Cutaneous Melanoma Attributable to Sunbed Use Systematic Review and Meta-analysis
Medicine (Baltimore). 2016 Mar; 95(11): e3034.
Parental Utilize and Educational Campaigns on Sunbed Utilize Among Teenagers and Adolescents
Ignazio Stanganelli, Physician, Luigi Naldi, Physician, Fabio Falcini, MD, Serena Magi, MSc, Laura Mazzoni, MSc, Matelda. Medri, Medico, Rita Bertoncini, MSc, Ombretta Calderoni, Doctor, Veronica Agnoletti, PhD, Luca Nadiani, MSc, Giuseppe Palmieri, MD, Sergio Di Nuzzo, MD, Calogero Pagliarello, Doc, and Sara Gandini, PhD
Monitoring Editor: Mauro Alaibac.
Received 2015 Nov 22; Revised 2016 February 13; Accustomed 2016 February 16.
Abstract
This written report aimed to evaluate the prevalence of sunbed employ amidst teenagers and the association between familial behavior and the adoption of UV-protective practices in this age group. Nosotros likewise assessed the impact of an educational plan on students' noesis about the potential risks of sunbed use. The educational intervention focused on: (i) skin effects of UV radiation, (ii) photoaging and photocarcinogenesis, (3) chance factors for skin cancer, (iv) indoor lord's day tanning and misleading concepts such as possible protective effect of sunbed use on skin cancer risk, (5) sun protection and relation with skin phototype, and (vi) early diagnosis of melanoma using the ABCDE check list and the ugly duckling sign. We carried out a survey of 3098 students and found a strong association between parental sunbed employ and students' use of the same (P < 0.0001). Students who attended the educational intervention were more aware that sunbed employ cannot prevent sunburns (P = 0.03) than those who did non attend, making adjustments for confounding variables. However, sunbed utilise by parents influenced the desire to utilize a sunbed more than participation in the educational intervention (P < 0.0001). In conclusion, although our results indicate that educational interventions tin improve cognition of the risk of sunbed use. They also reveal a strong correlation between sunbed apply by teenagers and parental behavior that highlights the importance of educational interventions involving families.
INTRODUCTION
Cutaneous melanoma and nonmelanoma skin cancer (NMSC) have undergone a substantial increase in incidence in developed countries over the final few decadesone,2 and are susceptible to early preventive measures.3 Ultraviolet light (UV) exposure is an established risk factor for cutaneous melanoma and NMSC4,5 and primary prevention is a crucial to decreasing the number of malignant skin cancers and costly melanoma treatments. In 2009, the International Agency for Research on Cancer classified the entire UV spectrum as carcinogenic.5 The pattern of sunday exposure may touch on the take chances of dissimilar skin cancers and the risk of the same cancer in different body locations in different ways.half-dozen,7 Recent studies take highlighted an increasing incidence of cutaneous melanoma and NMSC among young adults in several countries.viii–10 Although the lifetime hazard of melanoma is college in men than in women, recent studies accept documented that the opposite is true for young adults and adolescents, where the female person–male incidence ratio is as high every bit 1.viii.9 This finding may be owing to some sexual practice-specific behavior that lead to different UV light exposure.11 A meta-assay reported that sunbed utilize earlier the historic period of 35 years substantially increases the risk of melanoma.12 Over the final few decades, indoor tanning has become increasingly popular amidst adolescents, especially girls.xiii However, Italy, like many other countries in Europe, take further increased nationwide restrictions on the use of indoor tanning by people under 18.14,15 Melanoma is significantly associated with lord's day and sunbed exposure merely the run a risk is modified by several host factors. A systematic meta-analysis of all studies published from 1996 to 2002 showed that the most important phenotypical factors for melanoma are pilus, eye and skin color, skin type, presence of freckles, and number of mutual nevi.six
In that location is widespread consensus that UV protection habits should begin early in life and exist taught equally office of routine preventive healthcare.sixteen,17 A systematic review18 concluded that education approaches to increasing UV-protective beliefs were effective when implemented in primary schools and in recreational settings and that insufficient prove was available when implemented in other settings.
"'SAVE THE Peel" was a complex project funded by a nonprofit association called Istituto Oncologico Romagnolo (IOR) and including educational and enquiry components.nineteen,20 As a combined research-intervention project, the "SAVE THE SKIN" project served both educational and survey purposes. The survey questions covered areas of social medicine, preventive dermatology, and epidemiology of skin cancer risk factors. The general objective was to assess prevalence of sunbed use among teenagers and the association between familial behavior and the adoption of UV-protective practices in youth. A airplane pilot educational intervention was also conducted amid students to make up one's mind the impact of an educational programm on awareness of this issue.
