10.5826/dpc.1301a66
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.
text/xml
2160-9381
2873
en
Susan Chon
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
UV radiation
Review of the Impact of Sun Safety Interventions in Children
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2023-01-31
2022-09-27
2023-01-31
2023-02-27
e2023066
Dermatol Pract Concept
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.
Susan Chon
2023/01/31
10.5826/dpc.1301a66
e2023066
Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, United States
2160-9381
UV radiation
en
e2023066
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
Review of the Impact of Sun Safety Interventions in Children
https://dpcj.org/index.php/dpc/article/download/2873/1962
                   A Review of the Impact of Sun Safety
                         Interventions in Children
                     Imran T. Baig1, Allison Petronzio1, Brandy Maphet2, Susan Chon3


1 UTHealth McGovern Medical School at Houston, Houston, United States
2 Department of Dermatology, UTHealth McGovern Medical School at Houston, Houston, United States
3 Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, United States



Key words: behavioral change, skin cancer, sunscreen, sun protection, UV radiation
Citation: Baig IT, Petronzio A, Maphet B, Chon S. A Review of the Impact of Sun Safety Interventions in Children. Dermatol Pract
Concept. 2023;13(1):e2023066. DOI: https://doi.org/10.5826/dpc.1301a66
Accepted: November 3, 2022; Published: January 2023
Copyright: ©2023 Baig et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Imran T. Baig, B.S.A. UTHealth McGovern Medical School at Houston, Houston, United States, 1711 Old Spanish
Trail Apt 422, Houston, TX 77054 E-mail: imran.t.baig@uth.tmc.edu




  ABSTRACT             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 interven-
                       tions 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 avoid-
                       ance 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.




Review | Dermatol Pract Concept. 2023;13(1):e2023066                                                                                 1
Introduction                                                     must have clear interventions and outcomes (e.g. behavior or
                                                                 knowledge); and 3) study must be published in the English
In the United States, skin cancer is the most common ma-         language.
lignancy and is estimated to affect one in five individuals         The search for relevant articles utilized Ovid Medline,
in their lifetime [1]. The overall incidence of melanoma and     Ovid Embase, and Scopus to identify literature published
non-melanoma skin cancers (NSMC), including basal cell           through September 2020: The following MeSH terms
carcinoma (BCC) and squamous cell carcinoma (SCC), has           were used: “adolescent”, “child”, “infant”, “pediatric(s)”,
been increasing rapidly in recent decades. Melanoma is the       “students”, “teen”, “parent(s)”, “mother”, “father”, “sun-
most lethal type of skin cancer, and it is predicted that over   screening agents”, “sun protection factor”, “sunburn”, “skin
7,500 Americans will die from melanoma in 2022 [2]. Al-          neoplasms”, “sunlight”, “sun”, “skin”, “health education”,
though NMSCs typically carry a more favorable prognosis,         “health promotion”, “education”.
they place a large burden on the United States healthcare
system, with an estimated annual cost of $4.8 billion [3].
                                                                 Results
The largest preventable risk factor for both melanoma and
NMSC is ultraviolet radiation (UVR) exposure [4]. UVR is a       The initial literature search of Ovid Medline, Ovid Embase,
risk factor for skin cancer at any age; however, children are    and Scopus yielded 143 articles. After the articles were re-
at an increased risk of excessive UVR exposure [5]. Children     viewed and duplicates excluded, 66 articles met the inclusion
spend a significant portion of their time outdoors at school     criteria [9-74].
when the UV index is highest, where activities such as recess
and sporting events can result in extended periods of UVR        Types of Interventions:
exposure. In fact, sun damage is cumulative, and about 23        Most studies had an intervention that delivered sun-protective
percent of a person’s lifetime sun exposure happens by the       educational information to the study population (Figure 1).
age of 18 [6]. There is a strong relationship between total      Of the 62 studies that focused on providing information,
sun exposure and non-melanoma skin cancers, and there is         some of the most popular methods included giving a presen-
a clear relationship between sunburns and the development        tation, handing out newsletters or flyers, and implementing
of melanoma [7].                                                 sun safety lessons in the school curriculum. In addition, 17
    Interventions aimed at preventing excessive exposure to      studies relied on economic intervention. From these stud-
harmful UVR can decrease the incidence of skin cancer. The       ies, distribution of free sunscreen to children was the most
American Cancer Society provides several recommendations         popular provision. Other economic interventions included
aimed at primary prevention of skin cancer: 1) seek shade        providing protective clothing, hats, and sunglasses. Lastly,
when UV radiation is strongest (10:00 A.M. - 4:00 P.M.);         3 studies changed the physical environment by adding re-
2) wear sun-protective clothing (i.e. long sleeved shirts and    sources such as shaded structures for children to use during
pants); 3) wear wide-brimmed hats; 4) apply sunscreen with       peak UV light hours (Figure 2).
a minimal SPF of 30; and 5) avoid tanning beds [8]. In ad-
dition to primary prevention methods, secondary prevention       Knowledge as an Outcome:
methods include regular skin self-examinations and profes-       There were 32 studies that measured change in knowledge
sional skin examinations. Applying both prevention tech-         as an outcome after implementation of the intervention. Of
niques has illustrated a decrease in the incidence, morbidity,   those 32 studies, 27 assessed only for the child’s knowledge,
and mortality of skin cancer [4].                                4 assessed only for the parents’ knowledge, and 1 assessed
    Since childhood sun exposure increases the risk of skin      for both the child and parents’ knowledge. Of the studies
cancer, it is essential to educate children about primary        that focused only on measuring the change in the children’s
prevention measures as well as take action to promote            knowledge after intervention, twenty-six studies noted a sig-
sun-protective behaviors. In this review, we evaluated studies   nificant increase in baseline knowledge and only one study
that aimed to either educate or change the behavior of chil-     revealed nonsignificant changes. Winnett et al. illustrated
dren regarding sun safety. By doing this, we aimed to identify   that even after intervention, the children still had minimal
the techniques used and summarize them as an example for         knowledge of appropriate sunscreen use and frequency [67].
much-needed future educational efforts.                          Even though Hingle et al. showed a statistically significant
                                                                 overall increase in knowledge, it was primarily driven by

