Skin Cancer: Interventions in Outdoor Recreational and Tourism Settings

This CPSTF finding is based on evidence from a Community Guide systematic review published in 2004 (Saraiya et al., 9 studies on behavioral outcomes; search period January 1966 June 2000) combined with more recent evidence (8 studies, search period June 2000 April 2013). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to preventing skin cancer. This finding updates and replaces the 2002 CPSTF finding on Educational and Policy Approaches in Outdoor Recreational Settings Among Adults and Children.

Visitors to outdoor recreational and tourism settings may have an increased risk of excessive UV radiation exposure for several reasons, including:

• Spending an extensive amount of time outdoors
• Unfamiliarity with the settings, which may have high UV radiation intensity due to factors such latitude, altitude, and light reflective surfaces (e.g., water, sand, snow)
• Desire among vacationers to be carefree

Operators of outdoor recreational and tourist facilities can play an important role in helping to address the heightened risk of sunburns and ultimately skin cancer due to these factors by ensuring that visitors are aware of the risks and are able to effectively mitigate them.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement

The following results are primarily based on evidence from the updated search period. Included studies (8 studies and 13 study arms) assessed intervention effects on various measures of sun protection and physiological outcomes of UV radiation exposure.

Sunscreen use

• Included studies found the intervention increased sunscreen use (5 studies with 8 study arms)
  • Sunscreen use increased 12 percentage points for children and 9.1 percentage points for adults (1 study)
  • Amateur golfers used sunscreen an average of 1.13 more days per week when it was made readily available in locker rooms (1 study). During competitions, athletes increased reapplication of sunscreen by 22 percentage points (95% CI: 0.9, 43.1), though reapplication during practice did not change.
  • Children enrolled in ski and snowboard classes at high altitude resorts and their parents increased sunscreen use an estimated 20.0 percentage points (95% CI:10.1, 29.9) and lip balm use a non-significant 4.0 percentage points (95% CI: 6.2, 14.2).
  • Remaining studies used various measures of sunscreen use and showed similar increases in use, particularly during activities other than intentional sunbathing.

Sun protective behaviors

• Results were generally favorable for other sun protective behaviors, such as use of sunglasses or ski goggles (1 study), avoidance of sun exposure (4 studies, 8 study arms), and combined sun protective behaviors (3 studies, 5 study arms).

Physiological outcomes

• Two months following an intervention focused on educating beach goers about the effects of excessive UV exposure on appearance, a small and non-significant decrease in skin darkening due to UV exposure was seen among participants (1 study with 3 study arms).
• Sunburns decreased following interventions in two studies.
  • A non-significant decrease in number of red and painful sunburns was found among female beach goers in intervention group (p=0.8).
  • The proportion of tourists presenting with at least one sunburn during their stay at a beach resort decreased among both an intervention group that received free sunscreen ( 16.9 percentage points; 95% CI: 28.9, 4.9), and one that received free sunscreen and information on sun protection ( 25.6 percentage points; 95% CI: 36.9, 14.2).

A systematic review of economic evidence has not been conducted.

Based on results for interventions in different settings and populations, findings are applicable to the following:

• Diverse outdoor recreational and tourism settings and activities, including places where people go to be exposed to the sun (e.g., beaches) and places where sun exposure is incidental to the recreational activity (e.g., ski resorts, golf courses), provided messages are appropriately targeted to visitors and activities at these settings.
• Adults and children (considering evidence from the updated and original reviews)

The CPSTF identified several areas that have limited information. Additional research and evaluation could help fill remaining gaps in the evidence base. (What are evidence gaps?)

• Most of the available evidence comes from studies of predominantly white people with sun-sensitive skin. Future research should attempt to include understudied groups such as other racial/ethnic groups, people with less sun-sensitive skin, and people of lower socioeconomic status.
• To allow for better understanding of the maximally effective mixture of intervention components, it would be helpful for researchers to assess how intervention effectiveness varies based on the specific combination of components.
• Studies that follow participants for longer time periods would provide useful information about whether behavior changes are sustained over time and in different contexts.
• More studies are needed to evaluate interventions that include sun protection policies.
• It would be helpful for skin cancer researchers to adopt a set of standardized and readily interpretable outcome measures to evaluate the effectiveness of these interventions.

