TY - JOUR
AU - Tyc, Vida, L
AB - Abstract Better communication between families, schools, communities, and clinicians is critical for improved skin cancer prevention initiatives for children and adolescents. Contributions from research in this area, as exemplified by the two studies in this special issue, will help shape priorities for future sun protection research and will be useful in generating evidence-based policy to support sun safety for children and reduce their future skin cancer risk. Implications Practice: To advocate for increased coordination of family and schools in skin cancer prevention programs. Policy: To consider the value of policy being generated from evidence-based research in skin cancer risk reduction. Research: To identify priorities for future research that improves skin cancer prevention behaviors in children and families. INTRODUCTION Increasing the sun protection practices among children and adolescents is critical in reducing exposure to ultraviolet (UV) radiation and reducing their risk for skin cancer, particularly melanoma [1]. The recognition of melanoma as a public health problem and skin cancer prevention as a national priority is reflected in the U.S. Surgeon General’s Call to Action to Prevent Skin Cancer [2], the Federal Drug Administration’s efforts to reduce indoor tanning [3], and the recommendations established by the U.S. Preventive Services Task Force (USPSTF) [4] for providers to counsel patients about avoiding sun exposure. These efforts are largely directed at youth through educational efforts, behavioral interventions, and environmental policy changes [5] implemented across child day care centers, schools, clinical settings, and community activities in which parents and family members play important roles. Factors that affect sun protection behaviors in children and adolescents are multifaceted and modifying them requires a synergistic multilayered approach that involves the family, school, community, and national initiatives. Consistent with these efforts, the recent article by Coffin and colleagues [6] examined how parents’ sun protection behaviors influence their child’s risk reduction behaviors and calls for skin cancer prevention strategies that are family based. Similarly, Wu and her coauthors [7] demonstrated how interactive interventions delivered in the school setting can improve skin cancer prevention behaviors for high school students. Both studies in this special issue have important implications for practice, research, and policy for skin cancer prevention among our youth. THE ROLE OF SCHOOL AND FAMILY IN PRIMARY PREVENTION What we have learned from research to date is that sun exposure behaviors are complex and difficult to change. Schools provide an ideal platform for launching innovative strategies to address sun protection among children and adolescents. Adolescents are at risk for outdoor/indoor tanning and decreased practice of sun-protective behaviors and should certainly be targeted for intervention. Educational curriculums and skin cancer prevention programs should also be aimed at altering the behaviors of children at even younger ages, given this critical time period for development of melanoma [4]. However, a national survey of health policies and practices at U.S. schools [8] found that most states and school districts have no policies in place to support skin cancer prevention. Less than half of U.S. schools recommend practices related to sun protection, such as encouraging students to apply sunscreen at school, allowing students to wear sun-protective clothing, and avoiding scheduling outdoor activities during the hottest part of the day [8]. Only 66% of U.S. schools, elementary through high school, include sun safety as part of the required curriculum [9]. Unfortunately, it appears that many of our school efforts stop short at recommendations about sun practices and messages to change individual behaviors that are not supported by policy and legislation to optimally protect our youth. Like many schools throughout the USA, the schools included in the Wu et al. study [7] in this journal did not have comprehensive skin cancer prevention programs and information about the school’s policy on student use of sunscreen, hats, and availability of shaded areas was not available. Delivering educational and behavioral skin cancer prevention interventions in schools in the absence of strict sun safety policies or in those with rules that make sun-protective behaviors more difficult (i.e., restrictions on wearing a hat during the school day) offers limited opportunity to effect meaningful behavioral change. If future studies can demonstrate additive effects of interventions delivered in school settings where policies align with sun protection intervention goals, this information could arguably be used to convince school boards and policymakers of the need for comprehensive implementation