Methods                                                          knowledge about skin cancer types [27]. The rest of the
                                                                 knowledge-based questions related to UV radiation, pre-
The following criteria were used to identify eligible studies:   cautions to take to avoid sunburn, and suntanning showed
1) study subjects must be less than 18 years old; 2) study       no significant changes. Of the four studies directed at only



2                                                                            Review | Dermatol Pract Concept. 2023;13(1):e2023066
                                                TYPES OF INTERVENTION
                                          ENVIROMENTAL, 3,
                                                4%

                       ECONOMIC, 17,
                           21%




                                                                                                                EDUCATIONAL

                                                                                                                ECONOMIC

                                                                                                                ENVIROMENTAL




                                                                                      EDUCATIONAL, 62,
                                                                                           75%




Figure 1. A pie chart illustrating the various methods of intervention used from all 62 studies.




                                  SUCCESSFUL STUDIES BY TYPE OF OUTCOME
                                               MEASURED
                      70

                      60
  NUMBER OF STUDIES




                      50

                      40

                      30

                      20

                      10

                       0
                               BEHAVIOR            KNOWLEDGE                     SUN EXPOSURE               ATTITUDES
                                                             TYPE OF OUTCOME
                                                      SUCCESSFUL UNSUCCESSFUL

Figure 2. A bar chart comparing studies that were successful in improving the measured outcome to studies that were not successful in
improving the measured outcome.


Review | Dermatol Pract Concept. 2023;13(1):e2023066                                                                               3
measuring the change in parents’ knowledge, two of them                  adopting sun safety into their lessons, UV index announce-
did not result in an increase in the parents’ knowledge. Glanz           ments on the speaker, and guest presenters on UV and sun
et al. used questions to create a knowledge index that was               safety [62]. Although elementary students and middle school
measured for the parents [14]. The knowledge index was rel-              students had improved perceptions, high school students
atively high at baseline and remained virtually unchanged in             maintained a positive attitude towards tanned skin. Buller et
both intervention groups. Glanz et al. assessed the knowl-               al. utilized an educational computer program on sun safety
edge of parents and staff [53]. Although their knowledge                 based on the “Sunny Days, Healthy Ways” sun safety curric-
scores were relatively high to begin with, they improved                 ulum [33]. This CD-ROM program did not improve attitudes
slightly; however, neither of the changes was statistically              toward sun-protective behavior. Barankin et al. enhanced an
significant. In the study that tested both the children’s and            existing “Sun and the Skin” program by educating the par-
parents’ knowledge, parents were reported to have decreased              ents about the program, providing supplemental information,
in knowledge, while elementary and middle schoolers had                  and distributing sunscreen [28]. The students in the enhanced
increased and high schoolers had no change [62].                         group illustrated improvement over the control and standard
                                                                         groups in their attitude towards tanning. David et al. included
Attitudes Toward Tanning as an Outcome:                                  an educational presentation and interactive activities delivered
Five studies assessed children’s attitudes and perceptions of            by university students, who underwent rigorous training and
tanning before and after intervention. Three of the five inter-          volunteering as part of their undergraduate and graduate-level
ventions were considered failures. Kristjánsson et al. devel-            courses [32]. After the intervention, participants reported less
oped an educational tool kit about skin cancer prevention                appeal for tanned skin than before the intervention (p<0.001).
[74]. This tool kit included a manual for teachers, animated
comic figures, a 7-minute video, and recommendations on                  Behaviors as an Outcome:
how to behave in the sun. The students’ attitude to refrain              There were 60 studies that measured change in sun-protective
from tanning was not significantly changed. Regarding                    behaviors as an outcome after implementation of the inter-
mid-day sun avoidance, most students only progressed from                vention. Of those 60 studies, 48 had interventions that were
a pre-contemplation stage to a contemplation stage. K
                                                    ­ ouzes              successful at impacting at least one behavior relating to sun
et al. utilized a sun safety curriculum which included teachers          protection in either the children or their parents (Figure 3).




