Skin cancer is the most common malignancy in the United States, with approximately 1 million cases being diagnosed in 1997. Of these cases, more than 40,000 will be classified as malignant melanoma, the most serious and aggressive form of skin cancer. The worldwide incidence of melanoma is increasing more rapidly than any other form of cancer, and has shown an increase of about 4% per year in the United States.[1,2]
Exposure to ultraviolet radiation is widely recognized as the major risk factor for skin cancer, with an increased risk being linked to severe sunburns in childhood or adolescence.[3-5]
As skin cancer incidence rates have risen so has the need for prevention efforts. School-based interventions focusing on sun awareness and sun protection strategies are being developed and evaluated in several states.
These interventions have been designed around three main educational models: Teacher education, peer education, and, more recently, computer-based education, which uses tools such as interactive CD-ROMs or the Internet.
While the best ages for interventions have yet to be determined, it is generally agreed that prevention efforts should begin early in life when behaviors are more amenable to change and skin exposure is particularly important.
More than 80% of lifetime sun exposure occurs before the age of 18 years, and excess sun exposure and sunburns early in life increase the risk of skin cancer. Target childhood populations have generally been grade school students or junior high school students, with curricula being adjusted for age appropriateness.
Traditional teacher-led classroom interventions have been successful in increasing knowledge regarding sun safety but have not been shown to significantly affect behaviors. In one recent report from Arizona, a state epidemiologic study identified skin cancer as a rapidly worsening public health problem.
In the early 1980s, the Arizona Cancer Center developed "Sunshine and Skin Cancer," an educational program with a curriculum designed to complement existing skin cancer prevention information from national organizations, such as the American Academy of Dermatology, the American Cancer Society, and the National Cancer Institute.
The program has evolved to become "Sunny Days, Healthy Ways" and is composed of five 1-hour units discussing the suns physical properties, the composition of human skin, historical attitudes toward tanning, skin cancer, and skin cancer prevention.
The Sunny Days, Healthy Ways program has been evaluated for students in grades 4 to 6 in a study that compared changes in knowledge, attitudes, and behaviors for three schools.
One school received a one-unit condensed version of the standard five-unit curriculum; a second school had the curriculum presented in a sun safety fair; and a third school received no intervention. Surveys measuring knowledge, attitude, and behavior regarding the sun, skin cancer, and skin cancer prevention were completed 1 week prior to the interventions. Post-intervention surveys were conducted 1 week and 3 months later.
Both intervention groups showed an increased awareness of and knowledge of skin cancer, compared with the controls, with the greatest effect seen in fourth grade students. The classroom-based curriculum had a slightly greater impact than the sun safety fair.
Despite increased knowledge, none of the groups indicated an intention to change their sun safety behavior, and few changes in behavior were reported in the final surveys.
Another teacher-led intervention entitled "Sunshine and Skin Health" has also been developed and evaluated in Arizona. Sunshine and Skin Health is similar in content and structure to the Sunny Days, Health Ways program. The five-unit intervention includes take-home materials designed to increase parental involvement. It was evaluated for students in grades 4 to 6, with one unit being taught each week for 5 weeks.
Compared with the control group, the students receiving the intervention showed significant increases in overall knowledge as well as attitudinal improvements throughout the 8-week follow-up; however, there was no significant impact on behavior.
In contrast to teacher-led education, peer education has been shown to be an effective means of promoting both positive health beliefs and attitudes, and in a study from Wisconsin, this type of program was shown to foster a desire for positive behavior change.
In a Texas peer education program, students in the third through fifth grades were helped to develop interventions that could be used in educating first graders about sun awareness. Interventions ranged from skits to use of coloring books and were developed around American Cancer Society guidelines.
Sun protection knowledge increased significantly for both groups of students (the older children who developed the intervention program and the younger children who received it) when measured 1 week after the intervention; however, there was no long-term follow-up and no assessment of behavior change.
Another peer education intervention using the curriculum developed by the American Cancer Society and the American Academy of Dermatology was evaluated in Wisconsin.
Senior high school students were taught the curriculum at a 1-day seminar, and they, in turn, taught the curriculum to third-grade students. A survey instrument was administered before and after the intervention, with a follow-up being conducted 6 months later.
The groups receiving the intervention showed a significant increase in knowledge and improved attitudes about sun protection. There was also an increase in the desire for behavior change, an important finding considering the lack of significant behavior changes in teacher-led skin cancer prevention efforts.
The rapid development of technology has facilitated an increase in the use of computers for health education. Interactive CD-ROMs and the Internet have the ability to communicate information in stimuli-rich, individually tailored environments, have been shown to enhance learning of health information, and can potentially lead to improvements in knowledge, attitudes, and behaviors.[11,12]
A CD-ROM has recently been developed that targets skin cancer prevention in schoolchildren. The content of the CD-ROM was developed according to national guidelines established at the first National Skin Cancer Prevention Education Program in 1995, sponsored by the American Acacdemy of Dermatology and the Centers for Disease Control and Prevention.
The CD-ROM script was written by professional screenwriters who specialize in writing childrens shows, and children were involved in all stages of the development process to ensure that the CD-ROM was effectively targeting its intended audience of third and fourth graders.
To assess the program, third and fourth grade students completed surveys measuring knowledge, attitudes, and behaviors before and after the intervention, as well as in a 6-month follow-up study. The CD-ROM intervention group was compared with a group receiving a traditional teacher-led intervention and a control group receiving no intervention.
There was a significant increase in knowledge for the CD-ROM group, when compared with either the teacher-led or control group, and significant improvements in attitude were also reported. Improvements in knowledge and attitude remained fairly stable over 6 months, and there was a positive but not significant change in scores for behavior.
Future of Skin Cancer Interventions
Curricula for skin cancer interventions have been developed at the national level; however, the most effective way to communicate information and impact the target audience has yet to be determined.
The advent of new technology and the development of interactive educational programs has brought computers into the forefront of education, a trend being fostered at the national level with the establishment of programs such as national NetDay, which has the goal of connecting every classroom and library in the United States to the Internet by the year 2000.
The interactive nature of computer education gives it an advantage over traditional teacher-led education and even peer education by encouraging children to take an active role in the learning process. This may be especially important for programs like skin cancer interventions, which may include a great deal of concentrated material that must be absorbed at a faster rate than usual.
While all skin cancer interventions have had some degree of success in improving knowledge and sometimes even attitudes regarding sun exposure, if the interventions are going to accomplish their primary task of prevention, then behaviors need to change as well.
Health education programs achieving the greatest success in effecting behavior change have combined comprehensive curriculum components with environmental change and family participation, a model that could be applied to all types of skin cancer interventions to increase their efficacy in the future.