Review of the Impact of Sun Safety Interventions in Children
Keywords:
behavioral change, skin cancer, sunscreen, sun protection, UV radiationAbstract
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.
References
Prevalence of a History of Skin Cancer in 2007: Results of an Incidence-Based Model | Dermatology | JAMA Dermatology | JAMA Network. Accessed June 4, 2022. https://jamanetwork.com/journals/jamadermatology/fullarticle/209761
Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7-33. doi:10.3322/caac.21708
Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012. JAMA Dermatol. 2015;151(10):1081-1086. doi:10.1001/jamadermatol.2015.1187
Greinert R, Boniol M. Skin cancer--primary and secondary prevention (information campaigns and screening)--with a focus on children & sunbeds. Prog Biophys Mol Biol. 2011;107(3):473-476. doi:10.1016/j.pbiomolbio.2011.08.008
Armstrong BK. How sun exposure causes skin cancer: an epidemiological perspective. In: Hill D, Elwood JM, English DR, eds. Prevention of Skin Cancer. Cancer Prevention — Cancer Causes. Springer Netherlands; 2004:89-116. doi:10.1007/978-94-017-0511-0_6
Godar DE, Urbach F, Gasparro FP, van der Leun JC. UV doses of young adults. Photochem Photobiol. 2003;77(4):453-457. doi:10.1562/0031-8655(2003)077<0453:udoya>2.0.co;2
Vitols P, Oates RK. Teaching children about skin cancer prevention: why wait for adolescence? Aust N Z J Public Health. 1997;21(6):602-605. doi:10.1111/j.1467-842x.1997.tb01763.x
Be Safe in the Sun. Accessed June 4, 2022. https://www.cancer.org/healthy/be-safe-in-sun.html
Dietrich AJ, Olson AL, Sox CH, et al. A community-based randomized trial encouraging sun protection for children. Pediatrics. 1998;102(6):E64. doi:10.1542/peds.102.6.e64
Wu YP, Parsons BG, Nagelhout E, et al. A four-group experiment to improve Western high school students’ sun protection behaviors. Transl Behav Med. 2019;9(3):468-479. doi:10.1093/tbm/ibz021
Wu YP, Nagelhout E, Aspinwall LG, et al. A novel educational intervention targeting melanoma risk and prevention knowledge among children with a familial risk for melanoma. Patient Educ Couns. 2018;101(3):452-459. doi:10.1016/j.pec.2017.10.008
Crane LA, Deas A, Mokrohisky ST, et al. A randomized intervention study of sun protection promotion in well-child care. Prev Med. 2006;42(3):162-170. doi:10.1016/j.ypmed.2005.11.007
Norman GJ, Adams MA, Calfas KJ, et al. A randomized trial of a multicomponent intervention for adolescent sun protection behaviors. Arch Pediatr Adolesc Med. 2007;161(2):146-152. doi:10.1001/archpedi.161.2.146
Glanz K, Geller AC, Shigaki D, Maddock JE, Isnec MR. A randomized trial of skin cancer prevention in aquatics settings: the Pool Cool program. Health Psychol Off J Div Health Psychol Am Psychol Assoc. 2002;21(6):579-587. doi:10.1037/0278-6133.21.6.579
Dobbinson SJ, White V, Wakefield MA, et al. Adolescents’ use of purpose built shade in secondary schools: cluster randomised controlled trial. BMJ. 2009;338:b95. doi:10.1136/bmj.b95
Gritz ER, Tripp MK, James AS, et al. An intervention for parents to promote preschool children’s sun protection: effects of Sun Protection is Fun! Prev Med. 2005;41(2):357-366. doi:10.1016/j.ypmed.2005.01.007
Saridi MI, Rekleiti MD, Toska AG, Souliotis K. Assessing a sun protection program aimed at Greek elementary school students for malign melanoma prevention. Asian Pac J Cancer Prev APJCP. 2014;15(12):5009-5018. doi:10.7314/apjcp.2014.15.12.5009
