Skin Cancer: Multicomponent Community-Wide Interventions

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends multicomponent community-wide interventions to prevent skin cancer by increasing UV-protective behaviors, based on sufficient evidence of effectiveness in increasing sunscreen use. Some evidence also indicates benefits in reducing sunburns. Results for effects on other protective behaviors are mixed.


Multicomponent community-wide interventions to prevent skin cancer use combinations of individual-directed strategies, mass media campaigns, and environmental and policy changes across multiple settings within a defined geographic area (city, state, province, or country), in an integrated effort to influence UV-protective behaviors. They are usually delivered with a defined theme, name, logo, and set of messages. Programs vary substantially in duration and breadth of included components.

Studies were eligible for this review if they were delivered in a defined geographic area and included at least two distinct components that were either implemented in different types of settings (e.g., schools, recreation areas) or directed at an entire community (e.g., mass media campaigns).

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

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About The Systematic Review

The CPSTF finding is based on evidence from a Community Guide systematic review published in 2004 (Saraiya et al., 4 studies; search period January 1966 June 2000) combined with more recent evidence (3 studies, search period June 2000 May 2011). 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 2003 Task Force finding on Community-Wide Multicomponent Interventions.

Summary of Results

Seven studies were included in the evidence review, and results showed generally favorable effects for the following outcomes.
  • Sunscreen use (7 studies)
    • Sunscreen use increased by a median of 10.8 percentage points (interquartile interval [IQI]: 7.3 to 23.2; 6 studies)
    • One additional study showed a substantial and sustained increase in sunscreen use over a period of two decades after the implementation of the SunSmart campaign in Australia.
  • Sunburns (2 studies)
    • One study found significant decreases in painful sunburns among children.
      • 15.4 percentage points among those under 6 years of age (95% confidence interval [CI]: 21.2, 9.6)
      • 6.8 percentage points among children 6 to 13 years (95%CI: 14.8, 1.2).
    • Another study showed substantial reductions in sunburns among children and adults over the course of several years.
  • Risk behaviors in children and adults (3 studies)
    • Small decreases were seen in intentional sunbathing, use of tanning beds, and time spent in the sun during peak hours (3 studies).

Results from included studies were mixed for other sun protective behaviors, such as use of shade, hats, and other protective clothing (6 studies).

Summary of Economic Evidence

An economic review of this intervention was not conducted.


Based on the location, settings, and populations from included studies, results are applicable to the following:
  • Multiple settings including entire communities, schools, recreation centers, child care centers, and healthcare and workplace settings
  • All age groups including children, youth, and adults

Although most evidence for this review comes from outside of the United States, the finding is likely to be applicable to the U.S. context because results were similar across countries, and the strongest evidence of intervention effectiveness comes from a U.S. study.

Evidence Gaps

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?)
  • High-quality studies are needed to better understand the long-term effectiveness of multicomponent community-wide interventions (e.g., interrupted time series studies)
  • More evidence is needed to determine variability in the effectiveness of interventions by type of setting and population characteristics (e.g., general population, children and their caregivers, race/ethnicity, type of skin)
    • More information is needed about how intervention effectiveness varies depending on the key characteristics such as scope of intervention (national vs. local), intensity, and the combination of components or presence/absence of specific components.
  • It would be helpful to have more studies that measure skin cancer incidence as an outcome.

Study Characteristics

  • Studies were conducted in the United States (3 studies), Australia (3 studies), and the United Kingdom (1 study).
  • Most of the evidence came from interventions conducted from 1980-2000 (6 studies).
  • Most of the interventions reached a high proportion of the targeted community and included children, youth, and adults.
  • All of the interventions had individually-directed educational and persuasive components, such as didactic programs or small media (7 studies), and five of them also had considerable mass media components (5 studies).
  • Several studies also included environmental strategies to make it easier to engage in protective behaviors such as distribution of sunscreen or provision of shade structures (4 studies) and policy changes, often related to sun exposure during peak hours or tanning bed use (4 studies).

Analytic Framework

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.

