INTRODUCTION
The number one diagnosed cancer in the US is skin
cancer. As the population becomes more aware of the
damaging effects of ultraviolet (UV) light, efforts have
been made to promote UV protection from the sun and artificial
sources such as indoor tanning devices.
The 2012 US Preventative Services Taskforce recommended
counseling fair-skinned individuals ages 10-24 about minimizing
their exposure to UV light.1 Childhood is a vital period to encourage
protection from the sun. Weinstock et al2 found a relative risk
of 2.2 for developing melanoma following 5 or more blistering
sunburns between the ages of 15 to 20 years of age compared
with none. Additionally, adult health behaviors are often established
in childhood also giving a good reason for implementing
such programs during this age. Continued programs are encouraged,
particularly during adolescent years when health behaviors
tend to dwindle.3 In the US, rates of melanoma have increased by
2.4% each year for white populations4 with the global incidence
of melanoma continuing to rise as well.5 This article will review
and assess several different UV protection programs based on
their structure and studied effectiveness (Table 1).
Australia has set the pace by utilizing a multi-media campaign
for sun protection since the 1980s, including marketing against
tanning and strict regulations of indoor tanning devices. A
2004 study in Hawaii found that although school personnel in
elementary schools were concerned about children’s sun exposure,
the school policies did not address the problem.6
Several hurdles exist when trying to educate the public about
skin cancer. One hurdle to public education is misinformation.
The public has become more aware of the importance of vitamin D levels; however, the media have exaggerated the necessity
of obtaining Vitamin D only from the sun. Further, the
public needs more education on the limitations of sunscreen,
such as the importance of reapplication and not to use sunscreen
as an excuse to remain in the sun for longer periods. Not
only is it a challenge to educate the public on the importance of
skin protection, but it is also a challenge to conquer the public’s
resistance to changing their behavior especially in light of other
media encouraging poor sun habits.7
This hurdle of combatting the public’s unwillingness to change
their behavior is evidenced by a study published in 2010 of 492
students at a mid-sized southern US university. They found that
although 69% of the students strongly believed that people
should take precautions against the sun, only 51% felt that they
should personally practice sun safety. Additionally, as long as
the media correlates being tan with being attractive, the public
will continue to desire a tanned appearance despite the risks.8
In an Italian study of 1,204 secondary students, ages ranging
from 15-19, it was found that their behavior was not aligned with
their knowledge. Only 13.5% claimed always to use sun protection
and 39.1% claimed never to use any protection.9 These data
demonstrate that there is a misalignment between knowledge
and behavior, which is not just an issue within the US.
Review of UV Protection Programs
Sun protection programs aim to improve the knowledge, attitude,
and behavior regarding UV protection. In general, short-duration
programs (single presentations) are more effective at increasing
knowledge and, to a slightly lesser degree, changing attitude,
but they are less effective at changing behavior. Multi-unit programs
(multiple presentations over time) are more effective at