• Of the eight included studies, seven were randomized control trials.
• Follow up periods tended to be short, ranging from assessing outcomes on the same day as exposure to one year period after the intervention. Five of the eight included studies had follow-up periods of two months or less.
• Lack of consistency in outcome measures and metrics for reporting them made it more difficult to derive summary effect estimates and assess effect magnitudes.
• Studies assessed intervention effectiveness among children (1 study) and adults (6 studies), and a median of 84% of intervention participants were white (6 studies).
• Participants tended to be of higher than average socioeconomic status, with a median of 91% of adult participants having at least some college education (3 studies).
• Studies were conducted in the U.S. (6 studies), Canada (1 study) and France (1 study). Settings included beaches (5 studies), ski resorts (2 studies), and a golf club (1 study). In five studies, interventions were implemented at multiple sites.
• Interventions included education (3 studies), environmental changes, including provision of free sunscreen (1 study), or a combination of both (4 studies).
• Many interventions at beaches included appearance based messages to persuade participants to reduce intentional sun tanning. In contrast, interventions at golf courses or ski resorts, where excessive UV exposure is usually incidental to recreational activity or sporting activity, usually emphasized messages about the importance of sun protection (e.g., use of sunscreen, protective clothing, hat/helmet, sunglasses/ski goggles) while engaged in outdoor activity.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained n several publications).

Effectiveness Review

Dubas LE, Adams BB. Sunscreen use and availability among female collegiate athletes. J Am Acad Dermatol 2012;67:876.e1-6.

Mahler HIM, Kulik JA, Gibbons FX, Gerrard M, Harrell J. Effects of appearance-based interventions on sun protection intentions and self-reported behaviors. Health Psychology 2003;22(2):199 209.

Mahler HIM, Kulik JA, Gerrard M, Gibbons FX. Effects of two appearance-based interventions on the sun protection behaviors of Southern California beach patrons, basic and applied. Social Psychology 2006;28(3):263-72.

Nicol I, Gaudy C, Gouvernet J, Richard MA, Grob JJ. Skin protection by sunscreens is improved by explicit labeling and providing free sunscreen. Journal of Investigative Dermatology 2007;127:41 8.

Pagoto S, McChargue D, Fuqua RW. Effects of a multicomponent intervention on motivation and sun protection behaviors among Midwestern beachgoers. Health Psychology 2003;22(4):429 33.

Pagoto SL, Schneider KL, Oleski J, Bodenlos JS, Ma Y. A beach randomized trial of a skin cancer prevention intervention promoting sunless tanning. Arch Dermatol 2010;146(9):979-84.

Walkosz BJ, Buller DB, Andersen PA, Scott MD, Dignan MB, Cutter GR, Maloy JA. Increasing sun protection in winter outdoor recreation a theory-based health communication program. American Journal of Preventive Medicine 2008;34(6):502 9.

Walkosz B, Voeks J, Andersen P, Scott M, Buller D, Cutter G, Dignan M. Randomized trial on sun safety education at ski and snowboard schools in Western North America. Pediatric Dermatology 2007;24(3):222 9.

This literature search was performed to provide a systematic review of the evidence to the Guide to Community Preventive Services and update previous reviews of the literature on skin cancer prevention methods (Saraiya et al., 2004).

Effectiveness Review

The updated search applied a slightly broader search strategy than was used in the Saraiya et al. reviews. Three bibliographic databases were searched: MEDLINE, CINAHL, and PsycINFO. The databases searched covered publications in biomedical and behavioral sciences. The types of documents searched in the databases included journal articles, books, book chapters, reports, conference papers, and dissertations.

Search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. In addition, the bibliographies of all reviewed articles were used to identify any further literature.

The search period was from June, 2000 – May, 2011 for the following updated reviews, though the search was extended to include items published earlier if they had been added to the databases since the last search was performed.

• Mass media
• Multicomponent community-wide interventions
• Childcare center-based interventions
• High school- and college-based interventions
• Primary and middle school interventions

The search period was from 2011 – 2013 for the following updated reviews, though the search was extended to include items published earlier if they had been added to the databases since the last search was performed.