SUBJECTS AND METHODS
The "Salve THE SKIN" project was developed every bit part of the IOR Melanoma Project, a clinical cadre integrated into the Skin Cancer Unit of measurement of Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST IRCCS) with the partnership of the Center for Advanced Studies on the Humanization of Care, Health and Social Safety, University of Bologna and the European Institute of Oncology in Milan. The project included a summer beach surveyxix,xx and a workshop for beauty salon and lord's day tanning centre operators aimed to highlight the risk of artificial radiations and to provide data from the Italian Ministerial Decree of May 2011 on the limitation of artificial UV devices in minors and in a loftier-gamble subgroup of the population.14 Furthermore, a specific project module consisted in a survey combined with the piloting of an educational intervention in secondary schools of Ravenna and Forlì, 2 towns in east-key Italian republic.19,twenty
This report was approved past the Institutional Review Board (March 2011) of the "Centro Studi GISED" analogous the Italian Group for Epidemiologic Research in Dermatology aimed at improving scientific cognition and enquiry into dermatological diseases. Written informed consent was obtained from each participant's adjacent of kin and the procedure was approved past Ethics Committee. Eight secondary schools (6 in Ravenna and 2 in Forlì) participated in this project. All the students (ages ranging from thirteen to 20 years) were invited to accept part in the survey. A subsample of 9 classes from vi schools in Ravenna was also drawn randomly to participate in an Educational Intervention (EI). Students were between the ages of 14 and 19.
The EI was planned according to the Italian National Cancer Recommendations for 2010 to 2012, which included guidelines on activities for primary and secondary prevention of skin cancer. It should be noted that along the Romagna coastline, sunbathing on the beach is one of the most popular recreational activities amid young people.nineteen,20
The EI was conducted betwixt November and Dec 2011 in school meeting halls and consisted of an interactive 2-hour meeting with students and teachers focusing on: (i) peel effects of UV radiation, (2) photoaging and photocarcinogenesis, (iii) risk factors for skin cancer, (four) indoor lord's day tanning and misleading concepts such as possible protective effect of sunbed use on skin cancer risk, (v) sun protection and relation with skin phototype, and (six) early diagnosis of melanoma using the ABCDE cheque list and the ugly duckling sign. Lessons were held by an expert dermatologist (OC) or a specifically trained biologist (SM) using an identical didactic multimedia presentation. After the preparation lesson, education resource material was distributed. In January to March 2012, additional activities aimed at the production of educational materials were carried out in the pupil classes that received training. During the master prevention EI, students used different techniques to produce drawings, videos, and graphic projects that illustrated the correct behavior for acceptable sun protection, the hazards of excess UV radiations, and the benefits and harmful effects of UV radiation. This process was monitored by pedagogy staff and past 2 of our team (SM, RB). Furthermore, to promote active participation by the students in the educational program, IOR project funding launched an laurels for the winner of the best presentation highlighting the importance of primary skin cancer prevention.
The survey, based on a paper questionnaire, was conducted between April and May 2012 (6 months after the principal educational intervention and 2 months afterward the finish of additional activities) and involved all the students of the secondary schools, including those who had not participated in the educational intervention. The questionnaire consisted of 25 questions (Effigy one) and was adult on the basis of our previous feel with similar surveys21 and on published studies about dominicus protective beliefs in children and adolescents.22 The questionnaire explored dominicus exposure habits, attitudes to the use of sunbeds, cocky-reported sunburn history, and sun protection behavior. Information on skin phenotype, socioeconomic variables, and parental role on lord's day protection was also collected. Copies of the questionnaire were distributed systematically on a daily ground during school hours and were collected at the school desk. Teachers and one of the co-authors (RB) distributed the newspaper questionnaires and asked the students to complete them by hand and return them to the school desk-bound. Around 10 to fifteen minutes were needed to make full in the questionnaire and a full of 3098 questionnaires were completed (98% response charge per unit).
Statistical Methods
Descriptive analyses were carried out on data derived from the questionnaire. Data were stratified on the basis of (1) the response 'have used sunbeds' versus (vs) 'have never used sunbeds' and (ii) the participation of the students in the educational intervention. Differences between frequencies were assessed using chi-square tests for independence of categorical variables and by logistic regression including all significant factors and confounders. The office of factors influencing sunbed utilize, the desire to use them and the opinion about their safety was assessed by calculating the odds ratios and 95% confidence interval (95%CI) derived from multiple logistic regression analysis for selected predictive variables. Response variables of the logistic regression models were "accept used sunbeds," the want to use a sunbed and the awareness about the safe of sunbed apply ("Is sunbed less risky than sun exposure?"). We likewise evaluated the efficacy of the EI including a categorical variable ("participation vs not-participation") in the multivariate logistic regression model. Only factors significantly associated with the response variables were maintained in the models.
