Skin Cancer: Child Care Center-Based Interventions

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends child care center-based skin cancer prevention interventions that include implementation of sun protection policies along with education of staff and parents. This recommendation is based on sufficient evidence that these interventions increase children’s protection from excessive UV exposure.

Intervention

Child care center-based interventions to promote sun-protective behaviors include educational interventions, supportive behavioral interventions, and environmental and policy changes in daycare or preschool settings.

Educational and behavioral interventions generally provide information about sun safety and the effects of ultraviolet (UV) radiation, and may be directed to children, their caregivers (e.g., staff, parents), or both. Messages delivered in lectures or through small media can be reinforced by modeling or role-playing.

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).

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., one study with behavioral outcomes; search period January 1966 June 2000) combined with more recent evidence (6 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 2001 CPSTF finding on Education and Policy Approaches in Child Care Centers.

Summary of Results

Updated Evidence (search period June 2000 May 2011)

Included studies (6 studies, 7 study arms) evaluated intervention effects on various measures of sun protection and on physiological consequences of UV radiation exposure among children. These results were generally favorable across all of the outcomes.

  • Sunscreen use
    • Increase of 1.6 and 3.3 percentage points (2 studies, 3 study arms)
    • Other measures of sunscreen use also showed favorable results (2 studies)
  • Hat use
    • Median increase of 8.1 percentage points (3 studies, 4 study arms)
    • Other measures of hat use also showed favorable results (1 study)
  • Clothing use
    • Increase of 0.5 and 1.2 percentage points (1 study, 2 study arms)
    • Other measures of clothing use also showed favorable results (1 study)
  • Shade use while outdoors
    • Increase of 8.6 percentage points (1 study)
  • Sunburn incidence
    • Decreases in the number of sunburn episodes ranged from -1.7 to -1.5 percentage points (1 study, 2 study arms)

Included studies also found overall favorable results for the following outcomes.

  • Combined sun-protective behaviors (2 studies, 3 study arms)
  • Excessive sun exposure (3 studies, 4 study arms)
  • Incidence of new mole formation (1 study, 2 study arms)

Previous Review (search period January 1966- June 2000)

One study reported changes in behavioral outcomes and found the following.

  • Mixed and nonsignificant effects on an index of sun protection behaviors:
    • arms (mean increase of 0.3 points; p=0.23)
    • legs (no change; p=0.95)
    • head (mean decrease of -0.4 points; p=0.21)
  • Nonsignificant effects on whether play occurs in sun, shade, or partial shade (p=0.21)

Summary of Economic Evidence

A systematic review of economic evidence has not been conducted.

Applicability

Based on the settings and populations from included studies, results are applicable to:
  • Daycare centers
  • Nursery schools
  • Play schools
  • Preschools

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?)
  • Limited evidence is available to determine the variability in effectiveness of interventions based on:
    • Organization affiliation and size of center
    • Race or ethnicity, skin type, or socioeconomic status (SES)
  • Limited evidence is available on the following:
    • Interventions without policy components
    • Differential effectiveness of individual components used in multicomponent interventions
  • More research is needed to address the following questions.
    • How does implementation effectiveness vary by organization type (e.g., private vs. government)?
    • Which incentives (e.g., certification, accreditation) lead to greatest intervention effectiveness?

Study Characteristics

  • Most of the studies in the updated search period evaluated broad-based interventions that combined educational, environmental, and policy components with educational efforts directed at parents or caregivers, staff, and children (4 studies).
  • Two studies examined associations between policy implementation and outcomes of interest.
  • Five studies reported children’s ages. In these settings, ages ranged from birth to 12 years, with a mean or median age group of 3 to 5 years.
  • Five of the studies were conducted in pre-school settings.

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

Effectiveness Review

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

Aulbert W, Parpart C, Schulz-Hornbostel R. Certification of sun protection practices in a German child day-care centre improves children’s sun protection–the ‘SunPass’ pilot study. British Journal of Dermatology 2009;161 Suppl 3:5-12.

Bauer J, Buttner P, Wiecker TS, Luther H, Garbe C. Interventional study in 1,232 young German children to prevent the development of melanocytic nevi failed to change sun exposure and sun protective behavior. International Journal of Cancer 2005;116(5):755-61.

Gritz ER, Tripp MK, James AS, Carvajal SC, Harrist RB, et al. An intervention for parents to promote preschool children’s sun protection: effects of Sun Protection is Fun! Preventive Medicine 2005;41(2):357-66.

Gritz ER, Tripp MK, James AS, Harrist RB, Mueller NH, et al. Effects of a preschool staff intervention on children’s sun protection: outcomes of sun protection is fun! Health Education and Behavior 2007;34(4):562-77.

Kenfield SA, Geller AC, et al. Sun protection policies and practices at child care centers in Massachusetts. Journal of Community Health 2005;30(6):491-503.

Stover LA, Hinrichs B, et al. Getting in early: primary skin cancer prevention at 55 German kindergartens. British Journal of Dermatology 2012;167 Suppl 2:63-9.

Syson-Nibbs L, Peters J, Saul C. Can health visitor intervention change sun safety policies and practice in preschool establishments? A randomised controlled study. Health Education Journal 2005(64):129-41.

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

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 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/

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

Review References

Saraiya M, Glanz K, Briss P A, Nichols P, White C, Das D, et al. Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review [PDF – 782 kB]. 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.
  • Due to limited resources and competing priorities, policies and practices are most likely to be implemented if they are easily adopted and enforced, and require little staff time.
  • Child care centers should assess their sun protection practices, and enhance and formalize them to the extent possible.
  • In light of staff turnover, regular booster training sessions may be necessary to sustain staff awareness and support of sun protection measures.
  • Parental education and involvement is important in supporting effective implementation of sun protection practices in child care centers and increases the likelihood that parents will support similar sun protection practices in other settings (e.g., outdoor recreational facilities).

Crosswalks

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 2020

Healthy People 2020 icon Healthy People 2020 includes the following objectives related to this CPSTF recommendation.