Adapting a Skin Cancer Prevention Intervention for Multiethnic Adolescents

Introduction

Skin cancer is an uncontrolled growth of skin cells. Skin cancer is one the most common type of cancer in the United States and its rates have increased 3% annually. Avoidance of irregular sunburns and indoor tanning can reduce skin cancer risk 50% to 80%. There are some oppositions and challenges with applying UVR prevention plans and programs with young people, who are not discouraged by the danger and warning of cancer in life in future. More than half of a person’s lifetime skin cancer risk appear all along adolescence. About 84% of students are outdoors in the middle of UVR periods between 10 a.m. and 4 p.m., but only a few numbers of schools, almost 31% have sun protection action and guideline. These protection programs have been useful and effective in middle, however a few involvements labeled to help high school students who are no longer under their parents attention. There are some factors that effect UVR exposures like changes in social norms, risk-taking activities. Many high school students think that tanning is healthy and attractive, and they are unconscious about long-term dangers.

Skin cancer prevention attitude differ by skin type. Some people have pigmented or skin that easily tan underrate their cancer risk, however people with darker pigmented skin have lower risk of skin cancer compare to their Caucasian counterparts, because they are able to produce more melanin. Accurate risk perceptions in nonwhite individuals including Asians and Pacific Islanders can lead to prolonged UVR exposures, increased sunburn prevalence, delayed skin cancer diagnoses, and greater risk for death. Cokkinides et al found a significant in- creasing trend in severe sunburns among nonwhite adolescents ages 11-18 years despite sunscreen use. Currently, few skin cancer prevention interventions address multiethnic youths such as Asians and Pacific Islanders. In this study our aim was to use input from teachers and students to adapt a school-based intervention entitled “SunSafe in the Middle School Years” for use with multiethnic high school students.

Method

In Hawai’i, schools are built with open architectural layouts to facilitate natural cooling.30 These features expose students to direct sunlight during breaks, physical education classes, and athletic activities.30 To obtain objective measures of the students’ outdoor behaviors, 4 first- year medical students from the local medical school were trained in the use of the SOSPF field observation instrument to assess aggregate sun protection behaviors. SunSafe is a multicomponent intervention pro- gram that addresses environmental and behavioral skin cancer prevention factors and has been proven effective in decreasing UVR exposures in adolescents in the northeastern US.24 We hypothesized that SunSafe’s ecological approach, use of social learning theory, including observational learning, modification of behavioral capacities, and building of self-efficacy, could address the structural and behavioral factors related to UVR exposure in older, multiethnic students. One student stated: “We want to know…how skin cancer can affect us in life, show how you can get that from going in the sun, what it looks like and what happens when you get treatment. ”Following the intervention, students asked for de- tailed information about the benefits of sun protection including how sunscreen works and the types of sunscreen available. Discussion sessions in the classroom included testimony from a local well-known watersports athlete who shared a personal story about the importance of sun protection, and incorporated a hands-on activity where students tested the use of the UVR-sensitive wristbands which, as suggested by students, changed colors when exposed to outdoor UVR. Qualitative research methods included one-hour guided discussions with 50 students, 2 health education teachers, and the principal with the purpose of obtaining input on modifying the SunSafe intervention to appeal to high school aged multiethnic students. Similar with the male students, female students were initially unlikely to use several sun protection strategies; they perceived sunscreen as sticky, greasy and for use only at the beach and perceived protective clothing as unattractive. The 4 observers assessed the sun protection practices of 42 random students from the entire student population by counting the number of hats, sunglasses, and so on, which were in use within a specific predetermined area of the school campus, during the 10-minute interval between classroom periods when students walked to their next class. A standardized 28-item Sun Habits Survey (SHS) developed by Glanz et al was adapted to measure the effects of SunSafe’s modified intervention on UVR protection knowledge, attitudes, and self-reported be- haviors.28 The adapted survey used in this study contained 18 core items derived from expert reviews, which are usable across a range of age groups,28 and consisted of: (1) 8 items assessing UVR protection knowledge; (2) 3 items assessing sun protection attitudes; and (3) 7 items assessing UVR protection behaviors. The assessment of students’ knowledge, attitudes, and behaviors concerning sun protection conduct- ed before and after program delivery indicated positive changes in most items. Male students stated, upon becoming more knowledgeable about their skin cancer risk, they were more likely to use protection strategies such as shade, eyewear, and athletic apparel designed with sun protection features.