• Outdoor occupational settings
• Outdoor recreational and tourism settings

Once the literature search was completed, Community Guide staff reviewed the citations using the following inclusion and exclusion criteria to narrow down the publications to be reviewed.

Inclusion Criteria

General Criteria for Community Guide Systematic Reviews

• Written in English
• Journal article, government or NGO report
• Conducted in a high-income country
• Primary intervention study with one or more outcomes of interest

Intervention-Specific Criteria

Mass Media

• Interventions provided information through mass media channels
  • Print media (e.g., newspapers, magazines, and billboards)
  • Broadcast media (e.g., television, radio, and billboards)
• Interventions delivered via Internet or social media are eligible if the messages are intended for distribution to a large audience

Exclusion criteria: Mass media was part of a multicomponent intervention* (e.g., mass media plus environmental/policy interventions)

* Interventions were not considered multicomponent if mass media interventions were accompanied by:

• Delivery of complementary messages through small media
• Distribution of promotional materials to increase awareness of campaign messages

Multicomponent Community-Wide Interventions

• Delivered in a defined geographic area
• Included multiple distinct components
• Delivered in more than one type of setting (e.g., school, health care center), or using methods that reach the entire community (e.g., mass media, policy changes)

Childcare Center-Based Interventions

• Included educational and behavioral activities, environmental and policy changes, or a combination
• Delivered in child care centers (e.g., daycare, nursery schools, play schools. and pre-schools) with enrolled children of mean age of <5 years

High School- and College-Based Interventions

• Included educational and behavioral activities, environmental and policy changes, or a combination
• Delivered in high school, college, or university setting

Primary and Middle School Interventions

• Included educational and behavioral activities, environmental and policy changes, or a combination
• Delivered in primary or middle school setting. Studies were eligible if:
  • Median grade level: 8 or lower
  • Median age: 14 years or younger

Outdoor Recreational and Tourism Settings

• Interventions included educational and behavioral activities, environmental and policy changes, or a combination
• Delivered in outdoor recreation and tourism setting (e.g., beach resort, swimming pool, zoo park )
• Interventions must evaluate recommendation outcomes among visitors, including adults and children

Search Terms [ * = truncation ]

actinic keratosis

attitude*

awareness

behavior

carcinoma, basal cell

carcinoma, squamous cell

cognition

health education

health knowledge

health promotion

health screening

keratosis

knowledge

knowledge, attitudes, and practice

melanoma

nevi

nevus

photodamage

policy

prevention

prevention health care

preventive health services

primary prevention

protective clothing

public policy

screen*

skin aging

skin cancer

skin neoplasms

solar exposure*

solar keratoses

solar protect*

sun damage

sun exposure*

sun protect*

sun safety

sunburn*

sunlight

sunscreening agents

suntan

tanning

therapy

ultraviolet radiation

ultraviolet rays

Search Results

Search Strategies

Database: MEDLINE (OVID)
1. exp Skin Neoplasms/

2. skin-cancer.mp.

3. exp melanoma/

4. carcinoma, basal cell/ or carcinoma, squamous cell/

5. nevus/

6. nevi.mp.

7. exp keratosis/

8. actinic-keratoses.mp.

9. skin aging/

10. (sun-damage or photodamage).mp.

11. solar-keratoses.mp.

12. or/1-11

13. primary-prevention.mp.

14. prevention-health-care.mp. or exp preventive health services/

15. therapy.mp.

16. Health Knowledge, Attitudes, Practice/ or knowledge/ or health-knowledge.mp.

17. (knowledge and attitudes and practice).ti,sh.

18. awareness.mp. or exp cognition/

19. (attitude or attitudes).mp.

20. exp public policy/ or policy.mp. or policies.mp.

21. exp health promotion/

22. exp health education/

23. behavior.mp. or exp behavior/

24. or/13-23

25. 12 and 24

26. mass screening/ or health-screening.mp. or screen*.mp.

27. 25 not 26

28. 25 and 26 and prevention.mp.

29. 27 or 28

30. (sunburn* or suntan* or tanning).mp.

31. ultraviolet rays/ or ultraviolet-radiation.mp.

32. ((sun-exposure* or sunprotect*) and sun-safety).mp.

33. (solar-exposure* or solar-protect*).mp.