Jones SBW, Beckmann K, Rayner J. Australian primary schools’ sun protection policy and practice: evaluating the impact of the National SunSmart Schools Program. Health Promot J Aust Off J Aust Assoc Health Promot Prof. 2008;19(2):86-90. doi:10.1071/he08086
Crane LA, Schneider LS, Yohn JJ, Morelli JG, Plomer KD. “Block the sun, not the fun”: evaluation of a skin cancer prevention program for child care centers. Am J Prev Med. 1999;17(1):31-37. doi:10.1016/s0749-3797(99)00031-8
Aulbert W, Parpart C, Schulz-Hornbostel R, Hinrichs B, Krüger-Corcoran D, Stockfleth E. Certification of sun protection practices in a German child day-care centre improves children’s sun protection--the “SunPass” pilot study. Br J Dermatol. 2009;161 Suppl 3:5-12. doi:10.1111/j.1365-2133.2009.09443.x
Velasques K, Michels LR, Colome LM, Haas SE. Educational Activities for Rural and Urban Students to Prevent Skin Cancer in Rio Grande do Sul, Brazil. Asian Pac J Cancer Prev APJCP. 2016;17(3):1201-1207. doi:10.7314/APJCP.2016.17.3.1201
Tuong W, Armstrong AW. Effect of appearance-based education compared with health-based education on sunscreen use and knowledge: a randomized controlled trial. J Am Acad Dermatol. 2014;70(4):665-669. doi:10.1016/j.jaad.2013.12.007
Ho BK, Reidy K, Huerta I, et al. Effectiveness of a Multicomponent Sun Protection Program for Young Children: A Randomized Clinical Trial. JAMA Pediatr. 2016;170(4):334-342. doi:10.1001/jamapediatrics.2015.4373
Hoffmann III RG, Rodrigue JR, Johnson JH. Effectiveness of a School-Based Program to Enhance Knowledge of Sun Exposure: Attitudes Toward. Child Health Care. 1999;28(1):69-86. doi:10.1207/s15326888chc2801_5
White KM, Zhao X, Starfelt Sutton LC, et al. Effectiveness of a theory-based sun-safe randomised behavioural change trial among Australian adolescents. Psychooncology. 2019;28(3):505-510. doi:10.1002/pon.4967
Gritz ER, Tripp MK, James AS, et al. Effects of a preschool staff intervention on children’s sun protection: outcomes of sun protection is fun! Health Educ Behav Off Publ Soc Public Health Educ. 2007;34(4):562-577. doi:10.1177/1090198105277850
Hingle MD, Snyder AL, McKenzie NE, et al. Effects of a short messaging service-based skin cancer prevention campaign in adolescents. Am J Prev Med. 2014;47(5):617-623. doi:10.1016/j.amepre.2014.06.014
Barankin B, Liu K, Howard J, Guenther L. Effects of a sun protection program targeting elementary school children and their parents. J Cutan Med Surg. 2001;5(1):2-7. doi:10.1177/120347540100500102
Reynolds KD, Buller DB, Yaroch AL, Maloy J, Geno CR, Cutter GR. Effects of program exposure and engagement with tailored prevention communication on sun protection by young adolescents. J Health Commun. 2008;13(7):619-636. doi:10.1080/10810730802412149
Reinau D, Meier CR, Gerber N, Surber C. Evaluation of a sun safety education programme for primary school students in Switzerland. Eur J Cancer Prev Off J Eur Cancer Prev Organ ECP. 2014;23(4):303-309. doi:10.1097/CEJ.0000000000000040
Lowe JB, Balanda KP, Stanton WR, Gillespie A. Evaluation of a three-year school-based intervention to increase adolescent sun protection. Health Educ Behav Off Publ Soc Public Health Educ. 1999;26(3):396-408. doi:10.1177/109019819902600309
