Skin Cancer: Primary and Middle School-Based Interventions

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) 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.

The full CPSTF Finding and Rationale Statement and supporting documents for Preventing Skin Cancer: Primary and Middle School Interventions are available in The Community Guide Collection on CDC Stacks.

Intervention

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 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.

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

Summary of Results

Updated Evidence (search period June 2000–May 2011)

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.

Applicability

Results are applicable to:

  • 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

  • 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)?

Implementation Considerations and Resources

  • 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

Crosswalks

Find programs from the Evidence-Based Cancer Control Programs (EBCCP) website that align with this systematic review. (What is EBCCP?)