34. exp sunlight/

35. exp protective clothing/ or protective-clothing.mp.

36. exp sunscreening agents/

37. or/30-36

38. 24 and 37

39. 38 not 26

40. 38 and 26 and prevention.mp.

41. 39 or 40

42. 29 or 41

[For the April 2009 May 2011 search, performed in May 2011]

43. limit 42 to (English language and yr=”2009 Current”)

44. (200904* or 200905* or 200906* or 200907* or 200908* or 200909* or 200910* or 200911* or 200912* or 2010* or 2011*).ed.

45. 42 and 44

46. limit 45 to (English language)

47. 43 or 46

[For the May 2011 April 2013 search, performed in April 2013]

43. limit 42 to (english language and yr=”2011 -Current”)

44. (201105* or 201106* or 201107* or 201108* or 201109* or 201110* or 201111* or 201112* or 2012* or 2013*).ed.

45. 42 and 44

46. limit 45 to (English language)

47. 43 or 46

Database: CINAHL (EbscoHost)
Limiters – Published Date from: 20090101-20111231; English Language [For the April 2009 to May 2011 search, performed in May 2011]

Limiters – Published Date from: 20110101-20131231; English Language [For the May 2011 to April 2013 search, performed in April 2013]

S57 s56 or s35

S56 s52 or s55

S55 s53 or s54

S54 s51 and s30 and TX primary prevention

S53 s51 and s30 and TX prevention

S52 s51 NOT s30

S51 s50 and s28

S50 s36 or s37 or s38 or s39 or s40 or s41 or s42 or s43 or s44 or s45 or s46 or s47 or s48 or s49

S49 (MH “Sunscreening Agents+”)

S48 TX sunscreen

S47 TX protective clothing

S46 (MH “Protective Clothing+”)

S45 (MH “Sunlight+”)

S44 TX solar exposure* or TX solar protect*

S43 TX sun safety

S42 TX sun protect*

S41 TX sun exposure*

S40 TX ultraviolet radiation

S39 (MH “Ultraviolet Rays”)

S38 TX tanning

S37 TX suntan*

S36 TX sunburn*

S35 s31 or s34

S34 s32 or s33

S33 s29 and s30 and TX “prevention”

S32 s29 and s30 and TX “primary prevention”

S31 s29 NOT s30

S30 (MH “Health Screening+”) or (MH “Mass Screening+”) or TX screen*

S29 s13 and s28

S28 s14 or s15 or s16 or s17 or s18 or s19 or s20 or s21 or s22 or s23 or s24 or s24 or s26 or s27

S27 (MH “Behavior+”)

S26 TX behavior

S25 (MH “Health Education+”)

S24 (MH “Health Promotion+”)

S23 TX policy

S22 (MH “Public Policy+”)

S21 (MH “Cognition+”)

S20 TX “knowledge, attitudes, and practice”

S19 (MH “Knowledge+”) OR (MH “Health Knowledge”)

S18 TX “prevention health care”

S17 MH “Preventive Health Care+”

S16 TX attitudes or TX attitude

S15 TX “awareness”

S14 TX “therapy”

S13 s1 or s2 or s3 or s4 or s5 or s6 or s7 or s8 or s9 or s10 or s11 or s12

S12 TX solar keratoses

S11 TX sun damage or TX photodamage

S10 TX actinic keratoses

S9 TX nevi

S8 TX skin cancer*

S7 (MH “Skin Aging”)

S6 (MH “Keratosis+”)

S5 (MH “Nevi and Melanomas+”)

S4 (MH “Nevus”)

S3 (MH “Carcinoma, Basal Cell”) OR (MH “Carcinoma, Squamous Cell”)

S2 (MH “Melanoma+”)

S1 (MH “Skin Neoplasms+”)

Database: PsycINFO (OVID)
1 exp Skin Neoplasms/ or skin-neoplasm*.mp.

2 skin-cancer*.mp.

3 exp melanoma/ or melanoma*.mp.

4 carcinoma, basal cell/ or carcinoma, squamous cell/ or squamous-cell-carcinoma.mp. or basal-cell-carcinoma.mp.

5 nevus/ or nevus.mp.

6 nevi.mp.

