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Sun-Protective Behaviors: An Educational Intervention With Hospital Staff Aimed at Skin Cancer Prevention in Children

Amy F. Bruce
Theresa Cowan
CJON 2020, 24(1), 75-80 DOI: 10.1188/20.CJON.75-80

Background: Melanoma incidence and mortality rates are predicted to steadily increase. Sun protection is important during early development because of the potential for overexposure to ultraviolet radiation while outdoors.

Objectives: The purpose of this project was to design, implement, and evaluate an educational intervention provided to healthcare professionals (HCPs) with the intention of influencing the behaviors of child populations served.

Methods: The project evaluated HCPs’ baseline knowledge about sun-protective behaviors, their level of knowledge regarding sun-protective behaviors postintervention, their intent to change behavior, and the feasibility of implementing behavior change within the organization.

Findings: Pre- to post-test knowledge significantly increased. All participants reported that they would encourage children’s sunscreen usage, and 98% reported that they would support the behavior change; however, 35% indicated likeliness that they would personally use sunscreen or sun-protection methods.

Childhood is an important time for positive behaviors to be introduced. Healthcare professionals working directly with children and adolescents are positioned to affect behavior change. Melanoma is responsible for more than 9,000 new skin cancer deaths every year, with incidence and mortality rates predicted to steadily increase in the United States through 2030 (Guy et al., 2015). The annual cost of treating skin cancer is about $8.1 billion in the United States; $3.3 billion of that estimation is attributed to melanoma (Rogers, Weinstock, Feldman, & Coldiron, 2015). Data related to pediatric diagnoses of melanoma are particularly concerning. According to the the Children’s Hospital of Philadelphia (2019), melanoma is responsible for as much as 3% of all pediatric cancers. Ferrari et al. (2005) reported that childhood melanoma is often misdiagnosed as pigmented lesions; therefore, there is a delay in treatment as much as 40% of the time.

The most common cause of melanoma is overexposure to ultraviolet (UV) radiation, and the U.S. Department of Health and Human Services (2014) declared UV radiation as a human carcinogen. Although much of the exposure previously had come from natural sunlight, there was a significant increase of melanoma reported because of indoor tanning exposure (U.S. Department of Health and Human Services, 2014). Studies have shown that more than 419,000 cases of skin cancer annually in the United States were linked to indoor tanning, with 6,200 reported as melanomas (Wehner et al., 2014). Sun damage is cumulative, and 23% of lifetime exposure occurs by age 18 years (Godar, Urbach, Gasparro, & Van der Leun, 2003).

The American Society for Dermatologic Surgery ([ASDS], 2013) issued a white paper position statement on sunscreen use in schools. The position statement encouraged statewide policies that would allow students to apply, carry, and store sunscreen for personal use in school, as well as supported educational initiatives designed to encourage and promote safe, smart sunscreen use among all students. According to the ASDS (2013), major barriers to sunscreen use in schools were the lack of physician support allowing students to apply, carry, and store sunscreen for personal use, and potential policies prohibiting sunscreen from being given to students by school district officials (otherwise opposed by a parent or guardian). According to the Skin Cancer Foundation (2019c), one blistering sunburn during childhood or adolescence more than doubles the chance of being diagnosed with melanoma later in life.

In 2014, the U.S. Department of Health and Human Services issued the Surgeon General’s Call to Action to Prevent Skin Cancer. This report solidified skin cancer as a major public health problem, emphasizing the need to decrease incidence, mortality, and the economic burden. The report further addressed ways to reduce the risk of skin cancer through communities and schools, outdoor work settings, and with state and federal policies, legislation, and regulations. In essence, the call to action outlined the following goals:

•  Have more sun protection opportunities outdoors.

•  Provide information individuals need to make informed, healthy choices regarding UV exposure.

•  Make policies that advance the national goal to prevent skin cancer.

•  Reduce damage from indoor tanning.

•  Strengthen research, surveillance, monitoring, and evaluation around prevention of skin cancer.

