Review Article

Effectiveness of Sun Protection Interventions Delivered to Adolescents in a Secondary School Setting: A Systematic Review

Table 2

Studies identified in the systematic review and reviewed+.

First author
Data collection period
Study design
Global rating (EPHPP)Target population
Sample size
Demographic characteristics
Theoretical framework
Intervention
Control
Follow-upResult measure
Statistical improvement (in at least one intervention and one follow-up time)

Baghianimoghadam [13]
2009
Cluster RCT
ModerateTarget population: High school students—Yazd, Iran
Sample size:
Schools—4
Students—360
Demographic characteristics:
Age (years): mean 16.04 (0.98)
Sex: female—100%
Ethnicity/skin colour: not provided
Theoretical framework: Protection motivation theory
Intervention—individually directed
Format: Lecture, group teaching and performance
Content: Education (not further described)
Duration: 3 × 1 hour sessions
Delivery: Researchers
Control
Wait listed intervention
2 monthsBehaviour score (self-report)
Individual sun protection measures (self-report)
Sunscreen, sunglasses, gloves, hat, clothes

Brinkler [14]
2018
Cluster RCT
ModerateTarget population: High school students—Brazil
Sample size:
School—8 (52 classes)
Students—1,573
Demographic characteristics:
Age (years): mean 15.9 (1.3)
Sex: female—51.6%, male—48.4%
Skin type: 7.4% I or II, 34.9% III, 50.2% IV, 7.6% V
Theoretical framework: None mentioned
Intervention “Sunface” — individually directed
Format: Application (app) and education in classroom setting
Content: Adolescents’ selfies were altered by an app to show UVR effects on their future faces (taking into account skin type) and were shown in front of their class, accompanied by information about UVR protection. The app encompasses the effects of UVR on photoaging of the skin in general and the development of skin cancer.
Duration: 45 minutes
Delivery: Medical students
Control
No intervention received
6 monthsIndividual behaviour (self-report)
Sunscreen, tanning

Dobbinson [15]
2004–2006
Cluster RCT
ModerateTarget population: Secondary school students—Melbourne, Australia
Sample size:
Schools—51
Demographic characteristics:
Not collected
Theoretical framework: None mentioned
Intervention—Environmental directed
Format: Environmental
Content: Two full sun areas in each school (1 intervention (primary) and 1 alternate site) had building shade sail structures installed (at intervention site only) for students to use during passive activities such as eating lunch (mean cost A$11,500 of shade sail and installation costs varied, maximum $22,000)
Duration: NA
Delivery: Environmental
Control
No intervention received
Continuous 14 weeksIndividual Behaviour (direct observation)
Shade seeking

Jeihooni [16]
2016–2017
Cluster RCT
ModerateTarget population: High school students—Fasa city, Iran
Sample size:
Schools—4
Students—300
Demographic characteristics:
Age (years):
IG: 16.05 (1.76), CG: 16.20 (1.71)
Sex: 100% male
Ethnicity/skin colour: not provided
Theoretical framework: PRECEDE model
Intervention
Format: Educational session including group discussion, questions and answers, practical presentation, use of videos, PowerPoint presentation, instruction booklet.
Content: Education—skin health, skin cancer and risks, sunlight, sun protection. n.b. Telephone group also organised for students parents
Duration: 6 training sessions of 45–50 minutes duration held on weekly basis
Delivery: Research team
Control
No intervention received
4 monthsBehaviour score (self-report)

Rahmatiasl [17]
Year not provided
Pre/post (control group)
ModerateTarget population: 1st-grade high school students—Ahwaz, Iran
Sample size:
Schools—4
Students—215
Demographic characteristics:
Age (years): 1st grade (13 years)
Sex: 47.9%—females, 52.1%—male

Ethnicity/skin colour: not provided
Theoretical framework: Protection motivation theory
Intervention
Format: Lecture and question and answer session. Pamphlet also distributed.
Content: UVR, UVR and health effects of exposure to UVR, the factors affecting the exposure to UV light, the importance of sun protection in childhood and adolescence, how to protect from the sunlight, benefits of using protective devices against the sunlight and correct ways to use sunscreen.
Duration: Not specified
Delivery: Not specified
Control
No intervention received
4 monthsBehaviour score (self-report)

