Interventions to Prevent Skin Cancer by Reducing Exposure to - - PowerPoint PPT Presentation

Interventions to Prevent Skin Cancer by Reducing Exposure to Ultraviolet Radiation An Updated Review

National Center for Chronic Disease Prevention and Health Promotion

Mona Saraiya MD, MPH August 30, 2012 UICC

Division of Cancer Prevention and Control

Date of download: 8/29/2012

Annals of Internal Medicine May 2011

US Preventive Services Task Force Recommendation: Behavioral Counseling on Skin Cancer

General Steps in a Community Guide Review

! Recruit a multidisciplinary team ! Develop an intervention definition ! Determine research questions ! Develop an Analytic Framework ! Search for evidence ! Abstract and evaluate the identified studies ! Synthesize evidence ! Present findings to the Task Force ! Task Force adopts consensus conclusions Recommended for/against Insufficient Evidence

3

Task Force Recommendation Options

" Recommend – Strong Evidence – Sufficient Evidence " Recommend against – Strong Evidence – Sufficient Evidence " Insufficient evidence to recommend for or against

4

Coordination Team

CDC

! Paramjit Sandhu ! Randy Elder ! Dawn Holman ! Mona Saraiya

Task Force

! Karen Glanz….Univ of Penn

External Partners

! Frank Perna…... …………NIH ! Robert Smith…………….ACS ! David Buller……..Klein Buendel ! Craig Sinclair..Cancer Council

Victoria, Australia

! Tony Reeder… Cancer Research Unit

Dunedin, New Zealand

! Jen Makin…Cancer Council Victoria,

Australia

5

Previous Review (2004) vs. Current Review (2012) Interventions Implemented in Specific Settings

Primary school settings Recommended 2004 Recommended 2012 Outdoor recreation settings Recommended Pending 2012 Child care centers Insufficient evidence Pending 2012 Secondary schools and colleges Insufficient evidence Pending 2012 Outdoor occupation settings Insufficient evidence Pending 2012 Health care settings and providers Insufficient evidence Pending 2012

http://www.thecommunityguide.org/cancer/skin/education-policy/index.html 6

Previous Review Interventions Implemented in Cross-Cutting Settings

Mass media campaigns Insufficient evidence (2004) Insufficient evidence (2012) Community-wide multicomponent interventions Insufficient evidence Recommended (2012) Interventions targeting children’s parents and caregivers Insufficient evidence Pending (2012)

http://www.thecommunityguide.org/cancer/skin/parents-caregivers/index.html 7

Why were some categories considered insufficicent evidence

! The 2004 reviews found insufficient evidence

" Limitations in design and execution of available studies " Small number of qualifying studies " Variability in interventions and outcomes evaluated

8

Original Reviews and Subsequent Work

! Overview of original reviews

" Search period January 1966-June 2000 " Paper published in AJPM 2004

! Interim databases used to help update reviews

" Emory " New Zealand

! Updated review from January 2000-May 2011 ! Full update-Mass Media and Multicomponent community

–based intervention

! Interval update-hence forth

9

Considerations on this Update

! Update strategy: Full update vs. Interval Update ! Clarify definition of “mass media” as it relates to new

approaches (e.g., Internet, social media)

! Clarify definitions of “primary school” ! “Sunscreen use” and “tanning bed use” as

Recommendation outcomes

10

Mass Media

Intervention Description— Mass Media Interventions (Revised 2011)

! Mass media interventions to prevent skin cancer by reducing exposure

to ultraviolet (UV) radiation use mass media channels such as print media (e.g., newspapers, magazines), broadcast media (e.g., radio, television), billboards, and the Internet to disseminate information, behavioral guidance, or both to a wide audience. They may be aimed at specific target audiences, but typically use broad distribution

• channels. Some of these interventions simply provide the audience with

current information on the risk of UV exposure (i.e., a UV index), with the goal of raising awareness of the dangers of UV exposure and providing a basis for informed decision-making regarding outdoor

• activities. Others use persuasive techniques to attempt to change

knowledge, attitudes, beliefs, intentions, and behaviors related to sun- protection and skin cancer.

! Although this review assesses the effectiveness of mass media

interventions themselves, eligible interventions could also use small media (e.g., brochures, flyers, newsletters) or promotional products to increase awareness of campaign messages.