                               Percent Failure by Intervention
                               Type for Behavioral Outcomes

                                            0
    Type of Intervention




                           Enviromental




                              Economic                                                             12%


                            Educational                                                                                        18%

                                          0%      2%       4%       6%       8%       10%      12%      14%       16%      18%      20%

                                                                                Percent

Figure 3. A bar chart illustrating what percentage of studies were unsuccessful in changing behavior based on the type of intervention.



4                                                                                    Review | Dermatol Pract Concept. 2023;13(1):e2023066
A few commonly studied behaviors include frequency of              studies directed at the pediatric population can alter their
sunscreen application, use of hats and sun-protective cloth-       interventions to be better suited to have a significant impact
ing, shade-seeking, and avoidance of outdoor activities            on these outcomes.
during peak UV radiation. For example, Crane et al. is a              Children’s knowledge about skin cancer and the impor-
randomized controlled trial that found changes in many be-         tance of sun protection was improved in all but two studies
havioral outcomes after sending newsletters on sun protec-         [62, 67]. Kouzes et al. implemented a sun safety curricu-
tion and skin cancer to parents and their children over the        lum which included teachers incorporating sun safety into
course of three years [38]. Specifically, the post-intervention    their lessons, UV index announcements on the speaker, and
group demonstrated increased use of sunscreen, protective          guest presenters on UV and sun safety [62]. The curriculums
clothing, hats, shade-seeking, and midday sun avoidance            used differed based on grade level (preschool through first
compared to baseline; however, a statistically significant         grade used CATCH Global Foundation’s Ray and the Sun-
difference compared to the control group was only present          beatables, grades kindergarten through eighth grade used
for a few select behaviors and in certain years. Conversely,       the Environmental Protection Agency SunWise, and grades
Bauer et al. is a randomized controlled trial in which par-        six through twelve used SunSmart U developed by the Skin
ents were randomized to receive either educational material        Cancer Foundation). Knowledge was improved in elemen-
on sun protection, free sunscreen, or neither, and the results     tary and middle schoolers; however, high schoolers did not
demonstrated no significant differences between the groups         have any change in knowledge of sun protection strategies.
in sun-protective behaviors or the development of melano-          Knowledge deficits in older age groups could be attributed
cytic nevi in the ­children [36].                                  to inadequate use of the curriculum and could suggest that
                                                                   additional support may be needed from a statewide non-
Sun Exposure as an Outcome:                                        profit organization dedicated to cancer control. Skonieczna
There were 15 studies that measured sun exposure via phys-         et al. demonstrated the significance of partnerships within
ical skin changes as an outcome after implementation of the        schools to create long-lasting sun safety programs, so such
intervention. A few commonly studied metrics include inci-         support could encourage increased participation [75]. Win-
dence of new sunburns, number of new nevi, and change in           nett et al. studied the effects of an intervention that included
pigmentation of the skin. Of the 10 studies that measured          informational posters in prominent locations, a poster pro-
incidence of sunburn as an outcome, 8 studies showed fewer         viding feedback about how many people are practicing the
sunburns as a result of the intervention, whereas one study        SafeSun program, a weekly lottery ticket for people wearing
showed no effect on sunburns and another study showed an           sun-protective clothing, and lifeguards modeling the SafeSun
increase in the number of sunburns despite the intervention        logo on their clothing [67]. Knowledge about skin cancer,
[61]. Of the 6 studies that looked at increased pigmentation       its causes, and how to appropriately use sunscreen remained
(i.e. tanning, melanin) as an outcome, only 2 studies demon-       low. This intervention did not include formal information
strated that their intervention decreased the level of skin pig-   lessons, which could explain the lack of knowledge related
mentation. Of the 3 studies that looked at development of          to skin protection.
new melanocytic nevi as an outcome, none of them showed a             Several studies demonstrated positive attitudes towards
statistically significant difference in the development of new     tanned skin even after an intervention was implemented
nevi post-intervention.                                            [33, 62, 74]. In the previously mentioned study by Kouzes
                                                                   et al., in addition to not showing improvements in knowl-

