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

A Review of the Impact of Sun Safety Interventions in Children

INTRODUCTION

In the United States, melanoma and non-melanoma skin cancers comprise the largest proportion of new cancer diagnoses every year. The prevalence of skin cancer can be largely reduced if proper preventative behaviors are adopted at an early age.

OBJECTIVES

We assessed the impact of various informational, economic, and environmental interventions on sun-protective behaviors, knowledge, attitudes, and sun exposure in the pediatric population reported in previous studies.

METHODS

A systematic search for relevant articles was conducted using three databases. Studies were included if they met the following three criteria: study subjects less than 18 years old, clear, measurable interventions and outcomes, and publication in the English language.

RESULTS

A total of 66 studies were included, of which 48 resulted in positive behavioral changes (i.e. increases in sunscreen application, use of hats and sun-protective clothing, shade-seeking, and avoidance of outdoor activities during peak UV radiation), 28 resulted in increased knowledge, 2 resulted in changes in attitudes towards tanning, and 10 resulted in decreased sun exposure effects (i.e. new sunburns, number of new nevi, and change in pigmentation of the skin).

CONCLUSIONS

It is crucial that children be educated on the importance and benefits of sun protection. Although a variety of interventions showed promise in achieving this goal, the challenges associated with adopting change were evident. This review provides direction for future interventions aimed at improving sun safety in children and illustrates the potential impact that early intervention can have on the incidence of skin cancer in future generations.

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

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

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.

Encouraging sun safety for children and adolescents

The rise in the number of cases of skin cancers, both melanomas and nonmelanomas, has prompted increased awareness and educational efforts to limit sun exposure. Because 80% of lifetime sun exposure occurs before the age of 18, educating parents and adolescents to incorporate sun-protective behaviors into daily routines is particularly important. Education of parents is essential to establishing healthy behavior patterns in children. Educational interventions are recommended that encourage the following: using sunscreen, wearing hats with wide brims and clothing that blocks or absorbs ultraviolet rays, using sunglasses that block ultraviolet radiation, and seeking shade. Continued efforts are important through adolescence to maintain the established behaviors. School nurses are in a position to affect the health education curriculum, as well as school policies that promote sun safety behaviors.

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

BACKGROUND

Recognition that early sun exposure is an important risk factor for cutaneous melanoma in white populations has led to efforts to reduce children's sun exposure. 'Kidskin' was a non-randomized, school-based sun protection intervention trial in Perth, Western Australia (1995-1999). Its aim was to determine the extent to which such a program could reduce children's sun exposure.

METHODS

Kidskin involved 1614 children assigned to one of three groups: a Control, a 'Moderate' and a 'High' intervention group of 14, 11 and 8 schools respectively. The unit of assignment was the school. Control schools received the standard health education curriculum, while intervention schools received a multi-component intervention including a specially designed curriculum. The High intervention group received additional components. Outcomes included parent reported sun-related behaviors and objectively measured suntan at the end of summer vacation. These outcomes were observed every 2 years. Statistical analyses allowed for correlations between students within schools.

RESULTS

Kidskin initially had favorable effects on reported sun exposure and measured suntan. However, at the end of the 4-year program, and again 2 years later, little evidence of a favorable effect remained.

CONCLUSIONS

The benefits of childhood sun protection interventions may not last beyond the life of the program.

Sun protection initiatives in Cornwall

Recent evidence indicates that there are significant numbers of cases of malignant melanoma in the UK. In order to assess the current position with regard to sun awareness in Cornwall, a questionnaire survey of all state primary school heads (n = 123) and a survey of a random sample of GP practices (n = 9) was carried out. The data obtained were supported by visits to libraries and Tourist Information Centres at urban and rural centres--this enabled the identification of sun awareness literature. Key health professionals who worked within the field of health promotion were also contacted. The findings showed that in Cornwall public campaigns organized around the issue of sun protection took place only sporadically, although GP surgeries usually organize a display at the appropriate time of the year. None of the public places (e.g. Tourist Information Centres, libraries) surveyed had sun protection messages on display. It is concluded that insufficient sun awareness initiatives were being undertaken in Cornwall. Although most primary schools included sun awareness education in their curriculum in a form based on the Sun Awareness Guidelines produced by the Department of Health in 1995, few schools considered further measures to protect pupils on hot and sunny days. In particular the provision of shade, the scheduling of outdoor activities and the use of sunscreen and protective clothing were not standard.

A systematic review of educational interventions for promoting sun protection knowledge, attitudes and behaviour following the QUESTS approach

A literature review was performed to identify studies of educational interventions to promote sun protection behaviour. Fifty-nine clinical trials were identified. These studies were assessed using the QUESTS model. The studies showed that a wide range of educational interventions in different settings with a variety of target groups can be effective in promoting sun protection knowledge, attitudes, intended and actual behaviour. Relatively few studies made direct comparisons between different educational interventions. Therefore there was little evidence to suggest that any one form of intervention was more effective than any other. This review shows that the QUESTS criteria can be used to evaluate the effectiveness of patient education in the same way they are used to assess evidence in medical education. Performing systematic reviews on patient education topics should prove useful for health professionals developing educational interventions.