12

Analytic Framework: Mass Media Interventions

Mass Media Interventions

Increase knowledge of:

• UV effects

(photodamage, wrinkling)

• Skin cancer (different

types, prevention related)

• UV protection

(knowledge of how to protect oneself)

• Recognition of terms

(related to intervention) Change in attitudes re:

• UV exposure

(exposure during peak hours, limit exposure)

• Indoor tanning

Change in protective behavior

• Increased UV

protection (use of appropriate clothing, shade, and sunscreen)

• Limit UV exposure

(avoiding sun exposure during peak hours, avoid using tanning bed) Potential Harms:

• Vitamin D deficiency
• Less physical activity

Additional benefits: Early detection of skin cancer through:

• Self exam
• Increased doctor visits

Decrease incidence

• f sunburn

Decrease incidence

• f skin

cancer

13

Methods: Interval Search (Overall)

! Databases: Medline, CINAHL , PsycINFO ! Search Period: June 2000-May 2011 ! General Inclusion Criteria:

" Primary intervention study with one or more

• utcomes of interest to these update reviews

" Written in English " Conducted in a high-income country

14

Methods: Study Inclusion/Exclusion Criteria

! Inclusion criteria

" 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

15

Interval Search Yield: 2000–2011

16

Note: As per our update methods, we did not redo the original 1966-2000 search for evidence.

Broad Skin Cancer Topic Search

Potentially relevant articles from electronic databases and review of reference lists (2000–2011) (11,106) Articles potentially relevant to skin cancer interventions (143) Articles assessing interventions other than mass media (124) Studies that met inclusion criteria (5)

New studies included in analysis 5

Number of mass media papers identified (19) Articles excluded after full review (14) Studies with limited quality of execution

• Studies identified from original

review period 3

+

Body of Evidence (Search Period 1966-2011)

Quality of Execution Suitability of Design Greatest Moderate Least Good (0–1 limitations) 1 Dobbinson, 2008 Fair (2–4 limitations) (1) (Kiekbusch, 2000) 3 (3) Koster, 2011; Broadwater, 2004; Smith, 2002; (Lynch, 2003); (Geller, 1997); (Theobald, 1991) Limited (>5 limitations) Qualifying studies: 4; (Additional evidence studies: 4)

17

Study Design Characteristics

Suitability of Study Design Greatest Moderate Least Study Designs Described in the Included Studies Before and After with concurrent control: (1) (Kiekbusch, 2000) Time Series: 1 Dobbinson, 2008 Before-and-After: 3(1) Koster, 2011; Broadwater, 2004; Smith, 2002; (Theobald, 1991) Post only with treated comparison: (1) (Geller, 1997) Post only (comparison within exposed group): (1) (Lynch, 2003);

18

Locations of Included Studies and Study Samples

19

United States (24 cities) Geller, 1997 Utah Broadwater , 2004 Denmark Koster, 2011 Denmark Koster, 2011 Sweden Kiekbusch, 2000 Australia Dobbinson, 2008; Lynch, 2003; Smith, 2002; Theobald, 1991

Analytic Framework: Mass Media Interventions

Mass Media Interventions

Increase knowledge of:

• UV effects

(photodamage, wrinkling)

• Skin cancer (different

types, prevention related)

• UV protection

(knowledge of how to protect oneself)

• Recognition of terms

(related to intervention) Change in attitudes

• UV exposure

(exposure during peak hours, limit exposure)

• Suntanning

Change in protective behavior

• Increased UV

protection (use of appropriate clothing, shade, and sunscreen)

• Limit UV exposure

(avoiding sun exposure during peak hours, avoid using tanning bed) Potential Harms:

• Vitamin D deficiency
• Less physical activity

Additional benefits: Early detection of skin cancer through:

• Self exam
• Increased doctor’s visits

Decrease incidence

• f sunburn

Decrease incidence

• f skin

cancer

4

20

Changes in Protective Behaviors Reported in Studies

• f Mass Media Interventions: Adults

21

• 25
• 20
• 15
• 10
• 5

5 10 15 20 25

Study/Year(Baseline) Smith, 02 C1 ( 52) C2 (28) C1 (29 ) C2 ( 44 ) C1 ( 21 ) C2 ( 20 ) C2 (43) Broadwater, 08 (61) (13)

Use of Sunscreen Use of Protective Clothing Use of Hat Use of Shade

C1 (47)

Absolute percent change in protective behaviors

Changes in Protective Behaviors Reported in Studies of Mass Media Interventions: Children

22

• 25 -20 -15 -10
• 5

5 10 15 20 25

Study/Year(Baseline) Smith, 02 C1 ( 28) C2 (66 ) C2 ( 52 ) C2 ( 33) C2 (60) (30) C1 (75) C1 (71 ) C1 (58) Use of sunscreen Use of Protective clothing Use of Hat Use of Shade More careful about children’s sun protection

Absolute percent change in protective behaviors

Broadwater,08

Effect of Three Sequential Campaigns (Smith, 02)