Davis R, Loescher LJ, Rogers J, et al. Evaluation of Project Students are Sun Safe (SASS): A University Student-Delivered Skin Cancer Prevention Program for Schools. J Cancer Educ Off J Am Assoc Cancer Educ. 2015;30(4):736-742. doi:10.1007/s13187-014-0742-7
Buller DB, Hall JR, Powers PJ, et al. Evaluation of the “Sunny Days, Healthy Ways” sun safety CD-ROM program for children in grades 4 and 5. Cancer Prev Control CPC Prev Controle En Cancerol PCC. 1999;3(3):188-195. PMID: 10474766
Loescher LJ, Rawdin S, Machain T, et al. Implementation of Project Students Are Sun Safe (SASS) in Rural High Schools Along the Arizona-Mexico Border. J Cancer Educ Off J Am Assoc Cancer Educ. 2019;34(2):259-268. doi:10.1007/s13187-017-1296-2
Turrisi R, Hillhouse J, Robinson J, Stapleton J, Adams M. Influence of parent and child characteristics on a parent-based intervention to reduce unsafe sun practices in children 9 to 12 years old. Arch Dermatol. 2006;142(8):1009-1014. doi:10.1001/archderm.142.8.1009
Bauer J, Büttner P, Wiecker TS, Luther H, Garbe C. Interventional study in 1,232 young German children to prevent the development of melanocytic nevi failed to change sun exposure and sun protective behavior. Int J Cancer. 2005;116(5):755-761. doi:10.1002/ijc.21081
Steele C, Burkhart C, Tolleson-Rinehart S. “Live Sun Smart!” Testing the effectiveness of a sun safety program for middle schoolers. Pediatr Dermatol. 2020;37(3):504-509. doi:10.1111/pde.14141
Crane LA, Asdigian NL, Barón AE, et al. Mailed intervention to promote sun protection of children: a randomized controlled trial. Am J Prev Med. 2012;43(4):399-410. doi:10.1016/j.amepre.2012.06.022
Chao LX, Patterson SSL, Rademaker AW, Liu D, Kundu RV. Melanoma Perception in People of Color: A Targeted Educational Intervention. Am J Clin Dermatol. 2017;18(3):419-427. doi:10.1007/s40257-016-0244-y
Buller DB, Reynolds KD, Buller MK, et al. Parent reports of sun safety communication and behaviour for students in a randomised trial on a school policy implementation intervention. Aust N Z J Public Health. 2020;44(3):208-214. doi:10.1111/1753-6405.12987
Stanganelli I, Naldi L, Falcini F, et al. Parental Use and Educational Campaigns on Sunbed Use Among Teenagers and Adolescents. Medicine (Baltimore). 2016;95(11):e3034. doi:10.1097/MD.0000000000003034
Thornton CM, Piacquadio DJ. Promoting sun awareness: evaluation of an educational children’s book. Pediatrics. 1996;98(1):52-55. PMID: 8668412
Mayer JA, Lewis EC, Eckhardt L, et al. Promoting sun safety among zoo visitors. Prev Med. 2001;33(3):162-169. doi:10.1006/pmed.2001.0875
Hubbard G, Kyle RG, Neal RD, Marmara V, Wang Z, Dombrowski SU. Promoting sunscreen use and skin self-examination to improve early detection and prevent skin cancer: quasi-experimental trial of an adolescent psycho-educational intervention. BMC Public Health. 2018;18(1):666. doi:10.1186/s12889-018-5570-y
Horsham C, Ford H, Hacker E. Promoting sunscreen use in adolescents playing outdoor sports using UV detection stickers. Prev Med Rep. 2020;19:101166. doi:10.1016/j.pmedr.2020.101166
Gritz ER, Tripp MK, Peterson SK, et al. Randomized controlled trial of a sun protection intervention for children of melanoma survivors. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol. 2013;22(10):1813-1824. doi:10.1158/1055-9965.EPI-13-0249
Buller MK, Kane IL, Martin RC, et al. Randomized trial evaluating computer-based sun safety education for children in elementary school. J Cancer Educ Off J Am Assoc Cancer Educ. 2008;23(2):74-79. doi:10.1080/08858190701818267