of skin cancer prevention programs for U.S. students. In their novel study, Wu et al. [7] provided an examination of four brief high school-based interactive skin cancer prevention programs that moved beyond educational and didactic approaches. The authors reported significant improvements in sun protection behaviors for each approach employed, although improvements in other outcomes, including sunburns and intentional tanning, varied by the intervention delivered. Results suggested that effective intervention elements were those that allowed students to create personalized sun protection plans and provided students with a personalized photograph that showed current facial UV skin damage. Quantifying the level of skin damage and examining the effect of the extent of skin damage on behavioral change was not done in this study but is certainly an area of research that should be further explored. This study highlights the appeal of interactive programs and the value of providing youngsters with choice in determining their behavioral goals. Likewise, the provision of real-time feedback and information regarding one’s personal risk to sun exposure shows promise for teens. Whether such outcomes can be maintained over time is questionable as the study only examined the short-term effects of the intervention at 1 month postintervention. Moreover, interventions that lead to change in a single sun-protective behavior but do not impact multiple skin protection outcomes may not be sufficiently powerful to effect long-term practice of the broader repertoire of behaviors necessary to achieve optimal sun protection. Therefore, future studies should consider a combination of approaches or a higher dosage of effective intervention components for potentially greater impact. The results regarding gender, race, and urban/rural location variables in the Wu et al. study [7] raise important questions. The finding that male students displayed smaller increases in sun protection, tanning, and sunburn outcomes postintervention deserves further attention. Addressing the observed differences between non-White and White students and between rural and urban students on sun protection outcomes is also important. Tailored interventions or targeted messaging could be beneficial for different demographic subgroups. Whether factors like appearance enhancement, social conformity, and peer influences underlie gender and racial differences among adolescents warrants further investigation. In addition to these demographic factors, it may also be important to address the cultural context, as well as ethnic and regional differences that can impact a youngster’s views about sun exposure and tanning, and their decision-making about engaging in sun protection practices. Interventions that inform youngsters about the dangers of sun exposure or modify their perceived threat or susceptibility to skin cancer may motivate behavior change in some teens, but may not be a sufficient deterrent for sun-seeking behaviors among others. Accounting for demographic factors is important as they may potentially moderate intervention effects. Parents can also play a role in shaping school and community sun safety practices and policies. As demonstrated in the literature, family and community values and norms may impact a child’s sun-protective behaviors and parents are important sources of information about sun exposure for their children [10–12]. The study by Coffin and colleagues [6] in this special issue supports the link between parent melanoma prevention behaviors and the sun-protective behaviors of their children at risk for melanoma. In light of the relationship between parent and child behaviors, the finding that not all parents who were relatives of melanoma survivors practiced sun-protective behaviors was quite concerning. For example, only one-third of participants in their sample reported wearing a sunscreen with a sun protection factor of 15 or greater. The lack of an association between child prevention behaviors and parent perceptions regarding melanoma prevention (which the authors attributed to limited variance due to sampling) was also surprising given that prior studies have identified exposure to parental and family values and belief systems as influential in one’s decision-making and motivation about engaging in health behaviors [10–12]. Nonetheless, the results from this study highlight the important role of the parent and family in skin cancer risk reduction interventions. Health care providers can serve as an important source of information for parents, particularly those at risk for skin cancer. The 2018 USPSTF [4] recommends that adults older than 24 years of age with fair skin types be counseled about reducing their UV exposure to reduce their skin cancer risk as well as those with other risk factors for skin cancer, including a family history of skin cancer. The USPSTF also recommends