0% 20% 40% 60% 80% 100% Pre+1 Post+1 Pre+2 Post+2 Post+3 Children Adults

0% 20% 40% 60% 80% 100% Pre+1 Post+1 Pre+2 Post+2 Post+3 Children Adults

Use of Protective Clothing Use of Sunscreen

C1 C1 C2 C3 C2 C3 C1: Campaign 1 C2: Campaign 2 C3: Campaign 3

23

Effect of Three Sequential Campaigns (Smith, 02)

24

0% 20% 40% 60% 80% 100% Pre+1 Post+1 Pre+2 Post+2 Post+3 Children Adults 0% 20% 40% 60% 80% 100% Pre+1 Post+1 Pre+2 Post+2 Post+3 Children Adults

Use of Hat Use of Shade

C1: Campaign 1 C2: Campaign 2 C3: Campaign 3 C1 C2 C2 C3 C3 C1

Results: Effects of Changes in Intensity of Mass Media Exposure (Dobbinson, 2008)

! Assessed association of extent of SunSmart television

advertising exposure with weekend behaviors

" Exposure variable– Intensity of mass media campaign for the past 4-week period, measured in Target Audience Rating Points (TARPs) " Outcome variables—Self-reported sun exposure and protection behaviors during summer weekends

! Survey conducted for 13 weeks during summers

between1987 and 2002

25

Results: Effects of Changes in Intensity of Mass Media Exposure (Dobbinson, 2008)

Weekend behaviors (11 AM -3 PM) ORs for TARPs x 100 95% CI p-value Hat used 1.24 1.15 to 1.33 <0.001 Sunscreen used* 1.16 1.07 to 1.25 <0.001 ¾ or long sleeved top worn 1.08 0.98 to 1.18 0.109 ¾ or long leg cover worn 1.05

• 0. 97 to 1.12

0.225 Coefficient for TARPs x 100 Body exposure index**

• 0.02
• 0.02 to -0.01

<0.001

* Evidence for inadequate model fit (via the Hosmer–Lemeshow test, p<0.029) ** Results from multiple regression TARP, target audience rating points

26

Results: Effects of a Viral Marketing Campaign (Koster, 2011)

! Anti-sunbed campaign with two primary objectives

" Reduction or elimination of sunbed use among teens and adults " Advocacy to reduce access to sunbeds (esp. by teens)

! Channels

" Traditional mass media (e.g., magazines, radio) " Social media (e.g., MySpace, YouTube, Facebook) " Direct lobbying

! Reduction in overall use (past month)

OR=0.61(95%CI: 0.54 – 0.69)

! Reduction in teens who have ever used sunbeds

" <13-year-olds: -5 pct. pts. (13% to 8%; p<0.001) " 13-15-year-olds: -10 pct. pts. (75% to 65%; p<0.001)

27

! Effects of a multimedia CD-ROM housed in a kiosk with a

touch screen display at public places (Kiekbusch, 2000)

" “Behavior change”: 3 pct. pt. increase in intervention community

! Effects of television program about melanoma entitled

‘Goodbye SunShine’ (Theobald, 1991)

" Significant improvement in secondary prevention outcomes

• Self skin exam and someone else’s exam for “skin spots”
• 167% increase in melanoma diagnosis within 3 months after the show
• Increased proportion of melanomas removed at early stages

Both studies were included in original review

Additional Evidence

28

Additional Evidence

! SunSmart skin cancer messages on electronic

scoreboard at a 5-day cricket match (Lynch, 2003)

" Spectators who noticed the messages had a significantly higher Compound Index of Protection than those who did not recall the advertising (5.22 vs. 4.03, p<0.0002)

! Ultraviolet radiation forecast to the major television stations and

newspapers in 58 cities of U.S. (Geller, 1997)

" 24 cities ranked as high exposure cities (12) and low exposure cities (12) according to their UVI exposure ratio " Higher proportion of residents in high exposure cities (who were aware

• f UVI ) had “changed” their overall sun protective practices compared

to residents in low exposure cities (40.6% vs 35.2%, p= 0.268)

29

Additional Benefits

! Potential increase in early detection of skin cancer ! One study reported (Theobald, 1991)

" Increase in self examination of abnormal skin spots " Increase in number of doctor visits for abnormal spots " Early detection of melanomas

30

Potential Harms

! Potential harms postulated include

" Decrease in physical activity " Vitamin D deficiency

! Results from one study suggest no effect on time outdoors

(regression coefficient=0.01, p=0.283) (Dobbinson, 2008)

31

Information From Other Reviews and Recommendations

! Mass Media Campaigns Recommended by NICE ! Commissioners, organizers, and planners of national

mass-media skin cancer prevention campaigns should:

" Continue to develop, deliver ,and sustain these campaigns to raise awareness of the risk of UV exposure and ways of protecting against it " Try to integrate campaign messages within existing national health promotion programs or services to keep costs as low as possible (Sure Start is an example of an initiative where messages could be integrated) " Evaluate the impact using a range of knowledge, attitudes, awareness, and behavioral measures.

