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Skin Cancer: Primary and Middle School-Based Interventions


What the CPSTF Found

About The Systematic Review

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 pdf icon [PDF - 349 KB].

Summary of Results

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)

Summary of Economic Evidence

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)

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?)

  • 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)?

Study Characteristics

  • 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.