SunSafe in the Middle School Years

While several sun safety programs have targeted younger children, there is a great need to educate adolescents about the importance of sun protective behaviors. For this age group, peer influence and media messages often run counter to those from parents and public health professionals. During early adolescence, sun protection steadily declines as tan-seeking behaviors and pro-tanning attitudes increase. One study found that only 35% of middle school students protected themselves from sun damage, and 75% of teens had sunburns in the previous summer.

Skin cancer is currently the most common form of cancer in the United States, with rates increasing 3-5% per year. Exposure to ultraviolet (UV) radiation during childhood and adolescence, especially intense exposure causing sunburn, is a factor in the development of skin cancer during adulthood. Having one or more blistering sunburn before age 20 doubles one's risk of melanoma. It is therefore important to educate children and adolescents about sun-protective behaviors.

SunSafe in the Middle School Years is a multi-component, community-wide program that addresses sun protection in early adolescence (grades six to eight). It is designed to promote sun-protective behaviors in several ways, including training of change agents (teachers, school staff, athletic coaches, sports and recreation staff, primary care physicians and their staff as well as teens) to model and promote sun-protective behaviors. The program uses active role modeling of sun-protective behaviors, peer-led activities in the schools, branded program materials displayed in the community, and developmentally appropriate patient education materials and sun protection messages provided by primary care practices.

Teens receive the SunSafe health education program that includes use of the DermaScan^TM, a device that provides a darkened environment with a mirror to view skin changes not visible under normal light to highlight skin damage from overexposure to UV rays. Teachers recruit a group of teens to serve as peer role models on "Sun Teams" that promote sun-protective behaviors. Sun Teams conduct outdoor events, poster contests, fundraisers for the American Cancer Society, and school and community health fairs, and provide videotaped performances of sun safety messages.

Sun safety messages and materials are displayed in community venues; for example, posters at stores, beaches, community pools, and primary care practices; bookmarks at libraries; and SunSafe branded materials used by coaches, teachers, and life guards.

The Implementation Guide is a resource for implementing this program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the research-tested program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded in the Products page.

This program is an example of multicomponent community-wide interventions (Sun Safety) and education and policy approaches in outdoor recreation settings (Sun Safety), which are recommended by the Community Preventive Services Task Force, as found in the Guide to Community Preventive Services. It is also an example of education and policy approaches in secondary schools and colleges (Sun Safety) and education and policy approaches for healthcare settings and providers (Sun Safety) which has an insufficient evidence finding from the Community Preventive Services Task Force, as found in the Guide to Community Preventive Services. Insufficient evidence means the available studies do not provide sufficient evidence to determine if the intervention is or is not effective. This does not mean that the intervention does not work. It means that additional research is needed to determine whether the intervention is effective. To expand understanding of this intervention category consider communicating with members from NCI’s Research to Reality (R2R) community of practice who may be able to help you with your research efforts. Following is a link to start an online discussion with the R2R community of practice, after completing registration on the R2R site: https://researchtoreality.cancer.gov/discussions.

The amount of time required to administer SunSafe includes annual 30-minute introductory educational sessions for each adult audience (e.g., school personnel, sports/recreation staff, pool/beach staff, primary care facility staff) plus DermaScan^TM viewing opportunities. Time required for administration of the program within schools, sports/athletic centers, pools/beaches, and primary care facilities varies by venue and level of involvement of the adult change agents and peer role models.

The primary audience for SunSafe in the Middle School Years is early adolescents in grades 6 through 8.

SunSafe is designed to be offered as a multi-component, community-wide intervention in the schools, sports/recreational facilities, primary care practices, and community venues (e.g., libraries, stores).

The SunSafe in the Middle School Years program includes the following materials:

• Primary Care Practice Manual
• Sports Coach Manual
• Recreation Center/Lifeguard Manual
• School Policy Manual
• Teacher Manual
• Peer Group Manual
• Health Education Teacher Guide 
• Health Education Class PowerPoint Slides
• Classroom activities for teachers
• Sun safety fact sheet
• Parent information sheet
• Informational and Educational materials: (Bookmark, Fun and Sun Family Guide Sheet, Branded program materials)

Additional Items for Adult Audience:

• posters
• brochures/guide sheets
• temporary tattoos
• seasonal counseling cue cards for primary care practices
• water bottles
• pencils
• tote bags
• UV meters
• UV-exposure cards for teachers
• lanyards, tote bags, sunscreen samples, and magnets for sports/athletic/pool staff
• Dermascan^TM was also used in the sports/athletic venues, schools, and primary care practices to provide adolescents and adults a view of any existing skin damage not visible to the naked eye.