counseling to adolescents, children, and parents of young children about minimizing sun exposure. In addition to visits to their own providers, parents often have regular contact with their child’s medical providers. Therefore, pediatric providers are in an ideal position to address skin cancer prevention with caregivers in the context of the child’s routine medical care. As recommended by the American Academy of Pediatrics, pediatric providers should provide consistent and repeated messaging about sun safety (e.g., using sunscreen, avoiding mid-day sun, wearing sun-protective clothing, and avoiding outdoor and indoor tanning) to children and their parents and work with parents of younger children to increase their child’s personal protection behaviors, particularly if their child presents with a sunburn [13]. The degree to which providers comply with recommendations about counseling for sun protection and their awareness of skin cancer prevention is a relatively understudied area that should be examined in future research [1]. Most behavioral counseling interventions conducted in children and adolescents in the clinical setting have been directed at parents and include print materials and sometimes face-to-face counseling [4]. While education and print materials are necessary, they may not be sufficient to motivate complex behavioral change, particularly among children and teens. Perhaps more potent technologically based and interactive interventions in the health care setting may be necessary when working with children and their families. Broadening the provision of risk information beyond parents to all family members and creating family sun safety goals makes sense from a health promotion perspective when considering the risk for skin cancer among family members. Although inclusion of multiple family members in an intervention may prove to be more logistically challenging, the effects may be more far reaching. Encouraging families to adopt a family healthy lifestyle plan that includes sun safety, to which all family members must adhere, as part of family-based intervention, may be beneficial in establishing lifelong habits of sun protection among children. Health care providers, along with parents, can also play a role in policy development and educating policymakers about skin cancer prevention, particularly when their efforts are linked with public health initiatives. MOVING FORWARD The studies in this special issue pave the way for more sophisticated studies that employ innovative interventions to reduce children’s sun exposure. Given children’s reliance on technology, interventions that employ the internet, online programs, computer programs, texting, social media, and smart phone applications for skin cancer prevention intervention delivery should be considered. Application of these newer technologies in schools and clinical settings, along with the emergence of teledermatology, may allow for the development of more novel and interactive approaches. Consideration of implementing e-health and m-health (i.e., electronic and mobile health) technologies in clinical practice settings would enable clinicians and researchers to extend the impact of their services and interventions to insure long-term practice of sun safety behaviors. Use of portable and wearable UV sensors and/or other methods to quantify sun exposure, which keep pace with advances in medical advances in dermatology, may have great appeal to youngsters when providing messaging about sun protection and indoor tanning. The findings from the two important studies in this issue highlight several limitations that should be considered in future research. While studies typically rely on self-reported outcomes, more objective measures of sun exposure and direct observation of the practices of participants who receive study interventions may enhance the relevance of our studies. Examination of the reach and cost effectiveness of proposed skin cancer prevention programs may also help convince policymakers to make necessary changes. Empirically, testing our hypotheses in both geographically diverse and skin color diverse samples would enhance the generalizability of our results and confirm the robustness of our findings. Additionally, while most studies assess only short-term effects, long-term study outcomes are critical for determining maintenance of demonstrated treatment effects. Interventions should aim to target multiple sun protection behavioral outcomes as change in only a single behavior may not translate to meaningful risk reduction. There may also be much to be learned from participants who fail to benefit from our interventions, leading to suggestions for improving interventions, maximizing positive treatment outcomes, and broadening their effects in future studies. Despite the commendable efforts of the investigators in this two-paper series [6,7] to promote sun safety behaviors