Glanz K, Steffen AD, Schoenfeld E, Tappe KA. Randomized trial of tailored skin cancer prevention for children: the Project SCAPE family study. J Health Commun. 2013;18(11):1368-1383. doi:10.1080/10810730.2013.778361
Walkosz B, Voeks J, Andersen P, et al. Randomized trial on sun safety education at ski and snowboard schools in western North America. Pediatr Dermatol. 2007;24(3):222-229. doi:10.1111/j.1525-1470.2007.00390.x
Milne E, English DR, Johnston R, et al. Reduced sun exposure and tanning in children after 2 years of a school-based intervention (Australia). Cancer Causes Control CCC. 2001;12(5):387-393. doi:10.1023/a:1011294023498
Mayer JA, Slymen DJ, Eckhardt L, et al. Reducing ultraviolet radiation exposure in children. Prev Med. 1997;26(4):516-522. doi:10.1006/pmed.1997.0166
Criado PR, Ocampo-Garza J, Brasil ALD, et al. Skin cancer prevention campaign in childhood: survey based on 3676 children in Brazil. J Eur Acad Dermatol Venereol JEADV. 2018;32(8):1272-1277. doi:10.1111/jdv.14740
Glanz K, Chang L, Song V, Silverio R, Muneoka L. Skin cancer prevention for children, parents, and caregivers: a field test of Hawaii’s SunSmart program. J Am Acad Dermatol. 1998;38(3):413-417. doi:10.1016/s0190-9622(98)70498-0
Glanz K, Lew RA, Song V, Murakami-Akatsuka L. Skin cancer prevention in outdoor recreation settings: effects of the Hawaii SunSmart Program. Eff Clin Pract ECP. 2000;3(2):53-61. PMID: 10915324
Stankeviciūte V, Zaborskis A, Petrauskiene A, Valiukeviciene S. Skin cancer prevention: children’s health education on protection from sun exposure and assessment of its efficiency. Med Kaunas Lith. 2004;40(4):386-393. PMID: 15111755
Manganoni AM, Cainelli T, Zumiani G, et al. Study of sunbathing in children: the preliminary evaluation of a prevention program. Tumori. 2005;91(2):116-120. PMID: 15948536
Gooderham MJ, Guenther L. Sun and the skin: evaluation of a sun awareness program for elementary school students. J Cutan Med Surg. 1999;3(5):230-235. doi:10.1177/120347549900300502
Hughes AS. Sun protection and younger children: lessons from the Living with Sunshine program. J Sch Health. 1994;64(5):201-204. doi:10.1111/j.1746-1561.1994.tb03300.x
Cohen L, Brown J, Haukness H, Walsh L, Robinson JK. Sun protection counseling by pediatricians has little effect on parent and child sun protection behavior. J Pediatr. 2013;162(2):381-386. doi:10.1016/j.jpeds.2012.07.045
Hubbard G, Cherrie J, Gray J, et al. 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. BMC Public Health. 2020;20(1):131. doi:10.1186/s12889-020-8265-0
Duarte AF, Picoto A, Pereira A da C, Correia O. Sun protection in children: a behavioural study. Eur J Dermatol EJD. 2018;28(3):338-342. doi:10.1684/ejd.2018.3290
Kouzes E, Thompson C, Herington C, Helzer L. Sun Smart Schools Nevada: Increasing Knowledge Among School Children About Ultraviolet Radiation. Prev Chronic Dis. 2017;14:E125. doi:10.5888/pcd14.170202
Bruce AF, Cowan T. Sun-Protective Behaviors: An Educational Intervention With Hospital Staff Aimed at Skin Cancer Prevention in Children. Clin J Oncol Nurs. 2020;24(1):75-80. doi:10.1188/20.CJON.75-80
Olson AL, Gaffney C, Starr P, Gibson JJ, Cole BF, Dietrich AJ. SunSafe in the Middle School Years: a community-wide intervention to change early-adolescent sun protection. Pediatrics. 2007;119(1):e247-256. doi:10.1542/peds.2006-1579
