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ARTICLE |
a Departments of Pediatrics
b Community and Family Medicine, Dartmouth Medical School, Norris Cotton Cancer Center, Lebanon, New Hampshire
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. A randomized, controlled trial was conducted in 10 communities to assess the impact of the SunSafe in the Middle School Years program. The intervention sought to (1) educate and activate adults and peers to role model and actively promote sun-protection practices and (2) create a pro–sun protection community environment. It targeted school personnel, athletic coaches, lifeguards, and clinicians and enlisted teens as peer advocates. Annual observations of cross-sectional samples of teens at community beach/pool sites were used to assess the impact of 1 and 2 years of intervention exposure compared to grade-matched controls. The outcome was percent of body surface protected by sunscreen, clothing, or shade.
RESULTS. Observers determined the sun protection level of 1927 adolescents entering 6th to 8th grades. After 2 years of intervention exposure, adolescents at the beach/pool in intervention communities were significantly better protected than those in control communities. Over 2 years, the percent of body surface area protected declined by 23% in the control arm but only 8% in intervention arm. After intervention, the average percent of body surface protected at intervention sites (66.1%) was significantly greater than control sites (56.8%). Teens in intervention communities reported sun-protection advice from more adult sources, were more likely to use sunscreen, and applied it more thoroughly than control-site teens.
CONCLUSIONS. Our multicomponent model addressing adolescent sun protection shows the power of engaging teens and adults from across the community as role models and educators. This new ecological approach shows promise in changing adolescent sun protection behaviors and reducing skin cancer risks.
Key Words: adolescence • sun protection/screen • skin cancer • community pediatrics • randomized • control trial • health education • primary care • school • recreation
Abbreviations: SPF—sun-protection factor • BSA—body surface area
Skin cancer is currently the most common form of cancer in the United States, with rates increasing 3% to 5% per year.1 The most lethal skin cancer, malignant melanoma, is increasing more rapidly than any other type of cancer.2 Exposure during childhood and adolescence to more UV radiation and intense exposures resulting in sunburns both play a role in the future development of melanoma, as well as squamous and basal cell cancer.3–5 To prevent skin cancer, public health efforts need to begin before adulthood.
A variety of public campaigns focused on sun protection have addressed sun protection in younger children. However, beginning in early adolescence, the use of sun protection steadily declines and reaches its lowest level by high school and young-adult years.6,7 By the age of 14 years, routine use of sun protection is 50% less than that in 10-year-olds.6 One study reported that only 58% of adolescents reported sunscreen use at the beach and 30% of teens had at least 3 sunburns per summer.8 Unfortunately, during adolescence, media and peer influence run counter to parental and public health efforts by promoting the attractiveness of a tan. Protanning attitudes and tan-seeking behaviors begin during the early teen years.8,9 Thus far, most studies in this area are descriptive, and few interventions that address these challenging issues in adolescents have been evaluated.
Most effective interventions to improve sun protection target children or parents at the primary school level.10,11 Studies typically report on changes in knowledge, attitudes, or reported usual behaviors. Because most single-site interventions result in small short-term changes, a multicomponent community-wide approach has been recommended by experts in the field.10,12 Our earlier randomized, controlled trial of a multicomponent intervention, the "SunSafe" project, was effective in changing the observed sun protection in younger children (aged 2–10 years). We found that providing consistent messages to children and families through schools, day care, primary care offices, and recreational beach areas significantly improved sun protection at community beaches.13,14
This SunSafe approach was used in our new study, SunSafe in the Middle School Years, which addresses sun protection in early adolescence. Because of different activities and social influences during adolescence, new components involving sports teams and peer-led activities were added. We were guided by research that had shown that active role-modeling by soccer coaches influenced youth sun protection.15 In addition, adolescent-specific messages and new interventions to increase the immediate relevance of sun protection were developed. Our hypothesis was that a multicomponent community intervention would limit the decline in sun protection expected to occur between 6th and 8th grades.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Town Selection
Geographically distinct communities in New Hampshire and Vermont were selected that were separated by at least 20 miles, had not participated in the earlier SunSafe project, and had a middle school with grades 6 through 8 within 1 building. To be eligible, communities also had to have at least 1 primary care practice serving the community and a freshwater beach or town swimming pool used primarily by local residents. Because the school was a key location for intervention activities, we obtained agreement to participate from the principal of each school before we contacted other community partners. Ten middle schools in these communities were recruited in pairs matched for size and proportion of students eligible for federal free-lunch programs. Recreation directors, clinicians, and other community-based organizations were engaged in all 10 communities after the schools had been enrolled and randomly assigned by computer-generated numbers.