32

Summary of Findings

! Total evidence: Primary evidence from 4 studies (plus 4

with additional evidence)

! One moderate suitability of design and 3 least suitable

design

! Generally favorable results for sun protective behaviors

among children and adults (4 studies)

! Serious issues with internal and external validity

" External validity: Most evidence is from Australia

• Sun protection programs are more extensive in general
• Demographics (fair-skinned population)
• Climate (generally higher UV index)

" Internal validity : No studies with unexposed comparison groups

33

Task Force Finding-Mass Media

! The Task Force on Community Preventive Services finds

insufficient evidence to determine the effectiveness of mass media interventions to prevent skin cancer by reducing exposure to ultraviolet radiation. Although the available evidence generally indicates that mass media interventions are associated with improvements in protective and preventive behaviors, the small number of studies, several with methodological limitations, make it difficult to draw clear conclusions.

34

Additional Issues for Task Force Consideration

! Conclusion and finding

" Generally favorable results " Insufficient evidence

! Generalizability issues related to location of studies ! Inclusion of social media interventions with large target

audiences within the scope of mass media interventions

! Role of mass media interventions in facilitating longer-

term changes in social norms and policies

Community-wide Multicomponent Interventions

Community – wide Multi component Interventions

Increased UV protection in Adults and Children

• Increased in UV protective behaviors

(use of appropriate clothing, shade, and sunscreen)

• Limit UV exposure (limiting sun exposure

during peak hours, limiting/avoiding tanning bed use) Potential Harms:

• Decrease in Vitamin

D levels

• Less physical

activity Decrease incidence of sunburn in adults and children

37

Change in Adult/Children’s Knowledge, Attitudes and Social norms

• UV effects (photo damage, wrinkling)
• Skin cancer (different types, prevention related)
• UV protection (knowledge of how to protect
• neself)
• UV exposure (exposure during peak hours, limit

exposure)

• Indoor tanning

Individual – directed Components Environmenta l and Policy Components Media Campaigns Decrease in UVR exposure in adults and children

Analytic Framework: Community-wide Multicomponent Interventions

Decrease incidence of skin cancer

Interval Search Yield: 2000–2011

Note: As per our update methods, we did not redo the original 1966-2000 search for evidence.

Studies/reports that met inclusion criteria (5)**

New studies included in analysis 3

Studies with limited quality of execution

• Studies identified from original

review period 4*

+

Broad Skin Cancer Topic Search

Potentially relevant citations from electronic databases and review of reference lists (2000–2011) (11,106) Papers/reports potentially relevant to skin cancer interventions (143) Papers assessing interventions other than community- wide multicomponent (98) Number of community-wide multicomponent papers/reports identified (45) Papers excluded after full review (40)

*From 8 studies included in the original review, 4 were excluded from this review because 1 was superseded by more recent report (SunSmart ), and 3 were determined to be ineligible after reconsideration (Biger’94 , Carmel’94, and Sanson Fisher’ 95) **Of 5 studies that met the inclusion criteria, 3 evaluated the effectiveness of same program with in the subset of same population (Dobbinsom’08a, Dobbinson’08b, Dixon’08).

38

Body of Evidence (Search Period 1966-2011)

Quality of Execution Suitability of Design Greatest Moderate Least Good (0–1 limitations) _ _ _ Fair (2–4 limitations) Group RCTs Dietrich, 2000; Olson, 2007 _ Before-After Studies Rassaby, 1983; Miller, 1999; NSW Cancer Council, 1998; Dobbinson, 2008; ONS, 2010 Limited (>5 limitations) _ Qualifying studies: 7

39

Evidence on Effectiveness:

40

Rec Outcome #1

Research Question #1: How effective are CWMC interventions in changing UV protection in adults and children ? 7

• 5

5 10 15 20 25 30 35 40 45 50 55

Children (< 6 yrs.) Children (6-13 yrs.) Children Parents Male Female Adolescent General population

Changes in Sun Protective Behaviors (Sunscreen Use)

(37.2)

Program, Study, Year, (Baseline %)

(44.0) (58.0)

SunSmart, UK SunSafe, USA Falmouth Safe Skin Project, USA Miller, 1999

(72.8) (31.1) (27.0)

Seymour Snowman, AUS NSWCC, 1998 Slip! Slap! Slop!, AUS Rassaby, 1983

(55.0)

Olson, 2007 Dietrich,2000 ONS, 2010

(63.0)

Absolute percentage point change in sunscreen use Median effect estimate: +10.8 pct pts (IQI: 7.33, 23.23) 41 Favorable direction