Quantitative research methods included distributing a post-test (18 core items derived from a 28-item standardized surveys) to 250 students after delivery of the modified SunSafe intervention. However, unlike the male students, female students remained resolute in their preferences for a few sun protection strategies even after becoming knowledgeable about skin cancer risks. It seems one of the best ways to prevent skin cancer is to cover up, not necessarily with sunscreen, but I mean sunscreen works too, and I would use it more.” UVR protection in female students. Yeah, it turns colors and so what, when you go in the shade, it’ll change back? So, if we made it into wristbands, I think a lot of people would get it.” Students suggested using celebrities and athletes to promote sun protection to young people. Finally, these discussions supported buy-in, which provided students with prior knowledge about the intervention.

Results

Discussion sessions in the classroom included testimony from a local well-known watersports athlete who shared a personal story about the importance of sun protection, and incorporated a hands-on activity where students tested the use of the UVR-sensitive wrist- bands which, as suggested by students, changed colors when exposed to outdoor UVR. Following the intervention, students asked for de- tailed information about the benefits of sun protection including how sunscreen works and the types of sunscreen available. Male students stated, upon becoming more knowledgeable about their skin cancer risk, they were more likely to use protection strategies such as shade, eyewear, and athletic apparel designed with sun protection features. However, unlike the male students, female students remained resolute in their preferences for a few sun protection strategies even after becoming knowledgeable about skin cancer risks. Adapting a Skin Cancer Prevention Intervention for Multiethnic Adolescents were initially unlikely to use several sun protection strategies; they perceived sunscreen as sticky, greasy and for use only at the beach and perceived protective clothing as unattractive. Based on their response, male students viewed sunscreens as smelly, greasy, and uncomfortable when dripped into eyes and a hindrance to athletic performance.

Discussion and Conclusion

The assessment of students’ knowledge, attitudes, and behaviors concerning sun protection conducted before and after program delivery indicated positive changes in most items. Modifications were made to address the specific concerns voiced by high school students which included changing the project’s name and logos, and the enhancing the educational materials to include depictions of the appearance-based effects of UVR exposures (wrinkles, early aging skin cancer and surgical treatment). We anticipate that further research on geographic differences and the role of complexion in attitudes towards sun exposure will inform our planned development, implementation, and dissemination of a SunSafe type of educational curriculum in high schools for broad use.

Our qualitative research methods incorporated a participatory approach whereby co-learning among both students (concerning UVR exposure and skin cancer risks) and the research team (concerning adolescents’ skin cancer perceptions and motivating factors towards prevention) were promoted. Results from our pilot study suggest that the SunSafe in Middle School Years’ curriculum is feasible to adapt and implement with multiethnic high school students. Further investigations, including discussions with multiethnic students of various skin tones are needed to explore the implications of these findings. Additionally, these preliminary discussions created buy-in and power sharing; students had an active role in the project’s redesign. As a result, our modified SunSafe program now entitled, Love Your Skin, includes resources that may increase high school students’ self-efficacy to perform sun protection behaviors. Our use of SOSPF demonstrated the feasibility of objectively measuring students’ sun protection behavioral changes in a school population. Our use of teacher input may support planned implementation – teachers involved in this pilot study can now provide testimony about the program’s implementation and preliminary effectiveness to other faculty members. This identified lack of negative connotations surrounding tanned skin could be biased by the students’ positive self-perceptions regarding their own skin tone. These indications of the limited efficacy of the curriculum provide insights about areas of the curriculum that need to be improved.

We intend to use Web-based videos or other strategies to continue to include testimony as regular a feature of the curriculum. We believe that the implementation of high school-based skin cancer prevention intervention for adolescents will ultimately reduce risks for skin cancer in the US.