Intervention
A multicomponent intervention was designed to deliver sun-protection messages though multiple channels in the school and community (Fig 1). The intervention was provided at schools, athletic and recreation facilities, primary care practices, and other community venues. Program materials and training for adult role models emphasized 2 roles: protecting themselves and being an effective role model and educator for the teens. Teen materials emphasized being protected while having outdoor fun. Community environmental cues in each setting were used to increase awareness of sun protection. We reinforced the intervention messages by using branded program materials: a unique, bright logo and the slogan, "Be SunSafe." The socioecologic approach of our intervention was based on Bandura's social cognitive theory.16 In addition, the education sessions for students and adult role models were based on Rogers' protection motivation theory.17
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Schools
Each school had a volunteer school liaison selected by the principal. Most of the liaisons were school nurses or health education teachers. They served as ongoing advocates and were essential to gaining access to teachers and other school personnel to conduct training and classroom presentations. At the first school presentation, teachers were offered access to brief curricular activities that could be incorporated into the existing curriculum. The Environmental Protection Agency's SunWise curricular materials19 and additional activities we designed for art, language arts, and social studies enabled us to provide options for all subjects.
In the second and third years, project staff with physical education teachers conducted a 45-minute activity for all students. First, there was an interactive slide show about UV radiation and skin cancer and sun-protection strategies. This was followed by each student viewing his or her face in the Dermascan. Students could also view their teachers' and friends' faces. This activity helped us incorporate a more immediate message about the risk to appearance, which has been shown to increase motivation to change sun exposure in older adolescents.20
In addition, teachers were recruited to form and lead a group of 8th- to 12th-grade students, called a "sun team," to conduct peer-education activities. Each teacher received a small stipend, and their team had a small budget to support their activities. Teams met from March to June. The project staff developed a manual containing step-by-step directions for potential activities, but the teams were encouraged to develop their own ideas and activities. In the first year, teams held poster contests, videotaped performances of sun-safety messages, sold student-created buttons as fundraisers for the local American Cancer Society, promoted sun safety at school outdoor events, and presented weekly public service announcements on the school public-announcement system. Each school conducted at least 3 activities. Ideas were shared with other participating schools, and the most popular activities, poster contests, and weekly announcements were repeated in the second and third years. The liaison also served as an ongoing advocate for sun protection within the school setting. This led to sun safety being incorporated into school health fairs and inclusion of sun protection on school outdoor-trip permission forms.
Athletic Coaches and Lifeguards
Spring and fall sports offered through the school or community were targeted (ie, soccer, tennis, baseball/softball, lacrosse, track, field hockey). Educational sessions with the Dermascan were provided at the preseason coach meetings each year. Lifeguards received similar training during their preseason orientation. They were encouraged to develop specific approaches to promote sun protection for their audience (eg, pool announcements and sun-protection breaks, team hat/sunscreen policy).
Community Venues
SunSafe Bookmarks were distributed in the libraries in the summer each intervention year. Sun-protection posters placed in local stores in years 2 and 3. Both used student-produced SunSafe artwork.
Primary Care Practices
The training for this component was conducted in 2 phases. During the spring of the first year of intervention, the principal investigator conducted an introductory program on incorporating sun-protection messages into well visits at grand rounds in 5 community hospitals. Interested clinicians were contacted by the project staff for a follow-up office-based training with staff and other providers. Using a systems approach, roles and responsibilities for delivering sun-protection messages, maintaining patient education materials, and changing the office environment with posters and handouts were negotiated. The staff had a Dermascan-viewing opportunity as well. A practice liaison was identified, and the project staff periodically contacted the practice during the summer and in early spring of the second and third intervention years. Patient-education materials, posters, and other project materials, such as temporary tattoos, were provided to participating practices.
