State of the science on prevention and screening to reduce melanoma incidence and mortality: The time is now.

Answer questions and earn CME/CNE Although overall cancer incidence rates are decreasing, melanoma incidence rates continue to increase about 3% annually. Melanoma is a significant public health problem that exacts a substantial financial burden. Years of potential life lost from melanoma deaths contribute to the social, economic, and human toll of this disease. However, most cases are potentially preventable. Research has clearly established that exposure to ultraviolet radiation increases melanoma risk. Unprecedented antitumor activity and evolving survival benefit from novel targeted therapies and immunotherapies are now available for patients with unresectable and/or metastatic melanoma. Still, prevention (minimizing sun exposure that may result in tanned or sunburned skin and avoiding indoor tanning) and early detection (identifying lesions before they become invasive or at an earlier stage) have significant potential to reduce melanoma incidence and melanoma-associated deaths. This article reviews the state of the science on prevention and early detection of melanoma and current areas of scientific uncertainty and ongoing debate. The US Surgeon General's Call to Action to Prevent Skin Cancer and US Preventive Services Task Force reviews on skin cancer have propelled a national discussion on melanoma prevention and screening that makes this an extraordinary and exciting time for diverse disciplines in multiple sectors-health care, government, education, business, advocacy, and community-to coordinate efforts and leverage existing knowledge to make major strides in reducing the public health burden of melanoma in the United States. CA Cancer J Clin 2016;66:460-480. © 2016 American Cancer Society.

Measures of parents' self-efficacy and perceived barriers to children's sun protection: construct validity and reliability in melanoma survivors.

Valid and reliable psychosocial measures for parents are lacking in the children's sun protection literature. We examined the construct validity and reliability of measures of parents' self-efficacy and perceived barriers specific to four sun protection behaviors in children: sunscreen, clothing, shade and limiting time outdoors. Melanoma survivors (N = 205) with children aged 12 years and younger completed an interview. Confirmatory factor analyses supported a four-factor structure of self-efficacy in which each factor was specific to one of the sun protection behaviors. This structure, consistent with Bandura's conceptualization, suggests using behavior-specific scores. A bifactor model best fit the perceived barriers data. Each item loaded on both a general barriers factor and one of four behavior-specific factors. Based on the magnitude of general factor loadings relative to behavior-specific factor loadings, use of subscale scores or a total score is recommended. Correlations between self-efficacy measures (0.30-0.46) and between perceived barriers measures (0.22-0.42) suggested convergent validity. Correlations between self-efficacy and perceived barriers were strongest within behavior (-0.34 to -0.63), suggesting discriminant validity. Almost all measures were most strongly associated with corresponding behaviors, supporting construct validity. Reliabilities ranged from 0.72 to 0.90. Measures are valid and reliable for use in children's sun protection studies.

Tanning Addiction in Adolescents: Directions for Measurement and Intervention Development.

Little is known about tanning addiction in adolescents. Miller et al. found that 7.0% of 11th grade students met addiction criteria. After adjusting for all other comorbidities, the odds of addiction were two times greater for students who reported problem use of marijuana or obsessive-compulsive disorder symptoms. The likelihood of addiction increased with problem substance use and psychological symptoms.

Effects of a preschool staff intervention on children's sun protection: outcomes of sun protection is fun!

The preschool is an important yet understudied setting for sun-protection interventions. This study evaluates the effects of Sun Protection is Fun! (SPF) on preschool staff behavioral and psychosocial outcomes related to protecting children from sun exposure. Twenty preschools participated in a 2-year, group-randomized trial to evaluate SPF, a behavioral intervention grounded in social cognitive theory and designed to be more extensive than previous preschool sun-protection interventions. The staff intervention included training, a video, newsletters, a curriculum, and sunscreen. Cross-sectional samples of staff completed surveys at baseline (N= 245), a 12 month intervention assessment (N = 192), and a 24-month intervention assessment (N = 225). At the 12-month and 24-month assessments, significant behavioral effects were seen for use of sunscreen, protective clothing, and shade. Knowledge, self-efficacy, and norms were among the psychosocial variables most affected by the intervention. This study demonstrates that the SPF intervention is effective in improving staff outcomes related to children's sun protection.

