Dermatology: Practical and Conceptual Review | Dermatol Pract Concept. 2023;13(1):e2023066 1 A Review of the Impact of Sun Safety Interventions in Children Imran T. Baig1, Allison Petronzio1, Brandy Maphet2, Susan Chon3 1 UTHealth McGovern Medical School at Houston, Houston, United States 2 Department of Dermatology, UTHealth McGovern Medical School at Houston, Houston, United States 3 Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, United States Key words: behavioral change, skin cancer, sunscreen, sun protection, UV radiation Citation: Baig IT, Petronzio A, Maphet B, Chon S. A Review of the Impact of Sun Safety Interventions in Children. Dermatol Pract Concept. 2023;13(1):e2023066. DOI: https://doi.org/10.5826/dpc.1301a66 Accepted: November 3, 2022; Published: January 2023 Copyright: ©2023 Baig et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Imran T. Baig, B.S.A. UTHealth McGovern Medical School at Houston, Houston, United States, 1711 Old Spanish Trail Apt 422, Houston, TX 77054 E-mail: imran.t.baig@uth.tmc.edu Introduction: In the United States, melanoma and non-melanoma skin cancers comprise the largest proportion of new cancer diagnoses every year. The prevalence of skin cancer can be largely reduced if proper preventative behaviors are adopted at an early age. Objectives: We assessed the impact of various informational, economic, and environmental interven- tions on sun-protective behaviors, knowledge, attitudes, and sun exposure in the pediatric population reported in previous studies. Methods: A systematic search for relevant articles was conducted using three databases. Studies were included if they met the following three criteria: study subjects less than 18 years old, clear, measurable interventions and outcomes, and publication in the English language. Results: A total of 66 studies were included, of which 48 resulted in positive behavioral changes (i.e. increases in sunscreen application, use of hats and sun-protective clothing, shade-seeking, and avoid- ance of outdoor activities during peak UV radiation), 28 resulted in increased knowledge, 2 resulted in changes in attitudes towards tanning, and 10 resulted in decreased sun exposure effects (i.e. new sunburns, number of new nevi, and change in pigmentation of the skin). Conclusions: It is crucial that children be educated on the importance and benefits of sun protection. Although a variety of interventions showed promise in achieving this goal, the challenges associated with adopting change were evident. This review provides direction for future interventions aimed at improving sun safety in children and illustrates the potential impact that early intervention can have on the incidence of skin cancer in future generations. ABSTRACT 2 Review | Dermatol Pract Concept. 2023;13(1):e2023066 Introduction In the United States, skin cancer is the most common ma- lignancy and is estimated to affect one in five individuals in their lifetime [1]. The overall incidence of melanoma and non-melanoma skin cancers (NSMC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), has been increasing rapidly in recent decades. Melanoma is the most lethal type of skin cancer, and it is predicted that over 7,500 Americans will die from melanoma in 2022 [2]. Al- though NMSCs typically carry a more favorable prognosis, they place a large burden on the United States healthcare system, with an estimated annual cost of $4.8 billion [3]. The largest preventable risk factor for both melanoma and NMSC is ultraviolet radiation (UVR) exposure [4]. UVR is a risk factor for skin cancer at any age; however, children are at an increased risk of excessive UVR exposure [5]. Children spend a significant portion of their time outdoors at school when the UV index is highest, where activities such as recess and sporting events can result in extended periods of UVR exposure. In fact, sun damage is cumulative, and about 23 percent of a person’s lifetime sun exposure happens by the age of 18 [6]. There is a strong relationship between total sun exposure and non-melanoma skin cancers, and there is a clear relationship between sunburns and the development of melanoma [7]. Interventions aimed at preventing excessive exposure to harmful UVR can decrease the incidence of skin cancer. The American Cancer Society provides several recommendations aimed at primary prevention of skin cancer: 1) seek shade when UV radiation is strongest (10:00 A.M. - 4:00 P.M.); 2) wear sun-protective clothing (i.e. long sleeved shirts and pants); 3) wear wide-brimmed hats; 4) apply sunscreen with a minimal SPF of 30; and 5) avoid tanning beds [8]. In ad- dition to primary prevention methods, secondary prevention methods include regular skin self-examinations and profes- sional skin examinations. Applying both prevention tech- niques has illustrated a decrease in the incidence, morbidity, and mortality of skin cancer [4]. Since childhood sun exposure increases the risk of skin cancer, it is essential to educate children about primary prevention measures as well