Preventing Skin Cancer: Education and Policy Approaches in Outdoor Recreational Settings (2002 Archived Review)

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1 Preventing Skin Cancer: Educatin and Plicy Appraches in Outdr Recreatinal Settings (2002 Archived Review) Table f Cntents Review Summary... 2 Interventin Definitin... 2 Summary f Task Frce Finding... 2 Results frm the Systematic Reviews... 2 Publicatins... 3 Task Frce Finding... 4 Interventin Definitin... 4 Task Frce Finding... 4 Supprting Materials... 5 Analytic Framewrk... 5 Evidence Gaps... 5 What are Evidence Gaps?... 5 Identified Evidence Gaps... 5 Included Studies... 8 Disclaimer... 9

2 Archived Review Summary Review Summary Interventin Definitin Interventins in recreatinal r turism settings are designed t increase sun-prtective knwledge, attitudes, and intentins, and affect behavirs amng adults and children. Interventins may include ne r mre f the fllwing: Educatinal brchures (e.g., culturally-relevant materials, phtgraphs f skin cancer lesins) Sun-safety training fr, and rle-mdeling by, lifeguards, aquatic instructrs, and recreatin staff Sun-safety lessns, interactive activities, and incentives fr parents and children Increasing available shaded areas Prvisin f sunscreen Pint-f-purchase prmpts Summary f Task Frce Finding The Cmmunity Preventive Services Task Frce recmmends educatinal and plicy appraches fr adults in recreatinal settings, based n sufficient evidence f effectiveness in imprving the sun-prtective behavir f cvering up. There was insufficient evidence f effectiveness in reducing sunburn due t incnsistent results. The Cmmunity Preventive Services Task Frce finds insufficient evidence t determine the effectiveness f this interventin fr children, because t few studies reprted its effects n children s sunburn. Althugh there is evidence f imprvements in children s sun-prtective behavirs including sunscreen use and cmpsite sun-prtective behavirs these are nt recmmendatin utcmes. Results frm the Systematic Reviews Eleven studies qualified fr the review. Adult sun-prtective behavir f wearing prtective clthing (hat r shirt): median relative difference f 11.2% (interquartile range 5.1% t 12.9%; 5 study arms) Children s sun prtective behavir f wearing a hat, wearing a shirt, and seeking shade: incnsistent effects Incidence f children s sunburn: 41.2% decrease (2 study arms) Incidence f adults sunburn: incnsistent effects (2 studies) Children s sunscreen use: median relative increase f 9.8% (5 study arms) Cmpsite sun prtective behavirs: median relative increase f 15.4% (5 study arms) Available reprts fund incnsistent effects n the adult utcmes including: Infrmatin-seeking behavir r fllw-up study participatin (1 study) Knwledge (3 studies) Attitudes r beliefs (2 studies) Intentins (4 studies) Sun-prtectin measures and envirnmental supprts at utdr recreatinal centers r swimming pls (3 studies) Mst f the interventins cntributing t this review: Tk place in diverse utdr recreatinal, turism and gegraphical settings Included participants with ages ranging frm 6.5 years t 79 years Preventing Skin Cancer: Educatin and Plicy Appraches in Outdr Recreatinal Settings (2002 Archived Review) 2

3 Archived Review Summary Were based n studies cnducted with a predminantly white ppulatin Were cnducted amng predminantly female ppulatins These results are based n a systematic review f all available studies led by scientists frm CDC s Divisin f Cancer Preventin and Cntrl with input frm a team f specialists in systematic review methds and experts in research, practice and plicy related t preventing skin cancer. Publicatins CDC. Preventing skin cancer. Findings f the Task Frce n Cmmunity Preventive Services n reducing expsure t ultravilet light [ MMWR 2003;52(RR-15):1 12. Saraiya M, Glanz K, Briss PA, et al. Interventins t prevent skin cancer by reducing expsure t ultravilet radiatin: a systematic review [ Am J Prev Med 2004;27(5): Task Frce n Cmmunity Preventive Services. Recmmendatins t prevent skin cancer by reducing expsure t ultravilet radiatin [ Am J Prev Med 2004;27(5): Task Frce n Cmmunity Preventive Services. Cancer [ In: Zaza S, Briss PA, Harris KW, eds. The Guide t Cmmunity Preventive Services: What Wrks t Prmte Health? Atlanta (GA): Oxfrd University Press;2005: (Out f Print). Preventing Skin Cancer: Educatin and Plicy Appraches in Outdr Recreatinal Settings (2002 Archived Review) 3

