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Preventing Skin Cancer: Primary and Middle School-Based Interventions

Task Force Finding

The Community Preventive Services Task Force recommends primary and middle school interventions to prevent skin cancer, based on strong evidence of their effectiveness in increasing sun-protective behaviors and decreasing ultraviolet exposure, sunburn incidence, and formation of new moles.

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

Intervention Definition

Primary and middle school (kindergarten through 8th grade) interventions to promote sun-protective behaviors include educational interventions, supportive behavioral interventions, and environmental and policy changes. Student-focused educational and behavioral interventions include teaching children about sun safety and the effects of ultra-violet (UV) radiation, which is often reinforced by modeling, demonstration, or role-playing. Interventions may be delivered in a single session or as a comprehensive multi-session curriculum.

Student-focused sun-protective environmental and policy changes include increasing the availability of sun-protective items (e.g., sunscreen or protective clothing); adding sun-protective features to the physical environment (e.g. shade structures); and implementing sun-protection policies (e.g., clothing guidelines, restrictions on outdoor activities during peak sunlight hours). Interventions also may include efforts to change the knowledge, attitudes, and behaviors of caregivers at school or at home.

About the Systematic Review

The Task Force 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 Task Force 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 2004 Task Force finding on Education and Policy Approaches in Primary and Middle School Interventions.

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)

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.

Applicability

Based on the settings and populations from included studies, results 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)

Economic Evidence

An economic review is pending.

Considerations for Implementation

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.

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Supporting Materials

Publication Status

Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe External Web Site Icon to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.

Promotional Materials

Community Guide News

More promotional materials for Community Guide reviews about Preventing Skin Cancer.

References

Saraiya M, Glanz K, Briss PA, et al. Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review Adobe PDF File [PDF - 788 kB]. Am J Prev Med 2004;27(5):422-66.




Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Preventing skin cancer: primary and middle school interventions. www.thecommunityguide.org/cancer/skin/education-policy/primaryandmiddleschools.html. Last updated: MM/DD/YYYY.

Review completed: August 2012