Changes in Other Sun Protective Behaviors

• 20
• 15
• 10
• 5

5 10 15 20 25 30

GP Parents Children (<6 yrs.) Children (6-13 yrs.) Male Female Children (0-11 yrs.) Adolescents (6-8 grade)

Use of clothing Use of shade Overall protective behaviors

Range: (11.2, 12.0)

(58.0) (71.8) (8.0) (29.0) (18.0) (22.5) (46.4) (58.4) (26.1) (49.1) (53.0) (55.0)

Absolute percentage point change in protective behaviors

Median: - 3.1 pct pts Median: -1.0 pct pts Median: + 4.4 pct pts

42

Author, Year, Baseline (%)

ONS, 2010 Dietrich,2000 Olson, 2007 Miller, 1999 Rassaby, 1983 Rassaby, 1983 Miller, 1999 Miller, 1999 Miller, 1999 ONS, 2010 Dietrich,2000 NSWCC, 1998 NSWCC, 1998 NSWCC, 1998 NSWCC, 1998 Dietrich,2000

Use of hat

NSWCC, 1998 NSWCC, 1998

SunSmart Program: Change in Adolescents and Adult’s Sun Protective Behavior

5 10 15 20 25 30 35 40 45 50

Hat Use Sunscreen Use 3/4 Long Sleeves

Time period Prevalence (%)

Dobbinson’ 08a (Melbourne) Dobbinson’ 08b (Victoria) 43

SunSmart Program: Observed Sun Protective Behavior*

10 20 30 40 50 60

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Clothing male Clothing female

Prevalence (%) Time period

* Dixon 2008: Use of sun-protective clothing at outdoor leisure settings from 1992 to 2002: serial cross-sectional observation survey; 2008 Feb;17(2):428-34. Epub 2008 Feb 4 44

Changes in Risk Behaviors: Limiting UV Exposure

45

• 2
• 1

1 2 3 4 5 6 7 8 9 10

Children (6-13 yrs.) Parents General population

Author, year, Baseline (%)

Absolute percentage point change in risk avoidance

Limit time in sun

(6.8) (8.5) (3.1)

Avoid tanning beds

(1.2) Miller, 1999 Miller, 1999 ONS, 2010 ONS, 2010

Favorable direction

SunSmart Program: Change in Adolescents and Adult’s Sun Protective Behavior (Time Spent Outdoors)

115 117 119 121 123 125 127 129 131 133 135

Time spent outdoors between 11 a.m.- 4 p.m. (in Minutes)

Time Period

Dobbinson’ 08a (Melbourne) Dobbinson’ 08b (Victoria)

46

Evidence on Effectiveness:

47

Rec Outcome #2

Research Question # 2: How effective are CWMC interventions in reducing incidence of sunburn? 2

Draft Task Force Finding Statement

! The Community Preventive Services Task Force

recommends community-wide multicomponent interventions to prevent skin cancer by increasing UV protection behaviors, based on sufficient evidence of their effectiveness in increasing sunscreen use. The available evidence indicates mixed results for other protective behaviors, such as wearing protective clothing and hats, seeking shade, and limiting outdoor activities during peak hours for ultraviolet radiation. A small amount of evidence also indicated benefits in reducing sunburns.

48

Primary and Middle Schools

Inclusion)Criteria)

! Study&inclusion&criteria&

" Primary&interven3on&study&with&one&or&more&outcomes&of& interest& " Wri8en&in&English& " Journal&ar3cle;&government&or&NGO&report& " Conducted&in&a&highBincome&country&

! Interven3on&inclusion&criteria&

" Included&educa3onal&and&behavioral&ac3vi3es,&environmental& and&policy&changes,&or&a&combina3on& " Delivered&in&primary&or&middle&school&seGng.&Studies&were& eligible&if:&

• Median&grade&level:&8&or&lower&
• Median&age:&14&years&or&younger&

&

50&

Interval)Search)Yield:)2000–2011&

Note:&&As&per&our&update&methods,&we& did&not&redo&the&original&1966B2000& search&for&evidence.&

Reports)that)met)eligibility)criteria)))))))))(21)) Studies)included)in)analysis)))))))))))))))))))))))))(13)) AddiAonal)papers)related)to)an)included) study)(7) )

Broad)Skin)Cancer)Topic)Search)

PotenAally)relevant)citaAons)from)electronic) databases)and)review)of)reference)lists)(2000– 2011)))))) )(11,106)) Papers/reports)potenAally)relevant)to)skin) cancer)intervenAons) )(143) )& Papers)assessing)intervenAons)other)than)PrimaryO) and)MiddleOschoolObased)(80)) Number)of))community)wide)mulAcomponent)) papers/reports)idenAfied) )(63) )& Papers)excluded)aUer)full)review)(42)))))))))) ) 51& Studies)with)limited)quality)of)execuAon)(1)) )