4 Archived Task Frce Finding Task Frce Finding Interventin Definitin Many Americans spend significant amunts f time pursuing utdr recreatin r traveling t regins with high UV levels within the United States and abrad. Increases in recreatinal sun expsure appear t be assciated with increased risk f melanma. Therefre, recreatinal and turism sites cnstitute ptential pints f interventin fr sunprtectin prgrams targeting adults as well as children and their parents. Task Frce Finding (July 2002)* The Task Frce fund sufficient evidence f effectiveness f interventins in recreatinal r turism settings t change adult behavirs, based n imprvements in the adult sun-prtective behavir f cvering up, and recmmends these interventins. Available reprts prvide insufficient evidence t determine the effectiveness f the interventin in reducing sunburn in adults and children, because results were incnsistent (adult sunburn) r t few studies reprted n this utcme (children s sunburn). Althugh available reprts als demnstrate evidence f effectiveness f educatinal and plicy interventins in recreatinal settings in imprving children s sun-prtective behavirs including sunscreen use and cmpsite sun-prtective behavirs these are nt recmmendatin utcmes. *Frm the fllwing publicatin: Task Frce n Cmmunity Preventive Services. Recmmendatins t prevent skin cancer by reducing expsure t ultravilet radiatin [ Am J Prev Med 2004;27(5): Preventing Skin Cancer: Educatin and Plicy Appraches in Outdr Recreatinal Settings (2002 Archived Review) 4

5 Archived Supprting Materials Supprting Materials Analytic Framewrk A Cnceptual Apprach t Preventin f Skin Cancer thrugh Interventins t Reduce UV Light *Imprvements in sunscreen use alne wuld nt result in a recmmendatin utcme (see full MMWR reprt) Evidence Gaps What are Evidence Gaps? Each Cmmunity Preventive Services Task Frce (Task Frce) review identifies critical evidence gaps areas where infrmatin is lacking. Evidence gaps can exist whether r nt a recmmendatin is made. In cases when the Task Frce finds insufficient evidence t determine whether an interventin strategy wrks, evidence gaps encurage researchers and prgram evaluatrs t cnduct mre effectiveness studies. When the Task Frce recmmends an interventin, evidence gaps highlight missing infrmatin that wuld help users determine if the interventin culd meet their particular needs. Fr example, evidence may be needed t determine where the interventin will wrk, with which ppulatins, hw much it will cst t implement, whether it will prvide adequate return n investment, r hw users shuld structure r deliver the interventin t ensure effectiveness. Finally, evidence may be missing fr utcmes different frm thse n which the Task Frce recmmendatin is based. Identified Evidence Gaps Design and Analysis Cnsideratins All f the designs included in this review have imprtant strengths and weaknesses. Preventing Skin Cancer: Educatin and Plicy Appraches in Outdr Recreatinal Settings (2002 Archived Review) 5