Correlates of Sun Protection and Sunburn in Children of Melanoma Survivors.

INTRODUCTION: Sunburns during childhood increase melanoma risk. Children of melanoma survivors are at higher risk, but little is known about their sunburn and sun protection. One study showed that almost half of melanoma survivors' children experienced sunburn in the past year. This study evaluated sunburn and sun protection in melanoma survivors' children, and relevant survivor characteristics from Social Cognitive Theory and the Health Belief Model. METHODS: Melanoma survivors (N=340) were recruited from a comprehensive cancer center. Survivors completed a baseline questionnaire administered by telephone to report on the behavior of their children (N=340) as part of an RCT of a sun protection intervention. Data were collected in 2008 and analyzed in 2015. RESULTS: In the prior 6 months, 28% of children experienced sunburn. "Always" or "frequent" sun protection varied by behavior: sunscreen, 69%; lip balm, 15%; wide-brimmed hats, 9%; sleeved shirts, 28%; pants, 48%; sunglasses, 10%; shade, 33%; and limiting time outdoors, 45%. Survivors' sunburn and sun protection were positively associated with these outcomes in children. Correlates of sunburn also included older child age and higher risk perceptions. Correlates of sun protection behaviors included younger child age; stronger intentions, higher self-efficacy, and more positive outcome expectations about sun protection; and greater number of melanomas in survivors. CONCLUSIONS: Melanoma survivors may have a heightened awareness of the importance of their children's sun protection, but their children are not routinely protected. Correlates of children's sunburn and sun protection suggest subgroups of survivors to target with interventions to improve sun protection.

Children's skin cancer prevention: a systematic review of parents' psychosocial measures.

CONTEXT: Parents' knowledge, attitudes, and beliefs may be influenced through intervention to increase children's sun protection. Little is known about measures of these psychosocial characteristics, including psychometric properties. This paper systematically reviews parents' psychosocial measures in children's skin cancer prevention studies. EVIDENCE ACQUISITION: A search of standard databases conducted in 2008, updated in 2011, yielded 5797 unique citations. A study was eligible if (1) it was published between January 1980 and March 2011; (2) it was published in English; (3) it reported a psychosocial measure relevant to children's skin cancer prevention; and (4) the psychosocial measure was administered to parents, the majority of whom had children aged ≤12 years. Screening yielded 57 eligible studies. Data were analyzed in 2008 and 2011. EVIDENCE SYNTHESIS: Most studies measured one (n=24) or two (n=18) psychosocial constructs; few (n=7) measured more than three. The most frequently measured constructs were knowledge (n=41); attitudes (n=22); perceived susceptibility/risk (n=11); self-efficacy (n=9); and perceived barriers (n=9). Most studies did not mention theory. Theoretic mechanisms underlying interventions were not examined. There was little description of measure validity. Reliability, usually internal consistency, was reported more often (n=19). CONCLUSIONS: Few studies assessed more than two parent-related psychosocial constructs, so it was not possible to test theoretic models of parental influences on children's sun protection. Validated measures were lacking. There was conceptual overlap of measures because of the presence of analogous constructs across theories and assessment of multiple constructs within a single measure.

Randomized controlled trial of a sun protection intervention for children of melanoma survivors.

BACKGROUND: We studied whether a melanoma survivor-centered intervention was more effective than materials available to the general public in increasing children's sun protection. METHODS: In a randomized controlled trial, melanoma survivors (n = 340) who had a child ≤ 12 years received a targeted sun protection intervention (DVD and booklets) or standard education. Primary outcomes were children's sunburns, children's sun protection, and survivors' psychosocial factors at baseline and postintervention (1 and 4 months). RESULTS: The intervention increased children's sunscreen reapplication at 1 month (P = 0.002) and use of wide-brimmed hats at 4 months (P = 0.045). There were no effects on other behaviors or sunburns. The intervention improved survivors' hats/clothing self-efficacy at both follow-up assessments (P = 0.026, 0.009). At 4 months, the intervention improved survivors' clothing intentions (P = 0.029), knowledge (P = 0.010), and outcome expectations for hats (P = 0.002) and clothing (P = 0.037). Children's sun protection increased with survivors' intervention use. The intervention was less effective in survivors who were female or who had a family history, older children, or children with higher baseline sun protection scores. CONCLUSIONS: A melanoma survivor-centered sun protection intervention can improve some child and survivor outcomes. The intervention may be more effective in survivors who have younger children or less experience with sun protection. Intervention delivery must be enhanced to maximize use. IMPACT: This is the first study to examine a sun protection intervention for children of melanoma survivors. Findings will guide interventions for this important population at increased melanoma risk.