7 exp keratosis/ or keratosis.mp. or keratoses.mp.

8 actinic-keratoses.mp.

9 skin aging/ or skin-aging.mp.

10 (sun-damage or photodamage).mp.

11 solar-keratoses.mp.

12 or/1-11

13 primary-prevention.mp.

14 prevention-health-care.mp. or exp preventive health services/

15 therapy.mp.

16 Health Knowledge, Attitudes, Practice/ or knowledge/ or health-knowledge.mp.

17 (knowledge and attitudes and practice).ti,sh.

18 awareness.mp. or exp cognition/

19 (attitude or attitudes).mp.

20 exp public policy/ or public policy/ or policy.mp. or policies.mp.

21 exp health promotion/ or exp health education/

22 behavior*.mp. or exp behavior/

23(prevention-health-care or preventive-health-services).mp.

24 cognition/ or cognition.mp.

25 or/13-24

26 12 and 25

27 mass screening.mp. or exp health screening/ or screen*.mp.

28 26 not 27

29 26 and 27 prevention.mp.

30 28 or 29

31 (sunburn* or suntan* or tanning).mp.

32 ultraviolet rays/ or ultraviolet-radiation.mp.

33 ((sun-exposure* or sunprotect*) and sun-safety).mp.

34 (solar-exposure* or solar-protect*).mp.

35 exp sunlight/

36 exp protective clothing/ or protective-clothing.mp.

37 exp sunscreening agents/

38 sunscreening-agent*.mp.

39 sunscreen/

40 ultraviolet rays/

41 protective clothing/

42 sunscreen*.mp.

43 or/31-42

44 25 and 43

45 44 not 27

46 44 and 27 and prevention.mp.

47 45 or 46

48 30 or 47

[For the 2009-2011 search, run in May 2011]

49 limit 48 to (English language and yr=”2009 -Current”)

50 (200904* or 200905* or 200906* or 200907* or 200908* or 200909* or 200910* or 200911* or 200912* or 2010* or 2011*).up.

51 48 and 50

52 limit 51 to (English language)

53 49 or 52

[For the 2011-2013 search, run in April 2013]

49 limit 48 to (English language and yr=”2011-Current”)

50 (201104* or 201105* or 201106* or 201107* or 201108* or 201109* or 201110* or 201111* or 201112* or 2012* or 2013*).up.

51 48 and 50

52 limit 51 to (English language)

53 49 or 52

Saraiya M, Glanz K, Briss PA, et al. Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review. Am J Prev Med 2004;27(5):422-66.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Programs in recreational and tourism settings need to consider the small amount of extra time visitors are willing to spend on sun protection interventions and the wide dispersion of people in many of these settings. Strategies may include the following:
  • Displaying signage with key messages at a large numbers of locations; using multiple channels to disseminate sun safety messages (e.g., brochures, posters, interactive activities)
  • Incorporating sun safety messages into existing activities (e.g., swimming lessons; ski schools)
  • Disseminating information at strategic locations, such as waiting areas for tickets or events.
• Providing free sunscreen and ensuring adequate availability of shade may reduce barriers to effective sun protection related to inaccessibility and inconvenience. Providing free sunscreen also removes cost considerations that may cause people to use sunscreen less frequently than they should.
• Sun protection policies appropriate to a specific setting may complement other intervention components focused on educating people about sun safety and making sun protection more accessible. For example, outdoor activities may be scheduled in shaded areas or outside peak UV intensity periods.
• Policy development can play an important role in sustaining and helping to ensure consistent delivery of educational and environmental intervention components. For example, policies may require provision of sunscreen at the pool or incorporate sun safety instruction into curricula for swimming, skiing, or other lessons.
• Interventions may have beneficial consequences beyond individuals’ sun-protective behaviors. For example, programs may decrease risks of overexposure to heat by encouraging people to avoid peak sun exposure or cover up. Programs also can help participants guard against excessive sun exposure that may interfere with healthy outdoor pursuits.

One ongoing barrier to widespread implementation of these interventions is the belief among some operators of recreational facilities that implementing a sun safety program might adversely affect their business, or that they have no responsibility for their visitors’ sun safety.

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of students in grades 9 through 12 who report sunburn — C‑10