Data Collection
Subjects
Children entering grades 6 to 8 who were at community beaches and swimming pools or attending a school-sponsored function with water activities were included in the observational study. Observations were conducted between 11 AM and 3 PM during June through August. A cross-sectional sample of early adolescents at these swimming sites was obtained in year 1 (baseline) and in 3 subsequent years. Initially, observation of students in the summer before 9th grade was planned, but the marked decline in the number of older adolescents attending beach/pool sites resulted in only 20 subjects entering 9th grade in all communities in 2004. Therefore, we were unable to evaluate 3 years of exposure to the intervention through this method. Although we also found that fewer pre-8th-graders attended beaches, combining 2003 and 2004 provided a sufficient number of adolescents for analyses.
Observer Training and Procedures
The evaluation staff received extensive training in observations and interviewing based on detailed guidelines. Before being allowed to observe in the field, each observer passed an interrater reliability test on their accuracy. Accuracy checks continued between observers throughout the summer each year, and an interrater reliability of 0.90 was maintained. A UV meter was used to record the UV index every hour during the observation period. Temperature was recorded for the same hourly intervals.
Observers visited pools/beaches when weather reports did not predict rain or heavily overcast skies. During these visits the observer wore visible identification of the SunSafe project. All youth within the pool or beach area were approached and first determined if they were grade and community eligible. If eligible, they were asked if they were willing to be interviewed. No personal identifiers were obtained. Clothing coverage and shade protection as well as hair and eye color were observed directly. Adolescents were asked about sunscreen application for each of 4 body areas (face/neck, arms, legs, trunk) and the sun-protection factor (SPF) of any sunscreen used. They were asked to show the bottle to corroborate their report. In addition, observers asked the subject about their skin propensity to sunburn21 and if they had been told to protect themselves from the sun by people in school, their doctor, parent, or coach.
Outcome Evaluation
The evaluation end point was the proportion of the individual adolescents' body surface protected from the sun by clothing, sunscreen, or shade. Six levels of upper-body clothing, 4 levels of lower-body clothing, and 3 levels of hats, sunglasses, and whether in the shade were recorded. The total percent of body surface protected by different clothing types and/or sunscreen was calculated by using algorithms based on body surface area (BSA) charts. Our pilot work had shown high correlation between application on face and neck (r = 0.80), upper/lower arms, upper/lower legs, and front/back trunk (r 
0.85). Subjects in the shade were classified as 100% protected. The face was considered protected if a hat with a forward brim was worn, and the head and neck were considered protected if a hat with a 2-inch brim was worn. The BSA protected varied from 10% to 100% for boys and 25% to 100% for girls.
Statistical Analysis
The primary outcome of interest was change in the mean percent of BSA protected after 1 and 2 years of adolescent exposure to the intervention package. Protection levels of adolescents in intervention communities were compared with adolescents of the same grades in control communities at baseline (summer 2001) and follow-up years (summers 2002–2004). All subjects were considered baseline in 2001, as were subjects entering the 6th grade in subsequent years. In 2002, adolescents entering the 7th or 8th grade, and in years 2003 and 2004 students entering the 7th grade, were classified at "1-year follow-up." In 2003 and 2004, students entering the 8th grade were classified at "2-year follow-up." Thus, students who received 1 or 2 years of intervention exposure were compared with students of the same grade in control communities in each data-collection period.
Descriptive statistics (eg, means and SDs) were used to compare the characteristics of the cross-sectional samples and observation environment according to exposure/grade group and intervention status. Specifically, we compared environmental factors (temperature, UV index) and adolescent characteristics (skin type, gender). Items that differed between intervention and control sites during any of the time periods were included as adjustment factors in the multiple regression analysis.