An intervention for parents to promote preschool children's sun protection: effects of Sun Protection is Fun!

BACKGROUND: Young children are an important focus of sun-protection efforts, but there has been relatively little study of sun-protection interventions developed for preschool-aged children and their parents. This paper reports on the evaluation of Sun Protection is Fun! (S.P.F.), designed to improve parents' practices and psychosocial outcomes related to protecting preschool children from sun exposure. METHODS: A group-randomized trial was conducted in 20 preschools to evaluate the S.P.F. parent intervention that included a video, newsletters, and handbooks. A separate, on-site intervention for preschool staff aimed to create a preschool climate that encouraged parents' sun protection for their children. Cross-sectional samples of parents completed surveys at baseline (n = 384), 12 months (n = 640), and 24 months (n = 694). RESULTS: S.P.F. demonstrated significant effects on parents' sun-avoidance strategies at 12 months (P < .05) and sunscreen use at 24 months (P < .05). There were significant intervention effects on parents' sun-protection knowledge (P < .001), perceived norms of teachers' sunscreen use (P < .001), sunscreen impediments (P < .05), and sunscreen expectancies (P < .05) at 12 months. Parents' perceived norms of teacher sunscreen use were significantly improved at 24 months (P < .001). CONCLUSIONS: More intense intervention strategies may need to complement take-home materials to result in greater effects on parents' sun protection for their children.

Validity and reliability of the parental sun protection scales.

Skin cancer is the most common cancer diagnosed in the US and its incidence continues to rise. Epidemiological studies have shown that excessive sun exposure received during childhood may increase the risk of developing skin cancer later in life. Yet, there are few published reports on the development of reliable and valid theory-based scales that assess the factors associated with parental sun-protection practices to reduce sun exposure in preschool children. To fill this gap, the Parental Sun Protection Scales were developed and validated. Two series of confirmatory factor analytic models were employed to test the factor structure of the scales and to examine the inter-relationships among the proposed psychosocial factors. Sunscreen-use and sun-avoidance behavioral models were tested in a sample of 384 parents. The results provided a basis for the reliable and valid measurement of psychosocial factors related to parental sun-protection practices. These scales may be useful in more fully understanding the determinants of sun-protection behaviors and in evaluating intervention programs designed to improve such behaviors.

Skin cancer prevention counseling and clinical practices of pediatricians.

Little is known about pediatricians' counseling and clinical practices to reduce skin cancer risk among their patients. Thus our objectives were to characterize skin cancer preventive counseling and clinical practices in a sample of pediatricians and identify correlates of these practices. Physicians practicing general pediatrics in Harris County, Texas, received a mail survey that assessed their sun protection recommendations and skin cancer preventive counseling and clinical practices. Pediatrician, patient, and medical practice variables were assessed as correlates. Most (76%) pediatricians routinely recommended sunscreen; however, relatively few (24%) suggested reapplying it after prolonged periods outside. About half routinely recommended protective clothing (53%), shade (47%), or limiting midday sun exposure (46%). Even fewer pediatricians routinely discussed skin cancer risk factors, passed out sunscreen samples, made educational materials available, took a family history of skin cancer, or documented risk factors in a patient's chart. More than half reported that they routinely performed full-body skin examinations during a first visit (65%) and annually (56%). Perceived barriers, perceived relevance of skin cancer prevention, and personal sun protection practices were important factors associated with professional practices in this sample. Interventions are needed to increase pediatricians' counseling and clinical practices to reduce skin cancer risk among patients.