6 Archived Supprting Materials Additinal diverse appraches are wrth pursuing, in terms f study design and executin, and with attentin bth t internal and external validity. Cnsistently rigrus analytic methds are needed, and future studies shuld cntrl fr relevant cnfunders, such as risk levels and weather cnditins. Descriptin f Target Ppulatin and Cntext Several reprts in this area f research did nt cntain basic descriptins f the interventin r ppulatin. In many instances, the distributin f the ppulatin by race and ethnicity r sun sensitivity was nt described. Many f the settings culd have been better described. Better descriptins are needed f annual UV expsure in the places in which studies were cnducted. Better descriptins f these imprtant issues wuld help assess the likely applicability f the findings r explain any variability f effects. Descriptin f Interventin It was difficult t disentangle what specific interventin cmpnents were, r hw much emphasis there was n primary preventin (versus early detectin) r n prmting use f sunscreen versus n cvering-up r sunavidance behavirs. Further infrmatin is needed n which attributes f the interventins cntribute mst t interventin effectiveness r ineffectiveness (e.g., d plicy cmpnents r educatin cmpnents cntribute mre t interventin effectiveness; what are the central "active ingredients" in cmplex interventins). Describing interventin characteristics in greater detail might als help practitiners replicate successes. Duratin f Interventins and Length f Fllw up Given the seasnality f sun-prtective behavirs and the imprtance f encuraging habitual as ppsed t shrt-term behavir change, a lnger fllw-up is crucial. Interventin Quality An encuraging trend can be seen in increasing use f frmative research and pre-testing f interventins befre they are implemented. Mediating factrs deserve greater attentin and need t be crrelated with behavir changes. T date, few studies in this area f research have reprted n bth mediating factrs and behaviral r health utcmes. A need als exists t develp measures f the effects f envirnmental and plicy change strategies. Few interventins addressed plicy r envirnmental changes and in thse that did, the effects f the plicy r envirnmental cmpnents culd nt be disentangled frm ther aspects f the interventin. Measurement f Expsure Few studies reprted prcess evaluatin data, which can help t assess hw much f the interventin was actually implemented. Imprvement in this area wuld be helpful, especially fr interventins f lnger duratin and increased cmplexity. Measurement f Outcmes Mre behaviral and health utcmes need t be examined. Preventing Skin Cancer: Educatin and Plicy Appraches in Outdr Recreatinal Settings (2002 Archived Review) 6

7 Archived Supprting Materials Given recent cncerns abut the adequacy f sunscreen as a sle prtective strategy, additinal behaviral and health utcmes shuld als be measured. Outcmes need t be similar t evaluate effectiveness. Measurement f specific sun-prtective behavirs is imprtant. Mre interventins with a greater fcus n cvering up and sun- avidance, and a decreased emphasis n sunscreen use are needed. Given recent research findings n the effectiveness f sunscreens, mre detailed research n sunscreen use is needed. Are higher SPF sunscreens being used? Des sunscreen use extend the amunt f time ut in the sun? Hw d different sun-prtective behavirs interact (e.g., des seeking shade make wearing sunscreen r a hat unnecessary)? Further wrk is needed t increase cnsistency between at least a cre set f behavir change measures that can be used t cmpare and cntrast study results. Research Needs and Wrk in Prgress The field f behavir change fr skin cancer preventin has prgressed significantly, but imprtant areas fr further advancement exist. As utlined abve, these include design, measurement, better descriptin f interventins, develpment f a better understanding f hw envirnmental and plicy interventins wrk, and studies in multiethnic ppulatins. The use f new cmmunicatin technlgy and internatinal cllabratins can make significant cntributins in these areas. The team hpes that the availability f systematic reviews that identify bth prgress t date and the remaining gaps will help t reduce the gaps in available research. Specific Research Issues. Althugh mst f the evidence gaps described abve were general and culd explain why mst setting specific categries did nt prduce sufficient evidence t determine effectiveness, a few research issues were specific t the setting r target grup. Interventins fr Secndary Schls. Mre studies are needed t examine sun-prtective behavirs f adlescents and yung adults, and t determine what kind f apprach might wrk best in this ppulatin, especially given the lw baseline prevalence f sun-prtective behavirs. Interventins in Occupatinal Settings. Studies that target the mst cmmn utdr ccupatinal wrkers mail carriers, agricultural wrkers, landscapers, hrticulturists, fresters, cnstructin wrkers, telephne line wrkers, cmmercial fishery wrkers, land surveyrs and mappers, il field wrkers, amusement park attendants, and athletes are needed. Interventins in Healthcare Settings. Almst all studies in this categry examined the cunseling behavir f the prvider and nt the patient. Mre studies that examine the behaviral r health utcme f the end user the patient are needed. In this small subset f studies, the prvider was mst ften a physician r a physician-intraining, but studies examining the rle f the nnphysician prvider wuld help identify whether cunseling skills t change behavir might be better suited fr prviders with the time and skills, such as a nurse r a health educatr. Additinally, mre studies are needed t examine healthcare system studies riented directly t patients. Interventins fr Parents and Caregivers. Studies are needed t examine the effect f interventins n nnparental caregivers, as it is becming increasingly cmmn fr children t be cared fr by nnparental caregivers while bth parents are at wrk utside the hme. Preventing Skin Cancer: Educatin and Plicy Appraches in Outdr Recreatinal Settings (2002 Archived Review) 7