Miller KA, Langholz BM, Ly T, et al. SunSmart: evaluation of a pilot school-based sun protection intervention in Hispanic early adolescents. Health Educ Res. 2015;30(3):371-379. doi:10.1093/her/cyv011
Khani Jeihooni A, Moradi M. The Effect of Educational Intervention Based on PRECEDE Model on Promoting Skin Cancer Preventive Behaviors in High School Students. J Cancer Educ Off J Am Assoc Cancer Educ. 2019;34(4):796-802. doi:10.1007/s13187-018-1376-y
Winett RA, Cleaveland BL, Tate DF, et al. The Effects of the Safe-sun Program on Patrons’ and Lifeguards’ Skin Cancer Risk-reduction Behaviors at Swimming Pools. J Health Psychol. 1997;2(1):85-95. doi:10.1177/135910539700200109
Miller DR, Geller AC, Wood MC, Lew RA, Koh HK. The Falmouth Safe Skin Project: evaluation of a community program to promote sun protection in youth. Health Educ Behav Off Publ Soc Public Health Educ. 1999;26(3):369-384. doi:10.1177/109019819902600307
Olson AL, Gaffney CA, Starr P, Dietrich AJ. The impact of an appearance-based educational intervention on adolescent intention to use sunscreen. Health Educ Res. 2008;23(5):763-769. doi:10.1093/her/cym005
Miljković S, Baljozović D, Krajnović D, Tasić L, Sbutega-Milosević G. The impact of education on adolescents’ sun behavior: experiences from Serbia. Srp Arh Celok Lek. 2014;142(5-6):330-336. doi:10.2298/sarh1406330m
Hunkin H, Pollock K, Scupham R. The National SunSmart Schools Program: Impact on sun protection policies and practices in Australian primary schools. Health Promot J Aust Off J Aust Assoc Health Promot Prof. 2020;31(2):251-257. doi:10.1002/hpja.291
Fork HE, Wagner RF, Wagner KD. The Texas peer education sun awareness project for children: primary prevention of malignant melanoma and nonmelanocytic skin cancers. Cutis. 1992;50(5):363-364. PMID: 1468258
Stölzel F, Wolff M, Fieber V, et al. UV protection for young athletes: using participatory program planning to develop a sports schools program. Environ Health Prev Med. 2020;25(1):39. doi:10.1186/s12199-020-00872-7
Kristjánsson S, Helgason AR, Månsson-Brahme E, Widlund-Ivarson B, Ullén H. “You and your skin”: a short-duration presentation of skin cancer prevention for teenagers. Health Educ Res. 2003;18(1):88-97. doi:10.1093/her/18.1.88
Skonieczna J, Olejniczak D, Zakrzewska K, et al. “Assessment of knowledge about the effects of UV radiation on health behaviors associated with sunbathing in gymnasium students” - “Ocena stanu wiedzy gimnazjalistów na temat wpływu promieniowania UV na zdrowie oraz zachowania zdrowotne związane z opalaniem się.” Przegla̧d Epidemiol. 2016;70:65-70, 141. PMID: 27344477
Bränström R, Brandberg Y, Holm L, Sjöberg L, Ullén H. Beliefs, knowledge and attitudes as predictors of sunbathing habits and use of sun protection among Swedish adolescents. Eur J Cancer Prev Off J Eur Cancer Prev Organ ECP. 2001;10(4):337-345. doi:10.1097/00008469-200108000-00007
Hughes B r., Altman D g., Newton J a. Melanoma and skin cancer: evaluation of a health education programme for secondary schools. Br J Dermatol. 1993;128(4):412-417. doi:10.1111/j.1365-2133.1993.tb00201.x
Holman DM, Watson M. Correlates of Intentional Tanning Among Adolescents in the United States: A Systematic Review of the Literature. J Adolesc Health Off Publ Soc Adolesc Med. 2013;52(5 0):S52-S59. doi:10.1016/j.jadohealth.2012.09.021
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