Aarestrup [18]
2010–2011
Cluster RCT
WeakTarget population: 14–18-year-old students—Denmark
Sample size:
Schools—33
Students—3,635
Demographic characteristics:
Age (years): 14–8%, 15–42%, 16–47%, 17–3%
Sex: female—51%
Ethnicity/skin colour: not provided
Theoretical framework: None mentioned
Intervention—individually directed
Format: E-magazine, short films, advertisements, campaign materials, paintings, social media, poetry, fiction & literature
Content: Health risks associated with sunbed use as well as appearance damaging effects
Duration: Mean 5.6 lessons per class
Delivery: Classroom teacher—teachers guide provided
Control
No intervention received
6 monthsIndividual behaviour (self-report)
Sunbed use

Buendia-Eisman [25]
2009
Cluster RCT
WeakTarget population: Students 12–16 years—Andalusia, Spain
Sample size:
Schools—12
Students—1,290
Demographic characteristics:
Age (years): 12–16, mean 13.75
Sex: 49.8% female, 50.2% male
Skin type: 11.5% I or II, 76.8% III or IV, 11.8% V or VI
Theoretical framework: None mentioned
Intervention “Healthy sun Habits”—individually directed
Format: Online web page
Content: Webpage structured
The sun—sun & UVR characteristics, dangers of sunburn
sun without danger—emphasised factors associated with sunburn and appropriate sun protection behaviours
Key sun protection messages
Games and website links
Duration: Pupils used the website for at least 1 hour at school and then had it available for use through the summer.
Delivery: Entirely on the Internet with teachers only providing technical support for using web page.
Control
No intervention received
3 monthsPhysiological measures (self-report)
Sunburn, sunburn with blisters
Individual behaviour (self-report) -sunbathing, sun protection measures, sun protection cloudy day
Sun cream

Lai [20]
2012–2014
Cluster RCT
WeakTarget population: High school students aged 12–18 years in Beijing, China
Sample size:
Schools—3
Students—638
Demographic characteristics:
Age (years): mean 14.4 (2.5)
Sex: 51%—female, 49%—male
Ethnicity/skin colour: not provided
Theoretical framework: None specified
Intervention
IG1
Format: Presentations, photograph, and pamphlets
Content:
(i) Educationnature and dangers of UVR, sun protection methods, correct use of sunscreen
(ii) A photograph was taken of students to assess skin type and students were taught how to protect themselves according to skin type and UV index
(iii) Pamphlets contained highlights of presentation
Duration: 2 × 45 minutes per year (over 3 years)
Delivery: Received 2X during year 1 and year 2
IG2
Content: Educational pamphlet (as IG1)
Format: Pamphlet
Duration: Received 2X during year 1
Delivery: NA
Control
No intervention received
2 yearsPhysiological outcomes (self-reported)
Sunburn, suntan
Individual behaviour (self-report) -sunscreen, protective clothes, hats, sun umbrella, sunglasses, avoiding sun exposure, seeking shade

Lowe [12]
1993–1995
Pair RCT
WeakTarget population: Grade 8 high school students Queensland, Australia
Sample population:
Schools—26
Students—3400
Demographic characteristics:
Age (years): grade 8 (13 years)
Sex: not provided
Ethnicity/skin colour: not provided

3 yearsBehaviour score (self-report)∗

Sumen [21]
2013
Nonrandomised trial (with control group)
WeakTarget population: maritime high school students—Antalya, Turkey
Sample population:
Schools—2
Students—567
Demographic characteristics:
Age (years): 14–2.6%, 15–25.7%, 16–31.7%, 17–25.4%, 18–14.6%
Sex: 10.1% female, 89.9% male
Ethnicity/skin colour: not provided
Theoretical framework: None specified
Intervention
Format: Didactic (classroom), brochures (take-home), and posters (environment)
Content: Training regarding skin cancer, sun protection steps, and harmful effects of the sun followed by “Dear 16-year old me” video which emphasises the importance of sun protection in the adolescent period. Educational material also provided to students at the end of training session. Four weeks following training posters were hung within the school and classrooms as a reminder.
Duration: 35–45 minutes
Delivery: Not specified
Control
Wait listed intervention
3 monthsIndividual behaviour (self-report)
Sun protection cream∗, sun protection cream – beach∗, sun protection cream – long time outdoors∗, sun protection factor above 20∗, remain in shade∗, stay indoors∗, sunglasses∗, clothing – shoulders, sun protective hats