Literature Review

Lee, Rivers, and Gallagher (2005) conducted a randomized controlled trial evaluating the impact of sunscreen application on noncancerous nevus development among Caucasian school children. The study was followed for three years after implementation, and results showed that sunscreen use decreased the development of nevi in children, potentially reducing the risk of cutaneous malignant melanoma in later adult life.

Gritz et al. (2007) stressed that interventions aimed at increasing sun protection of younger children should focus on the children’s care providers, partly because of their dependence on them for sun-protective measures. Findings indicated that the staff in the intervention group were more likely to apply sunscreen to their students, carry sunscreen on field trips, and perform reapplication at the appropriate times of sun exposure.

In 2007, Naldi et al. conducted a cluster randomized trial examining an educational intervention to reduce sunburn rates and improve sun-protective measures in second- and third-grade children in Italian elementary schools. Unlike the Gritz et al. (2007) study, there was no significant influence of the proposed educational program one year post–follow-up. The authors proposed that the inability to achieve the desired outcome of decreasing sunburn rates and improving sun-protective measures could be because of the high level of protection currently present in the population. Seventy-one percent reported sunscreen use regularly; therefore, the authors argued against proposing generic educational interventions in schools involving written material distribution and short curriculum application to improve sun-protective behaviors.

Morwitz, Johnson, and Schmittlein (1993) performed original research on the mere measurement hypothesis. This indicates that merely measuring one’s intent to engage in a behavior will increase the act of that behavior. In summary, more products were proportionately acquired by households that were asked about intent to purchase compared to households not asked about intent to purchase. This project lends evidence to the possibility that individuals asked about intent to engage in sun-protective behaviors could be cognitively inclined to do so just by mere suggestion.

Objectives

The purpose of this project was to implement a formal educational intervention using a predetermined curriculum from the Skin Cancer Foundation (2019a) to increase hospital staff knowledge regarding sun-protective measures to influence the behaviors of children. By identifying the level of knowledge regarding these behaviors, the healthcare staff would be able to implement sun-protective measures for the children on-site at the participating facility. The particular sun-protective curriculum was chosen because of its ease of application and understanding for the project participants.

The project focused on using a predeveloped sun safety awareness tool to educate the healthcare professionals and staff working with institutionalized children about the risks of skin cancer related to sun overexposure. The measurable objectives were as follows:

•  Baseline level of knowledge regarding sun-protective behaviors

•  Level of knowledge regarding sun-protective behaviors post–formal educational intervention

•  Intent to change personal behavior

•  Demographic information revealing the characteristics of the participant population with inferences based on anonymous data

•  Likelihood and feasibility of implementing the education derived from the intervention into daily personal practice within the organization via the Personal Practice Change (PPC) survey

Methods

Staff’s level of intended behavior change was measured using a questionnaire developed by Légaré et al. (2017), called Continuing Professional Development–Reaction (CPD-R), in an attempt to measure desired behavior change for quality improvement (Cronbach alpha = 0.77–0.85) (see Table 1). A modified version of this tool was provided for the purpose of capturing participants’ intent to change behavior postintervention. Finally, a short three-question survey was given postintervention to identify the feasibility of the intent to change personal behavior as applied to daily practice.

The intervention included one 40- to 50-minute session delivered face to face using a multimedia approach. The staff members were asked to provide standard demographic information for reporting purposes only, and they were provided with a questionnaire regarding perception of implementation within daily practice.

Data analysis was completed using JASP, version 0.9.2. Descriptive statistics were used in discussing similarities and differences among the participants in the project. A pre-/post-test design was used with the Sun Smart U curriculum (Skin Cancer Foundation, 2019b) to reveal baseline data before the educational intervention, as well as measurements after the educational teaching. A convenience sample with 40 participants was given a packet of coded materials (#1–#40). The intervention was aligned with the Centers for Disease Control and Prevention (2019) National Health Education Standards for grades 6–12; therefore, ease of comprehending the material was taken into consideration (Skin Cancer Foundation, 2019b). The CPD-R tool was used to measure the level of intent to change behavior. Institutional review board approval was received prior to the implementation of this project.