RESULTS
Sunbed Employ
The vast majority of students were resident in Romagna (northward = 2872, 93%) and were <18 years of age (n = 2055, 66%). Most two% were <xiv years onetime, 25% were 15, 20% were xvi, 20% were 17, 20% were eighteen, and 12% were ≥xix. About 8% (n = 229) attended the educational intervention.
Information provided past students on their use of sunbeds and on parental characteristics and behavior is reported in Tabular array 1. The prevalence of sunbed use amid students was 7% (n = 216).
Tabular array i
Prevalence of Sunbed Utilise Co-ordinate to the Characteristics of Adolescents and Parents
More females than males reported using sunbeds (9% vs iv%; P < 0.0001) and teenagers <18 years reported using sunbeds less frequently than those aged ≥18 (5% vs 11% for age<18 and age≥eighteen; P < 0.0001). Furthermore, subjects with risk phenotypes used sunbeds more others. Students who often/always experienced red skin subsequently sunday exposure used sunbeds more than ofttimes (8% vs half dozen%; P = 0.02). Students with light hair color used sunbeds more oftentimes than those with other hair colors (10% vs 7%; P = 0.03). Subjects with numerous freckles used sunbeds more frequently than those with few freckles (nine% vs 7%; P = 0.04). Fair peel color was the only phenotypical factor associated with lower sunbed apply: six% of students with off-white pare colour use sunbeds versus 9% of students with night skin color (P = 0.01).
The prevalence of sunbed apply was 25% (n = 778) amid parents. Almost a third of students alleged accept had their parents' permission to employ the sunbed (due north = 893, 29%).
If parents used sunbeds, their children were more than probable to study using sunbeds every bit well (16% vs 4% for parents' utilize vs no use; P < 0.0001).
Parents' levels of pedagogy were very of import in influencing the utilize of sunbeds by students. The proportion of students using sunbeds was significantly higher if parents had simply had an elementary school education compared to those with a college educational level (18% vs 7% for low vs high educational level of mother and begetter: P < 0.001). We assessed Socio-Economical Status (SES), considering parents' professions (unskilled vs skilled workers). Low SES, indicated by the level of the father's profession was associated with limited sunbed apply past the students (five% vs 8% for unskilled and skilled workers, respectively; P = 0.002). Conversely, evaluating parents' educational levels we observed that a medium–high educational level was associated with a significantly lower sunbed use than that seen for low educational level parents (Table 1).
Multivariate logistic models (Tabular array 2) show that sunbed use by parents and parental permission was significantly associated with sunbed employ, after adjusting for confounding variables such as gender, parental instruction, and profession.
Table two
Multivariate Logistic Models Evaluating Factors Associated With "Ever Sunbed Utilize"
Educational Intervention
Overall, 229 students participated in the EI. Data on students' features, take a chance factors, and awareness of melanoma take a chance past participation in the EI on melanoma prevention are reported in Tables 3 and 4. Some differences were found in the 2 student grouping, that is, in the EI grouping at that place were significantly more girls (P = 0.0002), older students (P < 0.0001), and a higher number of students with fair hair color (P = 0.02).
TABLE three
Student Characteristics on the Basis of Participation in EI on Melanoma Prevention
TABLE 4
Risk Factors and Cognition by the Participation in EI on Melanoma Prevention
No deviation was seen in the utilize of sunbeds between students who attended the EI and those who did non (9% vs 7% respectively; P = 0.17). Nonetheless, students who attended the EI were more aware of the risks. The proportion of students who believed that sunbed employ was less risky than sun exposure was significantly higher in the group who did non attend the EI (14 vs 8 %; P = 0.009). Although EI students were also more aware that sunbeds cannot prevent sunburns (24% vs 16%, for the pedagogy group vs others, respectively; P = 0.007), more half of the students in the group (56%) did non know whether the utilize of sunbeds could decrease sunburn adventure.
Multivariate logistic models show that the utilize of sunbeds by parents was more of import (P < 0.0001) than EI participation in influencing the desire of students to use sunbeds, making adjustments for misreckoning variables such as gender, parental profession, and pare blazon (Table five). Nevertheless, it is of note that EI participation significantly improved (P = 0.03) the cognition that sunbed use is not less risky than sun exposure, adjusting for other confounding variables.
TABLE 5
Results From Multivariate Logistic Models
Give-and-take
This study was aimed at evaluating the association between sunbed use and the adoption of sun-protective practices in immature people with familial behavior. We also assessed the bear on of an educational program on students' noesis about melanoma adventure due to sunbed use.
Our survey reveals that ∼7% of adolescents in the Romagna region use sunbeds and that the use of sunbeds is associated with several individual characteristics, including gender, skin phenotype, and socioeconomic status. Off-white phenotype, female gender and lower SES of parents are associated with a higher sunbed use. More importantly, our information reveal a strong correlation between sunbed use by parents and their use past children, indicating the importance of educational interventions involving families. Finally, our report highlights that, although a cursory educational intervention may meliorate noesis and attitudes, we do not know whether it can alter habits. Our survey was a pilot written report and future enquiry will have into consideration these preliminary data.