This multi-component, community-wide intervention targeted members of communities in Vermont and New Hampshire from 2000 to 2003. To be eligible, communities had to have a middle school where grades six through eight were offered in one building, at least one primary care practice, and a freshwater beach or town swimming pool used primarily by local residents.

From the eligible communities, 10 middle schools were recruited in pairs matched for size and proportion of students eligible for federal free-lunch programs. Once the researchers had the buy-in of the schools, the schools were randomly assigned to an intervention or control condition through computer-generated numbers.

The participants included recreation directors, athletic coaches, teachers, primary care practice staff, and other community-based organizations, who were engaged in all 10 communities after the school had been enrolled.  Control communities were offered the intervention once the study was completed.  Children entering grades six to eight (ages 11 to 14) at the community beaches and swimming pools or school sponsored water activities were approached and screened for eligibility. If they were eligible, they were asked for their consent to be interviewed anonymously.

Cross-sectional samples of early adolescents were observed and interviewed in year 1, and in 3 subsequent years. Because of a dramatic decline in the number of older adolescents (those entering grades eight and nine, particularly nine) attending the beach and pool venues, data from year 3 were not included in the analyses. Trained observers visited the community beaches and swimming pools between 11:00 a.m. and 3:00 p.m. from June through August, when weather reports did not predict rain or heavily overcast skies.

Adolescents were asked about sunscreen application for each of four body areas (face/neck, arms, legs, and trunk) and the sun-protection factor (SPF) of any sunscreen they had used. They were also asked to show the sunscreen bottle to corroborate their self-report. The trained observers also noted the proportion of the individual participant's body surface that was protected from the sun by clothing, sunscreen, or shade. An inter-rater reliability of .90 was obtained for this measure. Observers noted the UV index and temperature during every hour of the observation period. They also interviewed participants regarding their propensity to burn, and whether key adults (school personnel, primary care staff, or coaches) had talked to them about sun safety.

Effects of the SunSafe in the Middle School Years Intervention on Adolescents' Sun-Protection Habits
At 2-year follow-up:

• Percent body surface area (BSA)* covered was 66.1% in the intervention group compared with 56.8% in the control group (p<.01).
• Any sunscreen use** was 47% in the intervention group compared with 13.8% in the control group (p<.01).

 

Effects of the SunSafe Intervention on the Average Number of Different Sources of Advice about Sun Protection Reported by Adolescents
The average number of different sources of advice about sun protection reported by adolescents at the 2-year follow-up were 1.7 for the intervention group compared with 1.0 for the control group. (p<0.001).

Effects of the SunSafe Intervention on Adolescents' Recall of Sun Protection Advice from Adults

• At the 2-year follow-up, in the intervention communities, recall of advice from school staff had increased from 53% at baseline to 64.3%, while it declined from 55.7% to 14.3% for the control group (p<.001). Recall of coach advice increased from 13% at baseline to 20% for the intervention group at 2-year follow-up, while it declined from 16% to 2% for the control group (p<.0001).
• There was no difference between the intervention and control group with regard to recall of clinicians' advice about sun protection at 2-year follow-up. 

Olson, A. L., Gaffney, C., Starr, P., Gibson, J. J., Cole, B. F., & Dietrich, A. J. (2007). SunSafe in middle school years: A community-wide intervention to change early-adolescent sun protection. Pediatrics, 119, 247-256.

Olson, A. L., Gaffney, C.A., Starr, P., Dietrich, A.J. (2008). The impact of and appearance-based educational intervention on adolescent intention to use sunscreen. Health Education Research, 23(5), 763-769.

Olson,A.L.; Starr,P.; . (2006). The challenge of intentional tanning in teens and young adults. Dermatologic Clinics, 24(2), 131-6, v.