Body)of)Evidence)(Search)Period)2000O2011))

Quality)of) ExecuAon) Suitability)of)Design) Greatest) Moderate) Least) Good)) (0–1)limitaAons)) _) _& _& Fair)) (2–4)limitaAons))

12)

Group)Randomized) (Buller’06;& Stankeviciute’04;&Lee’05;& Naldi&’08;&Hunter’10)&&& ) Group)non)Randomized)) Trial&(Milne’06;& Manganoni’05;&Buller’06;& Buller’06;&Quereux’09;& Buller’08;&Geller’02))

& _& 1) Before)and)AUer)

(Gilberte’08)&

Limited) (>5)limitaAons)) 1& Qualifying&studies:&&13&

52&

AnalyAc)Framework:))PrimaryO)and)MiddleOSchoolOBased) IntervenAons)

Poten3al&Harms:&

• &Vitamin&D&deficiency&
• &Less&physical&ac3vity&

Decreased&incidence&

• f&skin&cancer&

53&

SchoolObased) intervenAons)

Educa3onal& and& Behavioral& Environmental& and&& Policy&

+

Change&in&children’s& and&caregivers’& knowledge,& aGtudes,&inten3ons,& and&social&norms& about:&

• Sun&tanning&
• UV&effects&on&

appearance&

• Skin&cancer&&
• Methods&to&protect&

against&UVR&

Increased&UV& protec3ve& behaviors&

• Use&of:&
• Sunscreen&
• Appropriate&

clothing&&

• Hats&&
• Shade&&
• Sunglasses&
• Avoiding&sun&

exposure& (especially&during& peak&hours)& Reduced&incidence&of&

• Sunburn&
• Nevi&
• Ac3nic&keratosis&

Decreased& morbidity&and& mortality& Decrease&in& UV&exposure& 8)) 3)) 12)(13))

Evidence)on)EffecAveness)

54&

& & UV&Protec3ve& Behaviors&

Research&Ques3on&#1:&& How&effec3ve&are&primary&and&middle&school&&interven3ons&in:& a)&Changing&UV&protec3ve&behaviors&in&children&and&caregivers?& &b)&Avoiding&sun&exposure&(especially&during&peak&hours)?&

12)(13)))

55&

Sunscreen)Use)

B15& B10& B5& 0& 5& 10& 15& 20& 25& 30& 35& 40& 45& 50&

Educa3on&only& Educa3on,&policy&and&environment&

Favors)IntervenAon)

Absolute&Percentage&Point&Change&in&Sunscreen&Use&

Median:)+3.1)pct)pts)) (IQI:)1.28,)8.88)) N=9(10)) Kimlin&01&(40)&& Geller&02&(29)& Stankeviciute&04&(52)& Manganoni&05&(95)& Milne&06&B&Moderate(&25)&& Buller&06&(77)& Quereux&09&

Holiday&(51)& Beach&(76)& Garden&(14)& Swim&Pool&(34)&

Gilberte&08&(52)& Naldi&08&(72)&

Author,)year)(Baseline)%)))

High&(&25)& Milne&06B&

56&

Hat)Use)

B5& 0& 5& 10& 15& 20& 25& 30& 35& 40&

Educa3onal&only& Educa3onal,&policy,&and&environmental& Educa3onal&and&environmental&

Favors)IntervenAon)

&Hunter,&11&

Absolute&Percentage&Point&Change&in&Hat&Use&

Median:)+1.9)pct)pts)) (IQI:)0.3,)13.5)) N=9(10)) Kimlin&01&(1.0)&& Geller&02&(16.8)& Stankeviciute&04&(26.7)& Manganoni&05&(78)& Milne&06,&Moderate(&17.5)& Buller&06&(3.7)& Quereux&09& Beach&(62)& Garden&(57)& Naldi&08&(38)&

Author,)year)(Baseline)%)))

At&school&(24.3)& Outside&school&(2.0)&

(P<0.001)) (P=0.47))

Milne&06,&High(15)&

57&

Any))ProtecAve)Behaviors)

O5) 0) 5) 10) 15) 20) 25) 30) 35)

Favors)IntervenAon) Absolute&Percentage&Point&Change&in&Any&Protec3ve&Behavior&

Author,)year)(Baseline)%))) Manganoni&05&(94.0)& Gilberte&08& &&Mountains&(57.5)& At&beach&(82.4)& Sports&(37.0)& At&park&(31.3)& Range&of&values:&1.9,&5.2& N=&2& &

Any)ProtecAve)Behaviors)(contd.))