Discussion                                                         edge, high schoolers also continued to value the appearance
                                                                   of tanned skin [62]. Despite acknowledging the risks associ-
The goal of this review was to evaluate the impact of var-         ated with tanned skin, high school students still maintained
ious informational, economic, and environmental interven-          a positive attitude towards tanned skin. This illustrates that
tions on sun-protective behaviors, knowledge, attitudes,           because older children perceive tanned skin as desirable, they
and sun exposure in the pediatric population. Targeting            are willing to risk their health to fit into societal norms [76].
children is important because, theoretically, the earlier that     Another study provided a manual for teachers, animated
sun-protective habits are formed, the earlier primary preven-      comic figures, a 7-minute video, and recommendations on
tion methods from dangerous UV rays can be implemented             how to behave in the sun to adolescents [74]. The students’
and lower the burden of future skin cancer. As many of the         attitudes to refrain from tanning were not significantly
techniques reviewed were successful in instilling knowledge        changed. Previous studies have shown that when children
and sun safety practices, this discussion highlights the inter-    reach adolescence, their appreciation of suntans increases
ventions that failed to alter children’s behaviors, knowledge,     [7, 77]. Therefore, it might be beneficial to start motivating
attitudes, and sun exposure. Using this information, future        attitude changes to sunbathing before adolescence. Lastly,



Review | Dermatol Pract Concept. 2023;13(1):e2023066                                                                              5
Buller et al. used a CD-ROM educational computer program           measured and impacted outcome compared to the others. In
based on a sun safety education program and also failed to         response to sun exposure, sunburns develop rather quickly
improve children’s attitudes towards sun protective behav-         and can develop after only one outdoor exposure, whereas
iors [33]. Changing attitudes about suntanning is a challeng-      skin pigmentation and nevi formation are processes that take
ing task in this population. Branstorm et al. surveyed 2615        time and require more chronic exposure to sunlight. Many
adolescents and uncovered that the most frequent motive for        of the studies that assessed skin pigmentation and nevi for-
sunbathing was that it made them feel more attractive [76].        mation failed to demonstrate any significant change in these
Media influence plays a large role in affecting the desire to      metrics, likely due to a lack of significant behavioral change
tan by promoting the idea that tan skin equates to looking         and/or insufficient length of study. In the case of Bauer et al.,
healthy and attractive [78]. Changing the attitudes of chil-       educational and/or economic interventions were adminis-
dren towards tanning and their motivation to intentionally         tered, and the number of incident melanocytic nevi was mea-
tan will remain challenging as long as societal pressure and       sured after a three-year period with no significant difference
media influence promote tanned skin.                               between groups [36]. In this particular study, the interven-
    Many studies were able to demonstrate a positive effect        tion failed to impact sun-protective behaviors, which likely
on sun-protective behaviors; however, there were some that         directly affected the success of the intervention in impacting
were unsuccessful. A common theme among several of the un-         nevi formation. Of the studies that had a positive impact on
successful studies was the utilization of interventions that in-   sun-protective behaviors; a common theme was that changes
volved brief (30-60 minute), one-time lessons or presentations     in behavior were often transient or resulted in minimal
with or without periodic follow-up. As an example, Hubbard         change in the development of physical skin findings related
et al. involved a 50-minute presentation that addressed risk       to sun exposure. In this discussion of sun protection in chil-
factors for skin cancer, personal anecdotes from individuals       dren, our primary concern is whether early interventions can
with skin cancer, etc., after which the children were given an     reasonably decrease a child’s risk of developing skin cancer
informational booklet [60]. In the seven weeks following the       later in life. It is encouraging to see that children and their
presentation, motivational and informational text messages         parents are able to adopt sun-protective behaviors with the
were sent twice weekly in an effort to influence summer be-        right intervention; however, it is unclear if these behavioral
haviors. Similarly, Saridi et al. involved a 45-50-minute in-      changes will translate to physical changes in the skin and
teractive educational session with follow-up one year after        decreased incidence of skin cancer in the future.
the intervention [17]. Unfortunately, these studies and sev-
eral others with similar intervention strategies were unable       Conclusion
to affect meaningful behavioral change in children. Among
the three main types of intervention (i.e. economic, educa-        It is crucial that children be educated on the importance of
tional, and environmental), educational interventions were         sun protection. Although a variety of interventions showed
most associated with failure to impact sun-protective behav-       promise in achieving this goal, the challenges associated with
iors in children. Although educational interventions were          adopting behavioral change were evident. This review pro-
utilized in many studies that were successful at modifying         vides direction for future interventions aimed at improving
behaviors, those that incorporated additional economic (e.g.       sun safety in children and illustrates the potential impact
free sunscreen) or environmental (e.g. adding shaded areas at      that early intervention can have on the incidence of skin can-
school) interventions were more likely to achieve change. It is    cer in future generations.
not surprising that solely providing educational materials to
children might not be very fruitful. Children might find this      References
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