Results

Results illustrated which of the five constructs from the CPD-R (intention, social influence, beliefs about capabilities, moral norm, and beliefs about consequences) had the highest impact on the participants’ ability to change their behaviors.

The 40 participants’ age ranges were categorized into five groupings: 18–25 years (n = 5), 26–35 years (n = 11), 36–45 years (n = 7), 46–55 years (n = 9), and 56 years or older (n = 8). The majority (n = 27) had completed some level of college education, eight had some college- or vocational-level education, and five had a high school diploma. Sixteen participants claimed to use both sunscreen and protective clothing, 20 claimed to use either sunscreen or protective clothing, and 16 relied on sunscreen alone. Three participants indicated no use of sun protection, and one participant chose not to answer the question. On average, the time of sun exposure per day for the sample population was one hour and 15 minutes. As indicated in Table 2, participants who completed higher educational degrees (i.e., associate, bachelor’s, or master’s) significantly engaged in more sunscreen or both sunscreen and protective clothing (chi-square = 35.5, df = 20, p = 0.018) compared to participants without higher education (i.e., high school or vocational/technical school, or some college).

Pre- and Post-Test Scores

Regarding the participants’ level of knowledge about sun-protective behaviors, results revealed 93.08% pretest averages compared to 97.69% post-test averages. This indicates a 5.897% change in an upward direction. Some participants scored as low as 22% less on the post-test compared to the same pretest; however, some participants scored as much as 43% higher on the post-test compared to the same pretest. Conclusively, it can be deduced that the post-test groups scored as low as 1.3% and as high as 7.8% more than the pretest groups, indicating a statistically significant (t = 2.894, p = 0.006) increase in test scores after the skin cancer prevention educational intervention (mean = 4.615, SD = 1.595).

The most positive behavioral measurement construct likely to affect behavior change was beliefs about consequences, with a mean score of 6.4. The least influential were the social influence and moral norm constructs. The results for the social influence construct showed a mean of 4.4 (standard error of the mean [SEM] = 0.19, SD = 1.2). The moral norm construct showed a mean of 4.8 (SEM = 0.25, SD = 1.6).

The PPC survey focused on the likelihood and feasibility of implementing the education derived from the intervention into daily personal practice within the organization. About 35% (n = 14) indicated they would likely use sun protection and/or sunscreen while outdoors at the facility. All 40 participants indicated a likelihood to encourage children to use sun protection during outdoor time, and the majority felt the organization would completely support the practice change (98%, n = 39).

Discussion

This project confirmed the findings from a large-scale skin cancer screening initiative by Ferris et al. (2017), which revealed skin cancer screening as a feasible initiative resulting in higher rates of melanoma detection among screened versus unscreened patients. In the evaluation by Ferris et al. (2017), 333,735 patients were seen and only 53,195 received full-body skin evaluation. Of these 53,195 patients, there were 50 melanomas diagnosed, compared to 104 diagnosed from the unscreened 280,539 patients (Ferris et al., 2017). The current project’s findings support the need for healthcare professionals to understand the importance of skin cancer screenings and the need for further education supporting screening for all individuals. This project also confirms study results from Robinson et al. (2004), which suggested that healthcare professionals’ counseling could guide patients’ preventive practices, detection, self-efficacy, and knowledge related to skin cancer. In another study, Anderson, Matsumoto, Saul, Secrest, and Ferris (2018) compared the diagnostic accuracy for skin cancer using physician assistants and board-certified dermatologists. Patients screened by a physician assistant were significantly less likely to be diagnosed with a melanoma on-site when compared to a dermatologist (0.2% versus 0.4% of visits, p = 0.04) (Anderson et al., 2018). In the context of these previous studies, this project’s findings confirm that healthcare professionals lack specific education about and training on skin cancer screening and that proper education about skin cancer prevention, including counseling, could help shape patients’ preventive practices.