Our estimates of sunbed use by adolescents were lower than those reported in a systematic review of data from the United States, Europe, and Australia, pointing to a prevalence of exposure of 35.seven% (95% CI, 27.5–44.0%) in adults, 55.0% (33.0–77.ane%) in university students, and nineteen.3% (xiv.7–24.0%) in adolescents.13 This last percentage may be a consequence of a law passed in Italian republic prohibiting sunbed utilise by under 18 seconds. However, a German study showed that the prevalence of sunbed use in minors is very loftier, despite a legal ban in this age group, thus underlining the importance of education.23 With regard to predictive variables of exposure, our data are more often than not in understanding with those of previous surveys24–26 showing that sunbed utilise is influenced past several psychosocial and demographic variables including being female, being a teenager, having more pocket money, having a parent who uses an indoor tanning bed and who allows their boyish child to use information technology, and holding certain behavior virtually the consequences of indoor tanning.
Young people state that they primarily use sunbeds to get a suntan and to appear more attractive.27 All these variables should be taken into account when planning educational interventions aimed at reducing sunbed utilize.28 Our preliminary survey indicates that an educational intervention designed to reduce UV light exposure increases short-term awareness.
It has been seen that sun protection programs are more often than not more successful in improving sun-protective practices for infants (by parents) and among younger children, but less successful among adolescents.29 Efforts in sun-protection education, supportive environments, and policies are difficult to sustain effectively every bit main school children transfer to secondary schools.30 Interventions in secondary schools are potentially of import because adolescents and young adults are more probable to exist exposed to UV radiations than younger children and are less probable to adopt sun-protective behavior. Parents and caregivers have less influence in promoting lord's day protection in this age grouping and high schools and colleges can provide an infrastructure to support intervention activities.18 Despite high levels of knowledge most the wellness effects of unprotected sun exposure, changes in attitudes and social norms during adolescence are associated with an increase in high-risk behavior and present a unique claiming to wellness educators.31 Interestingly in our survey, in agreement with previous studies, adolescents who reported using sun protection most of the time were the least probable to report the use of an indoor tanning bed.32 Moreover, the probability of using sunbeds was much greater amid adolescents whose parents also used indoor tanning than in those whose parents did not. The aforementioned result was reported in other studies, pointing to the importance of social influences and perceived norms on behavior.33,34 Our results showed that sunbed use in adolescents was associated with lower educational levels of parents but as well higher professional person levels of parents. Hence, education and profession that are two aspects related to socio-economic factors seem to take different effects: teaching of parents seem to have a stronger effect on awareness than professional levels, which is a better proxy of socio-economic status.
Furthermore, previous studies have shown that known adventure groups, that is, individuals with a history of sunburn, pigmentation marks and familial melanoma history, do not apply solariums significantly less than those who are risk-costless.34 Our findings confirm that students with a high-hazard phenotype (pare becomes quickly red later exposure) use a sunbed significantly more than others, which is alarming. It is interesting to annotation that the off-white phenotype is associated with less sunbed utilize than the dark phenotype, whereas a history of sunburns afterwards sun exposure is associated with a higher incidence sunbed utilise (probably because the sunbed is used every bit a means to protect the skin from the gamble of sunburn earlier intense sunday exposure).
We are aware that our written report had limitations. We used a regional sample of secondary school students who may non be representative of the general Italian population of the same age group. It would exist useful to reproduce these findings in other regions. Other limitations were self-reporting, lack of data on the frequency of exposure to use of sunbeds, and the fact that no information on family-endemic sunbeds was nerveless. Furthermore, the questionnaire nosotros used is similar to others used in the literature, merely has never been validated.21,22 In the present written report it was not possible to assess the long-term bear upon of the educational intervention, just nosotros are now planning to utilise pre- and postintervention questionnaire to evaluate whether this type of intervention with students tin also help in changing habits. Despite these limitations, our information signal that young people are exposed to sunbeds to a substantial degree and that exposure is influenced by potentially modifiable factors.
In decision, our information indicate a loftier proportion of exposure to sunbed use among adolescents in Italy and highlight the existence of multiple determinants of behavior, pointing to the need for collaboration across multiple sectors to develop educational interventions aimed at reducing indoor tanning and preventing future cases of pare cancer.35
Acknowledgments
The authors are indebted to Trevor Crane and Grainne Eileen for the language editing.
Footnotes
Abbreviations: CI = confidence Interval, EI = educational intervention, IOR = Istituto Oncologico Romagnolo, NMSC = nonmelanoma pare cancer, OR = odd ratio., SES = socio-economic condition, UV = ultraviolet light
The authors have no funding and conflicts of interest to disclose.
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