Effect of a Face-Aging Mobile App–Based Intervention on Skin Cancer Protection Behavior in Secondary Schools in Brazil

Abstract

Because exposure to UV radiation early in life is an important risk factor for melanoma development, reducing UV exposure in children and adolescents is of paramount importance. New interventions are urgently required.OBJECTIVE To determine the effect of the free face-aging mobile app Sunface on the skin cancer protection behavior of adolescents.DESIGN, SETTING, AND PARTICIPANTS This cluster-randomized clinical trial included a single intervention and a 6-month follow-up from February 1 to November 30, 2018. Randomization was performed on the class level in 52 school classes within 8 public secondary schools (grades 9-12) in Itauna, Southeast Brazil. Data were analyzed from May 1 to October 10, 2019.INTERVENTIONS In a classroom seminar delivered by medical students, adolescents' selfies were altered by the app to show UV effects on their future faces and were shown in front of their class, accompanied by information about UV protection. Information about relevant parameters was collected via anonymous questionnaires before and 3 and 6 months after the intervention. MAIN OUTCOMES AND MEASURESThe primary end point of the study was the difference in daily sunscreen use at 6 months of follow-up. Secondary end points included the difference in daily sunscreen use at 3 months of follow-up, at least 1 skin self-examination within 6 months, and at least 1 tanning session in the preceding 30 days. All analyses were predefined and based on intention to treat. Cluster effects were taken into account. RESULTS Participants included 1573 pupils (812 girls [51.6%] and 761 boys [48.4%]; mean [SD] age, 15.9 [1.3] years) from 52 school classes. Daily sunscreen use increased from 110 of 734 pupils (15.0%) to 139 of 607 ( 22.9%; P < .001) at the 6-month follow-up in the intervention group. The proportion of pupils performing at least 1 skin self-examination in the intervention group rose from 184 of 734 (25.1%) to 300 of 607 (49.4%; P < .001). Use of tanning decreased from 138 of 734 pupils (18.8%) to 92 of 607 (15.2%; P = .04). No significant changes were observed in the control group. The intervention was more effective for female students (number needed to treat for the primary end point: 8 for girls and 31 for boys). CONCLUSIONS AND RELEVANCEThese findings suggest that interventions based on face-aging apps may increase skin cancer protection behavior in Brazilian adolescents. Further studies are required to maximize the effect and to investigate the generalizability of the effects.

Validation of SEPI in German—A German Translation of the Sun Exposure and Protection Index

“…In order to be able to do so, there is a need for valid and reliable tools to measure sun exposure habits and sun protection behaviour, both in order to identify individuals with a risky behaviour with regard to skin cancer, as well as to be able to communicate individually tailored sun protection advice [ 18 , 19 , 20 ]. For this purpose, the Sun Exposure and Protection Index (SEPI) has previously been developed and validated in English and in Swedish, as well as in two opposing UVR environments (Australia and Northern Europe) [ 21 ], and since then used as a measure in both epidemiologic and experimental studies [ 19 , 22 , 23 ]. It is composed of two parts; part 1 addresses present sun exposure habits, and part 2 the propensity to increase sun protection.…”

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

“…The geographical regions where the intervention was delivered were globally diverse; three studies each in Australia [ 12 , 15 , 23 ] and Iran [ 14 , 16 , 17 ], two in the United States [ 22 , 24 ], and one each in Brazil [ 14 ], China [ 20 ], Denmark [ 18 ], Spain [ 25 ], and Turkey [ 21 ]. Of the 13 studies, seven reported that they were based on a theoretical framework which included Protection Motivation Theory [ 13 , 17 ], the PRECEDE model [ 16 ], the Health Belief Model [ 22 ], the Theory of Planned Behaviour [ 23 ], the Extended Parallel Process Model [ 24 ], or some combination of behavioural frameworks [ 12 ].…”

“…All but one [ 15 ] of the interventions included didactic educational material on sun protection and the risk of sun exposure. Of the 10 studies for which information was provided on who delivered the intervention, half were delivered by the research team [ 13 , 16 , 23 , 24 ] or a medical student [ 14 ], two were delivered in the classroom using online [ 19 ] or video material [ 22 ], two by the classroom teacher [ 12 , 18 ], and one was an environmental intervention [ 15 ]. In addition to lecture material, five interventions had an interactive component such as games, role playing, or appearance-focused apps or photographs [ 14 , 19 , 23 , 24 ], [ 12 ].…”

“…One intervention was entirely environmental in that it was the provision of shade sails in the playground [ 15 ]. Of the12 studies where duration of the intervention was provided, five were single sessions of less than one-hour duration [ 14 , 19 , 21 , 22 , 24 ]. The remaining interventions were longer with six reporting multiple sessions, usually over a block of time [ 12 , 13 , 18 , 23 ] with one exception where two lessons were delivered each year for three years [ 20 ].…”

“…For studies where information on the sex of participants was reported ( n = 11), two were at single-sex schools (one each for male [ 16 ] and female [ 13 ] students), the proportion of females was higher in two studies (61–76%) [ 22 , 23 ] and lower in one study (10%) [ 21 ]. The participants in the remaining studies were approximately half female and half male [ 14 , 17 – 20 , 24 ]. Skin colour or ethnicity was not well reported with only five studies [ 14 , 19 , 22 – 24 ] collecting this information and responses varying greatly by country where the intervention was delivered.…”