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.

Levels and correlates of knowledge about cancer risk factors among 13,293 public school students in Morelos, Mexico

BACKGROUND

Data on young people's knowledge about cancer prevention are not currently available for many populations, including Mexican young people, although cancer is the second most common cause of death among the Mexican population.

METHODS

A questionnaire was applied to 13,293 public school students aged 11-24 years in Morelos, Mexico. A knowledge-based scale was constructed from survey answers about risk factors for cancer. Data were analyzed using multivariate logistic multinomial models.

RESULTS

Knowledge levels were low: 78% of male and 74% of female students had only wrong answers to questions about risk factors for cancer. A significant dose-response gradient was observed between age and knowledge of cancer risk factors (P < 0.001), with a higher prevalence in young women at all ages (female students OR 4.6, 95% CI 3.81-5.66). Students 18 years old and older knew more than 13-year-olds (OR = 2.39; 95% CI 1.89-3.01). Sexually active students (OR 2.10; 95% CI 1.70-2.58), especially those who consistently used condoms (OR 2.84; 95% CI 1.00-8.07), knew more about cancer prevention. Tobacco smoking was the most frequently recognized cancer risk factor, and smokers also recognized this as an important cause of cancer (OR 1.37; 95% CI 1.44-2.52).

CONCLUSIONS

Our results reveal a poor level of knowledge about cancer prevention among adolescents. These data are the first step in the development of an intervention based on empirical findings that will be susceptible to evaluation.

Do forecasts of UV indexes influence people's outdoor behaviour?

OBJECTIVE

To investigate Australian adults' awareness of the ultraviolet (UV) indexes forecast in the media, and whether these UV forecasts influence their behaviour in the sun.

METHODS

A self-administered questionnaire was used on two occasions in 1997 to ask about knowledge of UV indexes shown in the media and about possible influence on outdoor behaviour.

SETTING AND PARTICIPANTS

Participants were 977 residents (423 men; 554 women) of Nambour originally randomly selected in 1986 from the electoral roll, who have been followed up subsequently.

RESULTS

The majority of people--92% of men and 86% of women--reported having seen or heard the UV indexes forecast during summer. Of these, significantly fewer men (107; 28%) than women (209; 46%) reported that their outdoor behaviour was influenced by knowledge of the forecast (p = 0.001). Neither age nor skin type, nor history of sunburns or skin cancer, affected knowledge of UV forecasts or their influence on behaviour.

CONCLUSIONS AND IMPLICATIONS

Although most people are aware of the forecasts of UV indexes in the media, the majority do not take them into account in their outdoor behaviour. Compared with women, men were more aware of, but less influenced by, forecasts of UV indexes. Better communication of the implications of the UV indexes is needed, particularly to men, if they are to adapt their outdoor behaviour to improve their sun protection.

Improved sun protection behaviour in children after two years of the Kidskin intervention

OBJECTIVE

To evaluate a school-based intervention in terms of reducing children's sun exposure and improving their use of sun protection measures.

METHODS

'Kidskin' is a five-year, school-based intervention study in Perth, Western Australia, of a cohort of children who were five or six years old in 1995. The study involves three groups: control, 'moderate' and 'high' intervention. Children in the control schools received the standard health curriculum; those in the intervention schools received a multicomponent intervention, including a specially designed curriculum. Children in the high intervention group also received program materials over the summer holidays and were offered sun-protective swimwear at a low cost. After two years, parents completed a questionnaire about their child's sun-related behavior.

RESULTS

Children in the intervention groups--especially the 'high' group--were reported to have had less sun exposure. This involved covering the back more often, spending more time in the shade when outdoors and wearing a style of swimsuit that covered the trunk. There was also evidence that children in the intervention groups spent less time outdoors in the middle of the day. There was little difference between groups in the wearing of hats or sunscreen.

CONCLUSIONS

Our school-based intervention improved children's sun protection, but had little effect on specific behaviours that have already been vigorously promoted.

IMPLICATIONS

School-based prevention campaigns would benefit from focusing on sun protection using clothing and shade, and reducing sun exposure in the middle of the day. There may be little potential to improve hat and sunscreen use.

Skin cancer prevention for children: a critical review

Increasing sun protection for children may reduce their risk for skin cancer, so many health authorities recommend comprehensive sun safety for children. Sun protection of children in North America and Europe is generally lower than desired and lower than in Australia. This article provides a critical review of evaluations on the effects of 24 sun protection programs for children under age 14. Programs are classified based on the target population, setting, and features. Most programs improved sun safety knowledge, but changes in sun protection attitude and behaviors were smaller. Multiunit presentations were more effective than short-duration presentations. Peer education was effective but needs further evaluation. Some programs for parents have been shown to increase sun protection for children. Strategies to improve sun safety policies need further study. A few community-wide programs have effectively improved sun protection. Future research should address innovative strategies and issues of design and measurement. There is no gold standard for measuring sun protection behavior, but self-report, prospective diaries, and observational techniques show small positive correlations.