The primary analysis consisted of a multiple linear regression analysis that predicted the percent of BSA protected for each adolescent. Covariates included calendar year of assessment, intervention status, and the interaction between these factors. Additional covariates included adjustment factors as appropriate. A random-effect factor was included to control for community clustering. Effect modification for gender and UV-exposure level was evaluated including appropriate interaction terms in the regression model. On the basis of the fitted model, we computed the adjusted mean protection level for the adolescents in the intervention and control groups according to measurement time point. Subject reports of sunscreen application and protection-advice variables were analyzed by the 
2 test for proportions and the Wilcoxon rank-sum test for continuous variables.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Town populations varied from 6300 to 34000, with no significant difference in mean student-body size between intervention/control-town pairs. Of the population of middle school students, 94% were white. Information about the school population was available from a concurrent survey conducted at baseline in the 10 schools on 20% of the students (n = 827). Seventy percent of middle school students participated in spring or fall athletics, and 36% reported a visit to their primary care provider in the previous year. Adolescent refusal to be interviewed at the beach/pool was rare (<1% per observation session). Characteristics of the adolescent population observed and observation conditions during each of observation time periods (baseline and at 1 and 2 years) are listed in Table 1 for the intervention and control communities. There was considerable variation in the UV index and temperature across years resulting from weather-condition variation during New England summers with high UV-exposure levels with moderate temperatures.
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To better understand these differences over time, we determined the mean percentage of coverage for those in the intervention and control groups adjusted for the other significant predictors. Table 3 shows the adjusted mean percent of BSA protected for the adolescents in the control and intervention sites at baseline and after 2 years of intervention exposure. There was an 
8% decrease from baseline (–5.7%/71.8% BSA protected) in the intervention-group adolescents versus an 23% decrease in control-site adolescents (–16.9%/73.7%). This resulted in an average of 9.7% more BSA protected in our intervention teens after 2 years. This coverage would be comparable to adding sun protection to the head/neck area for the entire intervention population.
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15 were widely used in our region. Use of a sunscreen with an SPF 15 increased from 75% to 84% over the project period without significant differences between the intervention and control communities.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The middle school time period is particularly challenging time for influencing adolescent's sun protection. Two school-based surveys have provided more detailed sun-protection information within this age range. The first survey in Australia showed declining sun protection as adolescence progressed, with the greatest increases in sunburns in younger adolescents (12–13 years old).22 In the second survey with a US population, the proportion of teens who reported always using sun protection declined 16 percentile points between ages 11 and 14 years, with sun-protection rates low but stable for 14- to 18-year-olds.6 Although school curricula can be effective at younger ages,23 school education alone has increased knowledge but not changed early-adolescent students' attitudes or intent to use sunscreen or shade.24,25 Our study is the first multicomponent adolescent intervention that we are aware of that includes both the school and other community partners.
There are key elements of our SunSafe approach that differ from previous work. We sought to change the adolescents' environment and expectations of numerous adults interacting with them. Our school approach was to integrate sun messages into a wide variety of school subjects in addition to introducing a specific sun-protection unit in physical education classes. This approach provided interventions in all grades and was compatible with curricular overload at the middle school level. By using the Dermascan to personalize sun-protection education, we were able to make the issue of damage from UV radiation immediate rather than remote for both adults and teens. Shared viewing with peers increased the potential impact of the education. This is supported by research that has shown the risk-to-appearance approach (showing existing skin damage) is an effective motivator to changing UV-exposure behaviors.20,26 Appearance is particularly important to girls, who are also more likely to actively seek a tan than boys. This may explain why the intervention effect was greater for girls. Our new adult message of promoting better self-protection, as well as being a role model who actively promotes sun protection with youth, was well received and implemented by clinicians, coaches, teachers, and recreation program staff. Role models in control communities provided sun-protection messages at younger ages but did not continue later in middle school. Nearly three quarters of the school and community adult role models were female. More males modeling and promoting appropriate sun protection may be needed to impact adolescent boys' behavior.