as take action to promote sun-protective behaviors. In this review, we evaluated studies that aimed to either educate or change the behavior of chil- dren regarding sun safety. By doing this, we aimed to identify the techniques used and summarize them as an example for much-needed future educational efforts. Methods The following criteria were used to identify eligible studies: 1) study subjects must be less than 18 years old; 2) study must have clear interventions and outcomes (e.g. behavior or knowledge); and 3) study must be published in the English language. The search for relevant articles utilized Ovid Medline, Ovid Embase, and Scopus to identify literature published through September 2020: The following MeSH terms were used: “adolescent”, “child”, “infant”, “pediatric(s)”, “students”, “teen”, “parent(s)”, “mother”, “father”, “sun- screening agents”, “sun protection factor”, “sunburn”, “skin neoplasms”, “sunlight”, “sun”, “skin”, “health education”, “health promotion”, “education”. Results The initial literature search of Ovid Medline, Ovid Embase, and Scopus yielded 143 articles. After the articles were re- viewed and duplicates excluded, 66 articles met the inclusion criteria [9-74]. Types of Interventions: Most studies had an intervention that delivered sun-protective educational information to the study population (Figure 1). Of the 62 studies that focused on providing information, some of the most popular methods included giving a presen- tation, handing out newsletters or flyers, and implementing sun safety lessons in the school curriculum. In addition, 17 studies relied on economic intervention. From these stud- ies, distribution of free sunscreen to children was the most popular provision. Other economic interventions included providing protective clothing, hats, and sunglasses. Lastly, 3 studies changed the physical environment by adding re- sources such as shaded structures for children to use during peak UV light hours (Figure 2). Knowledge as an Outcome: There were 32 studies that measured change in knowledge as an outcome after implementation of the intervention. Of those 32 studies, 27 assessed only for the child’s knowledge, 4 assessed only for the parents’ knowledge, and 1 assessed for both the child and parents’ knowledge. Of the studies that focused only on measuring the change in the children’s knowledge after intervention, twenty-six studies noted a sig- nificant increase in baseline knowledge and only one study revealed nonsignificant changes. Winnett et al. illustrated that even after intervention, the children still had minimal knowledge of appropriate sunscreen use and frequency [67]. Even though Hingle et al. showed a statistically significant overall increase in knowledge, it was primarily driven by knowledge about skin cancer types [27]. The rest of the knowledge-based questions related to UV radiation, pre- cautions to take to avoid sunburn, and suntanning showed no significant changes. Of the four studies directed at only Review | Dermatol Pract Concept. 2023;13(1):e2023066 3 TYPES OF INTERVENTION ENVIROMENTAL, 3, 4% ECONOMIC, 17, 21% EDUCATIONAL, 62, 75% EDUCATIONAL ECONOMIC ENVIROMENTAL Figure 1. A pie chart illustrating the various methods of intervention used from all 62 studies. SUCCESSFUL STUDIES BY TYPE OF OUTCOME MEASURED N U M B ER O F ST U D IE S TYPE OF OUTCOME BEHAVIOR KNOWLEDGE SUCCESSFUL 0 10 20 30 40 50 60 70 UNSUCCESSFUL SUN EXPOSURE ATTITUDES Figure 2. A bar chart comparing studies that were successful in improving the measured outcome to studies that were not successful in improving the measured outcome. 4 Review | Dermatol Pract Concept. 2023;13(1):e2023066 adopting sun safety into their lessons, UV index announce- ments on the speaker, and guest presenters on UV and sun safety [62]. Although elementary students and middle school students had improved perceptions, high school students maintained a positive attitude towards tanned skin. Buller et al. utilized an educational computer program on sun safety based on the “Sunny Days, Healthy Ways” sun safety curric- ulum [33]. This CD-ROM program did not improve attitudes toward sun-protective behavior. Barankin et al. enhanced an existing “Sun and the Skin” program by educating the par- ents about the program, providing supplemental information, and distributing sunscreen [28]. The students in the enhanced group illustrated improvement over the control and standard groups in their attitude towards tanning. David et al. included an educational presentation and interactive activities delivered by university students, who underwent rigorous training and volunteering as part of their undergraduate and graduate-level courses [32]. After the intervention, participants reported less appeal for tanned skin than before the intervention (p<0.001). Behaviors as an Outcome: There were 60 studies that measured change in sun-protective behaviors as an outcome after implementation of the inter- vention. Of those 60 studies, 48 had interventions that were successful at impacting at least