Tuong [22]
2012
RCT
WeakTarget population: 11 grade students—California, USA
Sample population:
School—1
Students—50
Demographic characteristics:
Age (years):
∗IG: mean age 17.1 (0.88) CG: mean age 17.2 (0.44)
Sex: IG: 76% female, 24% male
CG: 84% female, 16% male
Skin type: IG: 12% White, 88% non-White
CG: 4% White, 96% non-White
Theoretical framework: Health Belief Model
Intervention
Format: Integrated into the classroom health education, viewed video assigned as a group
Content: Appearance-based video on UV induced premature ageing
Duration: video 5-minute duration
Delivery: Assume classroom teacher
Control
Health-based video emphasising UV exposure and skin cancer risk
6 weeksIndividual behaviour (self-report)
Sunscreen∗, shade, hat, long sleeved shirt,

White [23]
Date not provided
Cluster RCT
WeakSampling frame: High school students—Queensland, Australia
Sample population:
Schools —9
Students—382 students (analysed 213)
Demographic characteristics:
Age (years): mean 13.73
Sex: 61.1% female, 38.9% male
Skin type: 59% very fair or fair
Theoretical framework: Theory of Planned Behaviour
Intervention
Format: group-based discussions, role playing, and goal setting.
Content: Session 1: sun protection related attitudes and beliefs, long/short-term effects of sun exposure and advantages and disadvantages of sun protection
Session 2: Foster perceptions of normative beliefs on sun protection.
Session 3: Aimed to increased perceptions of self-efficacy over using sun protection measures
Duration: 1 hour per week for 3 weeks
Delivery: Facilitated by Cancer Council Queensland staff
Control
Wait-listed intervention
4 week follow-upIndividual behaviour (self-report)
Sunsafe behaviour weekend∗, Sunsafe behaviour—weekday

Wu [24]
2017
Cluster (school) non randomised trial (with control group)
WeakTarget population: High school students grades 9-12—Utah, USA
Sample population:
Schools—11
Students—1,573 students
Demographic characteristics:
Age (years): 9th grade—26.2%, 10th grade 52.3%, 11th grade—12.1%, 12th grade—9.3%
Sex: 49.5% female, 50% male, 0.5% other
Race: 62.5% non-Hispanic White, 25.8% Hispanic, 2.8% African American, 2.0% American Indian, 3.2% Asian American, 3.7% other
Theoretical framework: Extended parallel process model—communicate health risk and prevention information by targeted individual’s perceived threat and perceived efficacy.
Intervention
IG1
Format: Health or science class, PowerPoint and interactive activity (3-4 students per group), classroom discussion
Content: Education (see CG) plus a sunscreen activity which illustrates the UVR blocking properties of sunscreen of differing SPF levels
Duration: 1 classroom period
Delivery: Research assistants
IG2
Format: Health/science class
Content: Education (see CG) and receipt of a printed personalised photograph showing current skin damage cause of UVR exposure. Class discussion on how these photos related to UVR dam
GE and skin cancer risk.
Duration: 1 classroom period
Delivery: Research assistants
IG3
Format: Health/science class, PowerPoint and interactive activity (individual)
Content: Education (see CG) and behavioural change worksheet aimed to improve self-efficacy using sun protection goal setting and planning. Students first selected a behaviour they were willing to commit to implementing in the next month
Duration: 1 classroom period
Delivery: Research assistants
Control
Format: Health/science class— PowerPoint and interactive activity (individual), classroom discussion
Content: Skin cancer education—incidence, risk factors, causes, strategies to prevent and screen, common misconceptions, and prevention strategies
Duration: 1 classroom period
Delivery: Research Assistants
1 monthIndividual behaviour (self-report)
Sunscreen∗, long-sleeved shirt∗, long pants or skirt∗, wide brimmed hat∗, shade or umbrella∗, avoid peak hours∗, sunglasses, indoor tanning∗, outdoor tanning∗
Physiological behaviour (self-report)
Sunburn∗

+More detailed information and full results are provided in the Supplementary File 2.