Most studies have assessed short-term changes in self-reported behaviors. One strength of our study is that we assessed community-level change with observations over 2 years of intervention exposure. The actual BSA protected rather than self-report of usual or intended protection is a more rigorous outcome. It has previously only been used with adolescent daily recall diaries27 and other populations (younger children, outdoor workers).28,29
Another strength is that this was a community-level effectiveness study in which we primarily influenced the behavior of peers and role models. Although better protection levels might occur if research staff delivered each component, these favorable results occurred within the realistic limits of community partners incorporating the intervention into their routines and our staff only providing 1 direct teen component. This study also provides communities with new approaches to engage adults and teens in the issue of sun protection. This is a feasible model to disseminate through a school/community coalition and cancer advocacy organizations. The program materials are available on the Internet (www.cancer.dartmouth.edu/melanoma/sunsafe.shtml). The American Cancer Society provided the original SunSafe program for younger children to interested local chapters. This program could also be supported by health departments, outdoor recreational staff organizations, or existing adolescent health coalitions.
We found that it took 2 full years of exposure to observe a change in teen protection. In a northern latitude for only 4 to 6 months of the year could we fully engage community partners in promoting sun protection. We also provided the teen directed sun-protection education units with the Dermascan after the first year, which may have increased the later impact of the intervention. It is not clear within our design if the impact after longer exposure was a result of more opportunities to be exposed to the adult and peer role models or if it took time for role models to change their own behavior. It is likely that repeated advice and reinforcement are needed over time to maintain sun protection during adolescence.
There are certain limitations to our study. We were not able to study a longitudinal cohort of students but, rather, repeated cross-sectional observations of a beach/pool population. We did not anticipate the finding that fewer adolescents came to the beach or pool as they became older. Thus, we are unable to tell if the adolescents who continued to come to the beach or pool after 8th grade are teens with more tan-seeking behaviors than their peers who no longer attend. Cancellations of school events because of weather during 2 years made it impossible to obtain a large enough sample of adolescents to determine sun protection at other outdoor activities. A parent could have received information from their child's coach or clinician, articles in the school newsletter, or school health fairs or had sun protection included on an outdoor-event permission form. However, it was a limitation of our study that it was not feasible to have a direct-intervention component for parents, who remain important role models for their early-adolescent children.30 Expanding the parent outreach would be appropriate in future replications. Although we promoted improved adult self-protection and provided yearly information for adults, we were limited in our ability to follow-up on adults and cannot tell how much they changed their own personal protection. Finally, we were limited in our ability to assess the relative contributions of the intervention components.
We would have preferred to see adolescents increase use of clothing, hats, and shade rather than sunscreen. Our project promoted multiple methods of protection as well as shade. Use of sunscreen can extend the total length of time in the sun and increase overall UV-radiation exposure. However, 68% of young adolescent sunburns occur during water activities.31 Thus, better sunscreen use when engaged in water activities is an important step in preventing the high rate of sunburns in adolescents.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Future research needs to address 2 types of adolescent sun exposure: intentional and incidental sun-tanning.32 Girls are more likely than boys to be intentional tanners. Tan seekers are also more likely to use artificial tanning lights when they are older.33 Interventions and messages may need to vary for these patterns of sun exposure among boys and girls. Poor sun protection and tan-seeking are common in older adolescents. Evidence-based interventions specific to the high school level are lacking. Future interventions need to be developed that are responsive to their activities, motivations, and developmental stage.
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FOOTNOTES |
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Address correspondence to Ardis L. Olson, MD, Department of Pediatrics, Dartmouth Hitchcock Medical Center, HB7450, 1 Medical Center Dr, Lebanon, NH 03756. E-mail: ardis.olson{at}dartmouth.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
* The materials given to clinicians were posters, brochures, seasonal counseling cue cards, and temporary tattoos; teachers received water bottles, pencils, tote bags, UV meters for class activities, and UV-exposure cards; and coaches and lifeguards were given lanyards, tote bags, sunscreen samples (all identified with the SunSafe logo), and refrigerator magnets with sports-family home information. 
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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