among children and adolescents, many youngsters continue to engage in risky sun exposure behaviors that increase their risk for skin cancer. Environmental efforts and public policy initiatives that have the capacity to reduce children’s risk for skin cancer are slowly emerging but are not sufficient. As no single determinant or level of influence can account for health outcomes in our youth, a multipronged partnership between family, schools, communities, and government agencies will be necessary to address this significant public health problem. Most importantly, many of these factors are largely modifiable. Given the important findings from the sun protection research to date, it is unfortunate that many of our findings do not stimulate public health policies to fully protect our youth. Health promotion researchers, health behavior organizations, and professional working groups should utilize the available evidence base to start a dialogue with the public and lawmakers and to inform the translation of findings to best serve children and their families. It is only through working collaboratively and sharing existing knowledge that we can impact skin cancer incidence and mortality. Compliance with Ethical Standards Funding: There is no funding to declare. Conflict of Interest: Vida L. Tyc has no conflict of interest to declare. References 1. Tripp MK , Watson M , Balk SJ , Swetter SM , Gershenwald JE . State of the science on prevention and screening to reduce melanoma incidence and mortality: the time is now . CA Cancer J Clin . 2016 ; 66 ( 6 ): 460 – 480 . Google Scholar Crossref Search ADS PubMed 2. U.S. Department of Health and Human Services . The Surgeon General’s call to action to prevent skin cancer . Washington, DC : U.S. Dept of Health and Human Services, Office of the Surgeon General ; 2014 . 3. U.S. Food and Drug Administration; Department of Health and Human Services . General and plastic surgery devices: reclassification of ultraviolet lamps for tanning henceforth to be known as sunlamp products and ultraviolet lamps intended for use in sunlamp products. Final order . Federal Registry . 2014 ; 79 ( 105 ): 31205 – 31214 . 4. U.S. Preventive Services Task Force. Behavioral counseling to prevent skin cancer: US preventive services task force recommendation statement . JAMA . 2018 ; 319 ( 11 ): 1134 – 1142 . Crossref Search ADS PubMed 5. Community Preventive Services Task Force . Community-wide intervention to prevent skin cancer: recommendations of the community preventive services task force . Am J Prev Med. 51 ( 4 ): 540 – 541 . Crossref Search ADS PubMed 6. Coffin T , Wu Y , Mays D , Rini C , Tercyak KP , Bowen D . The relationship of parent-child sun protection among those at risk for and surviving with melanoma: implications for family-based cancer prevention . Transl Behav Med . 2019 7. Wu Y , Parsons BG , Nagelhout E , Haaland B , Jensen J , Zaugg K , et al. A 4-group experiment to improve western high school students’ sun protection behaviors . Transl Behav Med . 2019 . 8. Centers for Disease Control and Prevention . Results from the School Health Policies and Practices Study 2016 . Atlanta, GA : Centers for Disease Control and Prevention . 2016 . 9. Centers for Disease Control and Prevention . Results from the School Health Policies and Practices Study 2014 . Atlanta, GA : Centers for Disease Control and Prevention . 2015 . 10. Tercyak KP , Tyc VL . Opportunities and challenges in the prevention and control of cancer and other chronic diseases: children’s diet and nutrition and weight and physical activity . J Pediatr Psychol. 2006 ; 31 ( 8 ): 750 – 763 . Google Scholar Crossref Search ADS PubMed 11. Tripp MK , Peterson SK , Prokhorov AV , Shete SS , Lee JE , Gershenwald JE , et al. Correlates of sun protection and sunburn in children of melanoma survivors . Am J Prev Med. 2016 ; 51 ( 3 ); e77 – e85 . Google Scholar Crossref Search ADS PubMed 12. Tripp MK , Diamond PM , Vernon SW , Swank PR , Dolan Mullen P , Gritz ER . Measures of parent’s self-efficacy and perceived barriers to children’s sun protection: construct validity and reliability in melanoma survivors . Health Educ Res. 2012 ; 28 ( 5 ): 828 – 842 . Google Scholar Crossref Search ADS PubMed 13. Balk SJ . Section on dermatology, council on environmental health. Ultraviolet radiation: a hazard to children and adolescents . Pediatrics . 2011 ; 127 ( 3 ): 588 – 597 . Google Scholar Crossref Search ADS PubMed © Society of Behavioral Medicine 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. 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TI - Challenges in changing sun protection behaviors in children and adolescents
JF - Translational Behavioral Medicine
DO - 10.1093/tbm/ibz054
DA - 2019-05-16
UR - https://www.deepdyve.com/lp/oxford-university-press/challenges-in-changing-sun-protection-behaviors-in-children-and-DVn1AnEtxC
SP - 489
VL - 9
IS - 3
DP - DeepDyve
ER -