Summary Evidence Table

Included Studies

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

Dietrich AJ, Olson AL, Sox CH, Tosteson TD, Grant-Petersson J, et al. Persistent increase in children’s sun protection in a randomized controlled community trial. Preventive Medicine 2000;31(5):569-74.

Dobbinson SJ. 2006-07 National sun protection survey: Report 2; Australians sun protective behaviors and sunburn incidence on summer weekends, 2006-07 and comparison with 2003-04 in the context of the first national mass media campaign. The Cancer Council Australia and Cancer Australia 2008.

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 1999;26(3):369-84.

New South Wales, Cancer, Council. Report on the Seymour Snowman Sun Protection Campaign (1997 1998). North Sydney, New South Wales, Australia: New South Wales Cancer Council, 1998.

Olson AL, Gaffney C, Starr P, Gibson JJ, Cole BF, Dietrich AJ, et al. SunSafe in the Middle School Years: a community-wide intervention to change early-adolescent sun protection.Pediatrics 2007;119(1):e247-56.

ONS. Office of National Statistics Report: SunSmart Trends 03-10 summary report. 2010; Summary Report.

Rassaby J L, Hill D, Wake R. Slip Slop Slap: health education about skin cancer. Cancer Forum 1983;7(63):69.

Search Strategies

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




carcinoma, basal cell

carcinoma, squamous cell


health education

health knowledge

health promotion

health screening



knowledge, attitudes, and practice







prevention health care

preventive health services

primary prevention

protective clothing

public policy


skin aging

skin cancer

skin neoplasms

solar exposure*

solar keratoses

solar protect*

sun damage

sun exposure*

sun protect*

sun safety



sunscreening agents




ultraviolet radiation

ultraviolet rays

Search Results
Search Period (2011-2013)
Database Date Searched Results Results after
Removing Duplicates
Medline 4/10/2013 5477 5108
CINAHL 4/9/2013 418 325
PsycINFO 4/9/2013 119 78
Search Period (2009-2011)
Database Date Searched Results Results after
Removing Duplicates
Medline 5/17/2011 5069 4871
CINAHL 5/19/2011 449 443
PsycINFO 5/19/2011 128 87
Search Period (2000-2009)
Database Date Searched Results Results after
Removing Duplicates
Medline 1/06/2010 8120 8007
CINAHL 1/06/2010 1082 1058
PsycINFO 1/06/2010 239 230

Search Strategies

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


3. exp melanoma/

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

5. nevus/


7. exp keratosis/


9. skin aging/

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


12. or/1-11


14. or exp preventive health services/


16. Health Knowledge, Attitudes, Practice/ or knowledge/ or

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

18. or exp cognition/

19. (attitude or attitudes).mp.

20. exp public policy/ or or

21. exp health promotion/

22. exp health education/

23. or exp behavior/

24. or/13-23

25. 12 and 24

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

27. 25 not 26

28. 25 and 26 and

29. 27 or 28

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

31. ultraviolet rays/ or

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

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

34. exp sunlight/

35. exp protective clothing/ or

36. exp sunscreening agents/

37. or/30-36

38. 24 and 37

39. 38 not 26

40. 38 and 26 and

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 or

5 nevus/ or


7 exp keratosis/ or or


9 skin aging/ or

10 (sun-damage or photodamage).mp.


12 or/1-11


14 or exp preventive health services/


16 Health Knowledge, Attitudes, Practice/ or knowledge/ or

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

18 or exp cognition/

19 (attitude or attitudes).mp.

20 exp public policy/ or public policy/ or or

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

25 or/13-24

26 12 and 25

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

28 26 not 27

29 26 and 27

30 28 or 29

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

32 ultraviolet rays/ or

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

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

35 exp sunlight/

36 exp protective clothing/ or

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

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

Review References

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.

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • To maximize the effects, interventions should be implemented for an extensive time period.
  • Programs implemented at the community level are most successful when there is a substantial commitment of resources and infrastructure (e.g., implementation of sun protection policies at the national level).
  • Reinforcing skin cancer prevention messages delivered through mass media with setting-specific messages, policy changes, and environmental changes can produce a solid basis for initiating and maintaining behavior changes.


Evidence-Based Cancer Control Programs (EBCCP)

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

Healthy People 2030

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