one behavior relating to sun protection in either the children or their parents (Figure 3). measuring the change in parents’ knowledge, two of them did not result in an increase in the parents’ knowledge. Glanz et al. used questions to create a knowledge index that was measured for the parents [14]. The knowledge index was rel- atively high at baseline and remained virtually unchanged in both intervention groups. Glanz et al. assessed the knowl- edge of parents and staff [53]. Although their knowledge scores were relatively high to begin with, they improved slightly; however, neither of the changes was statistically significant. In the study that tested both the children’s and parents’ knowledge, parents were reported to have decreased in knowledge, while elementary and middle schoolers had increased and high schoolers had no change [62]. Attitudes Toward Tanning as an Outcome: Five studies assessed children’s attitudes and perceptions of tanning before and after intervention. Three of the five inter- ventions were considered failures. Kristjánsson et al. devel- oped an educational tool kit about skin cancer prevention [74]. This tool kit included a manual for teachers, animated comic figures, a 7-minute video, and recommendations on how to behave in the sun. The students’ attitude to refrain from tanning was not significantly changed. Regarding mid-day sun avoidance, most students only progressed from a pre-contemplation stage to a contemplation stage. Kouzes et al. utilized a sun safety curriculum which included teachers Percent Failure by Intervention Type for Behavioral Outcomes Ty p e o f I n te rv en ti o n Percent 12% 0 18% Enviromental 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% Economic Educational Figure 3. A bar chart illustrating what percentage of studies were unsuccessful in changing behavior based on the type of intervention. Review | Dermatol Pract Concept. 2023;13(1):e2023066 5 studies directed at the pediatric population can alter their interventions to be better suited to have a significant impact on these outcomes. Children’s knowledge about skin cancer and the impor- tance of sun protection was improved in all but two studies [62, 67]. Kouzes et al. implemented a sun safety curricu- lum which included teachers incorporating sun safety into their lessons, UV index announcements on the speaker, and guest presenters on UV and sun safety [62]. The curriculums used differed based on grade level (preschool through first grade used CATCH Global Foundation’s Ray and the Sun- beatables, grades kindergarten through eighth grade used the Environmental Protection Agency SunWise, and grades six through twelve used SunSmart U developed by the Skin Cancer Foundation). Knowledge was improved in elemen- tary and middle schoolers; however, high schoolers did not have any change in knowledge of sun protection strategies. Knowledge deficits in older age groups could be attributed to inadequate use of the curriculum and could suggest that additional support may be needed from a statewide non- profit organization dedicated to cancer control. Skonieczna et al. demonstrated the significance of partnerships within schools to create long-lasting sun safety programs, so such support could encourage increased participation [75]. Win- nett et al. studied the effects of an intervention that included informational posters in prominent locations, a poster pro- viding feedback about how many people are practicing the SafeSun program, a weekly lottery ticket for people wearing sun-protective clothing, and lifeguards modeling the SafeSun logo on their clothing [67]. Knowledge about skin cancer, its causes, and how to appropriately use sunscreen remained low. This intervention did not include formal information lessons, which could explain the lack of knowledge related to skin protection. Several studies demonstrated positive attitudes towards tanned skin even after an intervention was implemented [33, 62, 74]. In the previously mentioned study by Kouzes et al., in addition to not showing improvements in knowl- edge, high schoolers also continued to value the appearance of tanned skin [62]. Despite acknowledging the risks associ- ated with tanned skin, high school students still maintained a positive attitude towards tanned skin. This illustrates that because older children perceive tanned skin as desirable, they are willing to risk their health to fit into societal norms [76]. Another study provided a manual for teachers, animated comic figures, a 7-minute video, and recommendations on how to behave in the sun to adolescents [74]. The students’ attitudes to refrain from tanning were not significantly changed. Previous studies have shown that when children reach adolescence, their appreciation of suntans increases [7, 77]. Therefore, it might be beneficial to start motivating attitude changes to sunbathing before adolescence. Lastly, A few commonly studied behaviors include frequency of sunscreen application, use of hats and sun-protective cloth- ing, shade-seeking, and