! Two&studies&conducted&in&Western&US&evaluated&the&

effec3veness&of&program,&Sunny&Days&Healthy&Ways&(SDHW)&

! Buller&(2008)&

" Exposure&to&SDHW&via&computer&program,&teacherBled&presenta3on,&or& both&improved&composite&sun&protec3on&scores&& " Both&computer&and&teacher&led&program&was&more&effec3ve&than& teacherBled&only&for&youngest&children&(grades&KB2)&

! &Buller&(2006)&&

" Exposure&to&SDHW&for&a&single&year&resulted&in&no&significant& improvements&in&sun&protec3on&outcomes&for&K&through&5thBgraders& " Repeated&exposure&to&SDHW&resulted&in&significant&improvements&in& sun&protec3on&outcomes&and&in&measures&of&skin&darkening&&

&Buller&MK,&et&al.&Randomized&trial&evalua3ng&computerBbased&sun&safety&educa3on&for&children&in&elementary&school.&J&Cancer&Educ&2008;23(2):74B9.& Buller&DB,&et&al.&Evalua3on&of&the&Sunny&Days,&Healthy&Ways&sun&safety&curriculum&for&children&in&kindergarten&through&filh&grade.&Pediatr&Dermatol& 2006;23(4):321B9.&

58&

ProtecAve)Behaviors:)Time)Trends)(Milne,)06)))

O2) 0) 2) 4) 6) 8) 10) 12) 14) 16) Year)2) Year)4) Year)6)

Time)period) Percentage)point)change)

59&

O2) 0) 2) 4) 6) 8) 10) 12) 14) 16) Year)2) Year)4) Year)6)

Hat&Use& Shade&Use& Time)period) Percentage)point)change)

Moderate&Intensity&Interven3on& High&Intensity&Interven3on&

60&

Change)in)Risky)Behaviors)

B30& B25& B20& B15& B10& B5& 0&

Sun)exposure)

Favors)IntervenAon)

Absolute&Percentage&Point&Change&in&Risky&Behaviors&

Author,)year)(Baseline)%))) Stankeviciute&04&(41.0)& Naldi&&07&(79.0)&& Manganoni&05&(7.6)&& Manganoni&05&(0.7)&&

Use)of)sun)lamps)

Median:O3.1)pct)pts) (Range:)0.9,)O14.7))

Evidence)on)EffecAveness)

61&

& & UV&Exposure&

Research&Ques3on&#2:&& How&effec3ve&are&primary&and&middle&school&interven3ons&in:&& Reducing&UV&exposure?&&

3))

Evidence)on)EffecAveness)

62&

& & Incidence&of& sunburn,&nevi& forma3on&&&

Research&Ques3on&#2:&& How&effec3ve&are&primary&and&middle&school&&interven3ons& in&reducing&incidence&of:&

• Sunburn?&
• Nevi&forma3on?&

8))

63&

Sunburn)Incidence)

B20& B15& B10& B5& 0& 5& 10& 15& 20&

Favors)IntervenAon) Absolute&Percentage&Point&Change&in&Sunburn&Incidence&

Median:&B3.6&pct&pts&& (IQI:&B8.45,&1.45)& N=5& Naldi&07& Author,)year)(Baseline)%))) Manganoni&05&(10.0)& Buller&06&(15.1)& Any&sunburn&(13.8)& 1B2&sunburn&(10.3)&& Gilberte&08(23.5)& Quereux&09&(7.0)&

)&

64&

Incidence)of)New)Nevi)

O60) O55) O50) O45) O40) O35) O30) O25) O20) O15) O10) O5) 0) 5)

Environmental&only& Educa3onal&and&environmental& Educa3onal,&policy,&and&environmental&

Favors)IntervenAon) Rela3ve&Mean&Change&&in&Nevi&Forma3on&

Median&effect&es3mate:& &B16.52&pct&pts&(IQI:&B18.63&,&B7.52)& N=3&(4)& Author,)year)(Baseline))) Hunter&10&(9.0)& Milne&06& (Moderate)&

Back(3.5)& Arms&(&8.9)& All&sizes&on&freckled&face&(27.1)&

Lee))05)

2&mm&diameter(&2.2)& All&sizes&(&28.8)&

Milne&06& (High)&

Face(&4.4)& Back&(3.6)& Arms&(&9.8)& Face(&4.4)&

P=0.07&

ConsideraAons)on)ImplementaAon)

! Common&reasons&for&not&having&a&policy&included&&

! Principals’&lack&of&awareness&& ! Organiza3onal&barriers&in&the&school&districts&(Buller&et&al.,&2002)&

! Studies&indicate&that&ini3a3ves&to&change&schools’&sunBprotec3on&

policies&can&be&successful&

! Sun&protec3on&resources&& ! Guidance& ! Accredita3on&(Emmons,&2008;&Jones&2008)&