Based on sun-protective counseling guidelines, this project’s findings support the U.S. Preventive Services Task Force ([USPSTF], 2018) recommendations. In 2018, the USPSTF advised behavioral counseling concerning the reduction of exposure to UV radiation to reduce the risk of skin cancer in children, adolescents, and young adults aged 10–24 years. For adults aged 24 years or older with fair skin, the USPSTF selectively recommended providing behavioral counseling (USPSTF, 2018). The USPSTF (2018) also recommended that a healthcare professional speak with young individuals concerning the dangers of UV rays and how to prevent skin cancer during office visits. In addition, the healthcare professional may encourage the children to take simple actions to protect themselves from the damaging effects of UV rays, such as using a broad-spectrum sunscreen (protecting against both UVA and UVB rays) with a sun protection factor of 15 or greater; covering the skin with a wide-brimmed hat, sunglasses, long-sleeved shirt, and a long pair of pants or longer skirt; avoiding direct sunlight during peak hours from 10 am to 3 pm when the UV rays are strongest; and avoiding indoor tanning booths or sun lamps (USPSTF, 2018).

Limitations

This project was designed to be implemented in two sessions of 40- to 50-minute intervals. The participants were employed at a medical facility and provided direct and indirect care for the patient population; therefore, the pretest score of about 93% could have been a ceiling effect. Although the results of this project were statistically significant, this does not indicate clinical significance. A future recommendation is that larger sample sizes be used to support the validity, reliability, and dissemination of results; therefore, a follow-up CPD-R questionnaire would be helpful in assessing the actual intended sun-protective behavior change, as recommended by Légaré et al. (2017).

Implications for Practice

Similarities were discovered that supported the education of healthcare professionals about and early childhood implementation of sun-protective measures. When considering skin cancer preventive programs, childcare centers or other educational institutions should consider essential components for sustainability, such as including parents and caregivers, as well as tailored interventions for healthcare professionals, to yield positive outcomes. Lack of parent or caregiver supervision regarding sun-protective measures was identified as a variation factor, and lack of a standardized protocol for attaining sun awareness levels in healthcare professionals, or the general public, was identified. Because the methods of evaluating sunscreen’s effectiveness as a means of childhood malignant melanoma development were varied, researchers suggested that further epidemiologic studies be conducted with a standardized protocol of measurement (de Maleissye et al., 2013).

In examining possible application of this project in other settings, the level of education and ability to follow up on intent to change behavior should be considered. For example, those without a healthcare background or with lower levels of education should be targeted. This may assist in increasing the impact of preventive care with lower education groups through reaching adults and children less likely to have formal education. Another application would be implementation of the Sun Smart U curriculum in the public school system. This would bring education to the classroom while providing teachers and parents with the knowledge to partake in sun protection and skin cancer prevention methods. Legislation would need to be considered that would allow sunscreen dispensers to be placed in the school systems. In addition, this would involve educating local and state representatives about the importance of early detection and prevention of skin cancer.

Practitioners with a specification in oncology care should expose their patient populations to the usefulness of sun-protective measures, as well as help educate them about the effectiveness of formalized education for skin cancer prevention. Healthcare professionals would benefit from specific sun-protective education to improve personal health and patient care practices when engaging with children, adolescents, and young adults.

Conclusion

Skin cancer prevention is a priority, particularly with children. This project’s findings confirmed that healthcare professionals who are educated about skin cancer prevention can provide education that influences childhood behaviors in skin cancer prevention. These findings also suggest that implementing the Sun Smart U curriculum would increase participants’ sun-protective behaviors.

About the Author(s)

Amy F. Bruce, DNP, MSN, RN, NE-BC, is the director of nursing in the Capito Department of Nursing at the University of Charleston in West Virginia; and Theresa Cowan, DHED, MSN, RN, ACNS-BC, is the department chairperson in the School of Nursing at West Virginia University, Charleston Campus. The authors take full responsibility for this work and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Bruce can be reached at amybruce@ucwv.edu, with copy to CJONEditor@ons.org. (Submitted June 2019. Accepted September 8, 2019.)

 

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