8 Archived Supprting Materials Interventins in Multicmpnent Cmmunity Settings. Appraches t better define the "active ingredients" (i.e., the mst imprtant cmpnents that cntribute t the success f these interventins) wuld be helpful, as wuld determining the applicability f these interventins t the U.S. ppulatin. Included Studies Detweiler JB, Bedell BT, Salvey P, Prnin E, Rthman AJ. Message framing and sunscreen use: gain-framed messages mtivate beach-gers. Health Psychl 1999;18: Dey P, Cllins S, Will S, Wdman CBJ. Randmised cntrlled trial assessing effectiveness f health educatin leaflets in reducing incidence f sunburn. BMJ 1995;311: Glanz K, Carbne E, Sng V. Frmative research fr develping targeted skin cancer preventin prgrams fr children in multiethnic Hawaii. Health Educ Res 1999;14: Glanz K, Chang L, Sng V, Silveri R, Muneka L. Skin cancer preventin fr children, parents, and caregivers: a field test f Hawaii's SunSmart prgram. J Am Acad Dermatl 1998;38: Glanz K, Geller AC, Shigaki D, Maddck JE, Isnec MR. A randmized trial f skin cancer preventin in aquatic settings: the Pl Cl prgram. Health Psychl Glanz K, Lew RA, Sng V, Murakami-Akatsuka L. Effects f skin cancer preventin in utdr recreatin settings: the Hawaii SunSmart Prgram. Eff Clin Pract 2000;3:1-5. Glanz K, Lew RA, Sng V, Murakami-Akatsuka L. Skin cancer preventin in utdr recreatin settings: effects f the Hawaii SunSmart Prgram. Eff Clin Pract 2000;3: Glanz K, Maddck JE, Lew RA, Murakami-Akatsuka L. A randmized trial f the Hawaii SunSmart prgram's impact n utdr recreatin staff. J Am Acad Dermatl 2001;44: Glanz K, Silveri R, Farmer A. Diary reveals sun prtective practices. Skin Cancer Fundatin J 1996;14:27-8. Keesling B, Friedman HS. Interventins t prevent skin cancer: experimental evaluatin f infrmatinal and fear appeals. Psychl Health 1995;10(6): Lmbard D, Neubauer TE, Canfield D, Winett RA. Behaviral cmmunity interventin t reduce the risk f skin cancer. J Appl Behav Anal 1991;24: Mayer JA, Lewis E.C, Eckhardt L et al. Prmting sun safety amng z visitrs. Prev Med 2001;33: Mayer JA, Slymen DJ, Eckhardt L et al. Reducing ultravilet radiatin expsure in children. Prev Med 1997;26: Segan C, Brland R, Hill D. Develpment and evaluatin f a brchure n sun prtectin and sun expsure fr turists. Health Educ J 1999;58: Weinstck MA, Rssi JS, Redding CA, Maddck JE, Cttrill SD. Sun prtectin behavirs and stages f change fr the primary preventin f skin cancers amng beachgers in sutheastern New England. Ann Behav Med 2000;22: Preventing Skin Cancer: Educatin and Plicy Appraches in Outdr Recreatinal Settings (2002 Archived Review) 8

9 Archived Supprting Materials Weinstck MA, Rssi JS, Redding CA, Maddck JE. Randmized trial f a multi-cmpnent stage-matched interventin t increase sun prtectin in at-risk beach bathers. Prev Med Disclaimer The findings and cnclusins n this page are thse f the Cmmunity Preventive Services Task Frce and d nt necessarily represent thse f CDC. Task Frce evidence-based recmmendatins are nt mandates fr cmpliance r spending. Instead, they prvide infrmatin and ptins fr decisin makers and stakehlders t cnsider when determining which prgrams, services, and plicies best meet the needs, preferences, available resurces, and cnstraints f their cnstituents. Dcument last updated May 14, 2014 Preventing Skin Cancer: Educatin and Plicy Appraches in Outdr Recreatinal Settings (2002 Archived Review) 9

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