avoidance of outdoor activities during peak UV radiation. For example, Crane et al. is a randomized controlled trial that found changes in many be- havioral outcomes after sending newsletters on sun protec- tion and skin cancer to parents and their children over the course of three years [38]. Specifically, the post-intervention group demonstrated increased use of sunscreen, protective clothing, hats, shade-seeking, and midday sun avoidance compared to baseline; however, a statistically significant difference compared to the control group was only present for a few select behaviors and in certain years. Conversely, Bauer et al. is a randomized controlled trial in which par- ents were randomized to receive either educational material on sun protection, free sunscreen, or neither, and the results demonstrated no significant differences between the groups in sun-protective behaviors or the development of melano- cytic nevi in the children [36]. Sun Exposure as an Outcome: There were 15 studies that measured sun exposure via phys- ical skin changes as an outcome after implementation of the intervention. A few commonly studied metrics include inci- dence of new sunburns, number of new nevi, and change in pigmentation of the skin. Of the 10 studies that measured incidence of sunburn as an outcome, 8 studies showed fewer sunburns as a result of the intervention, whereas one study showed no effect on sunburns and another study showed an increase in the number of sunburns despite the intervention [61]. Of the 6 studies that looked at increased pigmentation (i.e. tanning, melanin) as an outcome, only 2 studies demon- strated that their intervention decreased the level of skin pig- mentation. Of the 3 studies that looked at development of new melanocytic nevi as an outcome, none of them showed a statistically significant difference in the development of new nevi post-intervention. Discussion The goal of this review was to evaluate the impact of var- ious informational, economic, and environmental interven- tions on sun-protective behaviors, knowledge, attitudes, and sun exposure in the pediatric population. Targeting children is important because, theoretically, the earlier that sun-protective habits are formed, the earlier primary preven- tion methods from dangerous UV rays can be implemented and lower the burden of future skin cancer. As many of the techniques reviewed were successful in instilling knowledge and sun safety practices, this discussion highlights the inter- ventions that failed to alter children’s behaviors, knowledge, attitudes, and sun exposure. Using this information, future 6 Review | Dermatol Pract Concept. 2023;13(1):e2023066 measured and impacted outcome compared to the others. In response to sun exposure, sunburns develop rather quickly and can develop after only one outdoor exposure, whereas skin pigmentation and nevi formation are processes that take time and require more chronic exposure to sunlight. Many of the studies that assessed skin pigmentation and nevi for- mation failed to demonstrate any significant change in these metrics, likely due to a lack of significant behavioral change and/or insufficient length of study. In the case of Bauer et al., educational and/or economic interventions were adminis- tered, and the number of incident melanocytic nevi was mea- sured after a three-year period with no significant difference between groups [36]. In this particular study, the interven- tion failed to impact sun-protective behaviors, which likely directly affected the success of the intervention in impacting nevi formation. Of the studies that had a positive impact on sun-protective behaviors; a common theme was that changes in behavior were often transient or resulted in minimal change in the development of physical skin findings related to sun exposure. In this discussion of sun protection in chil- dren, our primary concern is whether early interventions can reasonably decrease a child’s risk of developing skin cancer later in life. It is encouraging to see that children and their parents are able to adopt sun-protective behaviors with the right intervention; however, it is unclear if these behavioral changes will translate to physical changes in the skin and decreased incidence of skin cancer in the future. Conclusion It is crucial that children be educated on the importance of sun protection. Although a variety of interventions showed promise in achieving this goal, the challenges associated with adopting behavioral change were evident. This review pro- vides direction for future interventions aimed at improving sun safety in children and illustrates the potential impact that early intervention can have on the incidence of skin can- cer in future generations. References 1. Prevalence of a History of Skin Cancer in 2007: Results of an Incidence-Based Model | Dermatology | JAMA Dermatology | JAMA Network. Accessed June 4, 2022. https://jamanetwork. com/journals/jamadermatology/fullarticle/209761 2. 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