! Challenges&with&

! Implementa3on&at&school&level&vs.&organiza3on&level&(i.e.,&stakeholder&

interest&to&consider)&

! Addi3on&of&a&specific&sunBprotec3on&curriculum&–&integra3on&with&exis3ng&

curricula&may&be&beneficial&&

65&

Effects)of)IntervenAons)to)change)School)Policies)

! Jones,&2008;&Dobbinson,&2000&&

" Na3onal&SunSmart&Schools&Program&& " Encourage&sun&protec3on&in&schools&by&recognizing&schools&and&providing& resources& " SunSmart&schools&were&found&to&have&higher&level&of&policy& implementa3on&compared&with&nonBSunSmart&schools&(e.g.,&enforcement&

• f&sun&protec3ve&hat&wearing,&sunscreen&available&in&classrooms,&

provision&of&shade,&schedule&PE&classes&outside&peak&hours,&indoor&lunch)& " Wri8en&policies&were&linked&to&corresponding&prac3ces&

! Emmons,&2008&

" SunWise&ProgramB&Massachuse8s&elementary&school&nurses&or&health& educators& " SunWise&curricula&training,&the&SHADE&Founda3on&brochures,&and& SunWise&toolkit&& " Increase&adop3on&of&schoolBbased&sun&protec3on&policies&

66&

Con$nued…)

Effects)of)IntervenAons)to)change)School)Policies)(contd.))

! Buller,&2011&

" Sun&Safe&Schools:&During&2005–2010&RCT&conducted&in&Southern& California&(61&districts)&and&in&Colorado&(68&districts)& " Districts&assigned&to&interven3on&received&policy&program&over&2&years:& Policy&informa3on,&tools,&and&technical&assistance&provided&through& printed&materials,&a&website,&mee3ngs&with&administrators,&and& presenta3ons&to&school&boards& " 24%&of&interven3on&districts&adopted&a&policy&vs.&12%&of&control&districts& (p=0.142).&Interven3on&districts&adopted:&

• stronger&sun&safety&policies&than&control&districts&(adjusted&M=3.10&of&21&

total&score&vs.&1.79;&p=0.035)&&

• improved&&policies&on&sun&safety&educa3on&for&students&(adjusted&M=0.76&

vs.&0.43,&p=0.048)&

• improved&provision&of&outdoor&shade&(adjusted&M=0.79&vs.&0.28,&p=0.029)&
• improved&policies&for&outreach&to&parents&(adjusted&M=0.59&vs.&0.20,&

p=0.027).&

67&

Evidence)Gaps)

! Limited&evidence&available&to&determine&variability&in&effec3veness&of&

interven3ons&based&on&

• Presence&of&local,&state&,&or&na3onwide&ini3a3ves&
• Race/ethnicity&and&skin&type&

! Limited&evidence&&available&on&

" Interven3ons&with&environmental&and&policy&components& " Interven3ons&for&older&children&(7th&&&8th&grade)& " LongBterm&effects&of&these&interven3ons&

! Several&&implementa3on/transla3on&remained&unanswered,&such&as:&

" Infrastructure&required&to&scale&up&interven3ons&while&sustaining&their& effec3veness&(e.g.,&technical&assistance,&support&to&school&districts)& " Level&of&school&administra3on&most&helpful&to&engage&with&to&foster& implementa3on&of&schoolBbased&interven3ons&(e.g.,&schoolBlevel&vs.&districtBlevel)

68&

DraU)Task)Force)Finding)Statement)

! The&Community&Preven3ve&Services&Task&Force&recommends&

primaryB&and&middleBschoolBbased&interven3ons&to&prevent&skin& cancer&by&increasing&UV&protec3on&behaviors,&based&on&strong&& evidence&of&effec3veness&in&increasing&sun&protec3ve&behaviors& and&decreasing&ultraviolet&exposure,&sunburn&incidence,&and& forma3on&of&new&nevi.&The&evidence&was&derived&mainly&from& studies&of&implementa3on&of&sun&protec3on&curricula.&&

69&

Summary

! Updated review partially conducted

" Many categories show stronger evidence (primary school) " Multicomponent sufficient evidence " Sunscreen use may be driving this change

! Team geographically diverse ! Interventions can be used to highlight areas where there

is evidence –

! Interventions can be used to highlight research gaps and

continued research

CG)Website)

&www.thecommunityguide.org&

71&

Visit the Community Guide Web site (www.thecommunityguide.org) and find out what works to promote health and safety in your community. Learn about:

! Evidence-based Task Force findings and

recommendations

! Systematic review methods ! Interventions on 18 public health topic areas ! How to use the Community Guide ! And more!