Skin Cancer: Primary and Middle School-Based Interventions

The CPSTF finding is based on evidence from a Community Guide systematic review published in 2004 (Saraiya et al., 20 studies with behavioral outcomes; search period January 1966 June 2000) combined with more recent evidence (13 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 2002 CPSTF finding on Education and Policy Approaches in Primary and Middle School Interventions.

Updated Evidence (search period June 2000 May 2011)

Thirteen new studies were identified in the update period, and results consistently demonstrated beneficial effects on varied outcomes, including the following.

Sun protective behaviors:

• Sunscreen use: median increase of 3.1 percentage points (interquartile interval [IQI]: 1.28 to 8.88, 9 studies with 10 study arms)
• Hat use: median increase of 3.0 percentage points (IQI: 0.30 to 10.18, 9 studies with 10 study arms)
• Use of protective clothing: median increase of 8.7 percentage points (IQI: 3.2 to 13.5, 6 studies with 7 study arms)
• Use of shade: median increase of 9.2 percentage points (IQI: 5.6 to 11.2, 4 studies with 5 study arms)
• Use of sunglasses: median increase of 6.6 percentage points (range: 2.7 to 17.6, 3 studies)

Physiological outcomes

• Direct measures of UV exposure or changes in skin pigmentation: consistent evidence of decreased UV exposure (4 studies)
• Sunburn incidence: median decrease of 3.6 percentage points (IQI: 8.45 to 1.45, 5 studies)
• New mole formation: median relative decrease of 18.63% (range: 24.3% to 9.6%, 3 studies)

Studies also found overall favorable results on composite measures of sun-protective behaviors (4 studies) and reduced use of sunlamps (1 study).

Previous Review (search period January 1966-June 2000)

Twenty studies were included in the evidence review, and results showed significant improvements in behavioral outcomes.

• Sunscreen use: median increase of 1.3 percentage points (8 studies)
• Use of protective clothing: median increase of 1.5 percentage points (18 studies)
• Combined protective behaviors: median increase of 1.0 percentage points (IQI: 0.94 to 1.72; 15 studies)

An economic review of this intervention was not conducted.

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

• Schools in the United States and other countries
• All grade levels and ages
• All educational methods of delivery (e.g., interactive, text, technology-based, lectures)

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?)

• More evidence is needed to determine variability in effectiveness of interventions based on:
  • Presence of local, state, or nationwide initiatives
  • Race or ethnicity, and skin type
• More research is needed on:
  • Interventions with environmental and policy components
  • Interventions for older children (7th and 8th grade)
  • Long-term effects of these interventions
• Several implementation/translation questions remain unanswered, including the following.
  • What infrastructure is required to scale up interventions while sustaining their effectiveness (e.g., technical assistance, support to school districts)?
  • What level of school administration is most helpful to engage with in order to foster implementation (e.g., school-level vs. district-level)?

• Studies from the updated search period were conducted in the United States (5 studies), Europe (5 studies), Australia (2 studies), and Canada (1 study).
• Most of the evaluated interventions involved education only (10 studies); two interventions also included environmental or policy components, and one solely involved distribution of sunscreen.
• More than half (7 studies) of the interventions also targeted caregivers (parents) by sending home informational materials, resources for interactive activities, or sun-protection items (e.g., sunscreen, hats) with instructions for appropriate use.
• Though the systematic review included interventions aimed at students from kindergarten through eighth grade, only two studies included seventh- or eighth-grade students. Studies were generally well-controlled, with five individual or group-randomized trials, and seven non-randomized trials.
• The majority of outcomes were assessed using self-reported or caregiver reported behavior.

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

Buller DB, Reynolds KD, Yaroch A, et al. Effects of the Sunny Days, Healthy Ways curriculum on students in grades 6 to 8. Am J Prev Med 2006;30(1):13-22.

Buller DB, Taylor AM, Buller MK, et al. Evaluation of the Sunny Days, Healthy Ways sun safety curriculum for children in kindergarten through fifth grade. Pediatr Dermatol 2006;23(4):321-9.

Buller MK, Kane IL, Martin RC, et al. Randomized trial evaluating computer-based sun safety education for children in elementary school. J Cancer Educ 2008;23(2):74-9.

Geller AC, Cantor M, Miller DR, et al. The Environmental Protection Agency’s National SunWise School Program: sun protection education in US schools (1999-2000). J Am Acad Dermatol 2002;46(5):683-9.

Gilaberte Y, Alonso JP, Teruel MP, et al. Evaluation of a health promotion intervention for skin cancer prevention in Spain: the SolSano program. Health Promot Int 2008;23(3):209-19.

Hunter S, Love-Jackson K, Abdulla R, et al. Sun protection at elementary schools: a cluster randomized trial. J Natl Cancer Inst 2010;102(7):484-92.

Kimlin M, Parisi A. Usage of real-time ultraviolet radiation data to modify the daily erythemal exposure of primary schoolchildren. Photodermatol Photoimmunol Photomed 2001;17(3):130-5.

Lee TK, Rivers JK, Gallagher RP. Site-specific protective effect of broad-spectrum sunscreen on nevus development among white schoolchildren in a randomized trial. J Am Acad Dermatol 2005;52(5):786-92.

Manganoni AM, Cainelli T, Zumiani G, et al. Study of sunbathing in children: the preliminary evaluation of a prevention program. Tumori 2005;91(2):116-20.

Milne E, Jacoby P, Giles-Corti B, et al. The impact of the kidskin sun protection intervention on summer suntan and reported sun exposure: was it sustained? Prev Med 2006;42(1):14-20.

Naldi L, Chatenoud L, Bertuccio P, et al. Improving sun-protection behavior among children: results of a cluster-randomized trial in Italian elementary schools. The “SoleSi SoleNo-GISED” Project. J Invest Dermatol 2007;127(8):1871-7.

Quereux G, Nguyen JM, Volteau C, et al. Prospective trial on a school-based skin cancer prevention project. Eur J Cancer Prev 2009;18(2):133-44.

Stankeviciute V, Zaborskis A, Petrauskiene A, et al. Skin cancer prevention: children’s health education on protection from sun exposure and assessment of its efficiency. Medicina (Kaunas) 2004;40(4):386-93.

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.

• Primary and middle school interventions to promote sun-protective behaviors may be challenging to implement because of many other competing priorities, and limited time and resources.
• Implementation of sun-protection efforts at a higher organizational level than individual schools (e.g., school districts) may result in increased reach and face fewer organizational barriers.
• Several initiatives to promote adoption of school-based sun-protection programs and policies, such as curricular materials and activities, have demonstrated success at increasing the number of schools that implement these interventions.
• When schools restrict outdoor activities, they should ensure students have the opportunity for supervised indoor physical activity.

Evidence-Based Cancer Control Programs (EBCCP)

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