. Sun protection practices adopted during the preceding weekend were assessed using a validated self-report diary. A formula that quantifies protection status was then employed to categorize adolescents into those who were using adequate versus low levels of solar protection.

RESULTS

Overall 54% of males and 44% of females were classified as adequately protected during the preceding weekend. Logistic regression analyses identified the following as significant predictors of having an adequate level of sun protection--gender (males more likely to be protected), age (11 to 13 year olds more likely to be protected than 14 to 16 years olds), ownership of a broad-brimmed hat or cap, attitudes relating to the discomfort associated with wearing a hat, image to peers, "hassle" associated with the use of sun protective measures, school attended, and sun protective policies of the school.

CONCLUSIONS

Implications of these findings for future preventive strategies are discussed and include improved targeting of sun protection programs to non-adopters, modification of attitudes relating to suntans and image to peers, reducing the level of perceived difficulty associated with utilizing sunscreen, and the potential role that schools may play in fostering sun protection.

Factors that influence health risk behaviors among tanning salon patrons

A principal components analysis identified the immediate convenience of indoor tanning (i.e., relaxation, perceived attractiveness of tans) as a major factor that motivates people to visit commercial tanning salons frequently and continually. Long-term considerations, such as price, socializing, and perceived health, also emerged as a motivating factor that was related to tanning frequency. Furthermore, almost half of the participants mentioned that regulations restricting indoor tanning would not make them more cautious in their tanning behavior. Findings confirm several other studies indicating that knowledge of the danger of UV exposure may have little influence on actual tanning behavior. Suggestions for alternative approaches that focus on the perceived attractiveness of tanned skin rather than the susceptibility of frequent tanners to skin cancer are discussed.

Teaching children about skin cancer prevention: why wait for adolescence?

The baseline knowledge about skin cancer prevention of 983 children aged 8 to 12 years was assessed by a pretest questionnaire. After the pretest, half were given a formal presentation about skin cancer prevention. The other half participated in an informal, question-and-answer session, which covered all material from the formal presentation. Two weeks later, all students completed an identical post-test. The students had a high baseline level of knowledge about skin cancer prevention. Knowledge increased for most items in the post-test questionnaire. In all age groups there was no difference in results between the formal and interactive teaching sessions, except among eight-year-olds, for whom the formal presentation was more effective. As much solar skin damage occurs before adolescence, the younger age group is the important target for skin cancer prevention programs.

Application of Azjen's theory of planned behavior to predict sunbathing, tanning salon use, and sunscreen use intentions and behaviors

Ajzen's (1988) theory of planned behavior (TOPB) was used to examine psychological determinants of high-risk UV radiation exposure-related behaviors (sunbathing, tanning salon use, and sunscreen use). Undergraduates at a midsized southeastern university were assessed on their psychological and behavioral tendencies toward high-risk UV radiation exposure-related behaviors. The results generally supported the utility of the TOPB as an explanatory model for high-risk behavior. Attitudes were strongly associated with high-risk intentions (e.g., not utilize sunscreen, use salons), whereas subjective norms were less so. Perceived behavioral control was found to moderate the relationship among attitudes, norms, and intentions to sunbathe and tan at a salon. Implications for intervention strategies and future model building in this area are discussed.

Summer sun exposure: knowledge, attitudes, and behaviors of Midwest adolescents

BACKGROUND

Extensive print, radio, and television coverage about the dangers of sun exposure and benefits of sun protection occurred over the past decade. Illinois teen knowledge and attitudes about sun exposure/protection, sun-exposure/protection behavior, and information sources were determined by a summer telephone survey.

METHODS

Telephone interviews with 658 teenagers between ages 11 and 19 included African-American, Asian, Hispanic, Native American, and white teenagers.

RESULTS

Teens knew that too much sun was harmful as it caused skin cancer and sunburn. Sunburn was mentioned more often by those with skin types that burned easily and tanned poorly (I,II) (P < 0.001), was better known to girls than to boys (P < 0.001), and was recognized more by those with higher socioeconomic status (P < 0.001) but was not associated with age. Widely held sun exposure attitudes were socializing with friends and feeling better when outdoors. On weekdays, boys averaged 5.3 hr (SD, 1.65 hr) outside compared with 3.9 hr (SD, 0.75 hr) for girls (P < 0.001). Teenage boys were more likely to obtain occupational sun exposure, and girls sunbathed. Subjects with skin types I and II reported an average of 3.3 sunburns in the past year. During unprotected sun exposure, extensive numbers of teens with moderate-risk skin type experienced at least 1 sunburn per year. Indoor tanning use was more prevalent among older girls and those with skin types I and II. Sunscreen use was associated with water recreational activities (swimming, water sports, and going to the beach) by girls slightly more than by boys (P < 0.001). Hat-wearing was more common among boys than among girls.

CONCLUSIONS

Teen knowledge that excessive sun exposure causes skin cancer and sunburns and that wearing sunscreens and hats were sun-protective methods did not enable sun protection that prevented burning. This is particularly troublesome because severe sunburns in youth are associated with an increased risk of melanoma. Existing teen sunscreen use could be broadened by educating teens to use adequate quantities of sunscreen prior to daily sun exposure to prevent painful burns. Messages to teens that emphasize the short-term consequence of painful sunburns because of inadequate protection during outdoor occupational and non-water-related recreational exposure would increase the relevance of the message and may enable behavioral change. Parents and physicians need to be included in messages that are directed to teens and to become part of their education. Parents could ensure an adequate sunscreen supply for daily use by the family, encourage teens not to deliberately tan, and serve as role models for the use of protective clothing.

Melanoma and Skin Cancer Control: An International Perspective

Approximately one million Americans are diagnosed with skin cancer each year. Since melanoma and skin cancer are amenable to prevention, education, and early detection, efforts to reduce the incidence of and death from melanoma have developed in many countries. Programs promoting behavioral changes and the incorporation of skin cancer control into national health care agendas have begun in a number of countries. Additional programs for the at-risk and general populations require further development and evaluation.

Parental knowledge and practices of skin cancer prevention: a pilot study

Skin cancer is a growing health threat in the United States; effective prevention logically begins with sun avoidance practices initiated early in childhood. However, little is known about the current level of skin cancer knowledge or skin cancer prevention practices among parents. A pilot survey of these levels was conducted among parents attending a single pediatric office in a nationally-affiliated health maintenance organization. This article reports the findings of that survey and identifies areas of knowledge and practice deficit. Implications and interventions are discussed.