our intervention teens after 2 years. This coverage would
be comparable to adding sun protection to the head/
neck area for the entire intervention population.
We examined more closely how specific sun behaviors
changed at the beach/pool setting. Because of the
attire for water activities, it was not surprising that we
did not find significant changes in the use of clothing
(data not presented), but more youth applied sunscreen
and applied it more thoroughly in our intervention communities
after 2 years of intervention (see Table 4). This
resulted in more teens that were well protected (ie,
75% of BSA). After 2 years, 36.1% of intervention
subjects were well protected versus 12.8% of controls (P
.001). We found that sunscreens with an SPF of 15
were widely used in our region. Use of a sunscreen with
an SPF 15 increased from 75% to 84% over the project
period without significant differences between the intervention
and control communities.
With our multicomponent intervention we sought to
increase the input from multiple adult role models about
sun protection. We hypothesized that teens would report
receiving advice from more sources (ie, school,
parent, doctor, coach). Table 5 shows that the average
number of different sources of advice about sun protection
steadily declined in the control communities but
was maintained over time in our intervention communities.
Examining the changes in advice from specific
types of adults during the project showed that parental
advice continued at high levels in both the intervention
and control groups (85%–92%). The advice from adults
in the school increased after 2 years of intervention
exposure (baseline: 53%; year 1: 52%; year 2: 64.3%)
but declined in control communities (baseline: 55.7%;
year 1: 41.3%; year 2: 14.3%), with significant differences
between study arms after 1 (P . 01) and 2 (P .
001) years. Recall of coach advice declined for control
teens (baseline: 16%; year 1: 12%; year 2: 2%) but
increased for intervention-site youth (baseline: 13%;
year 1: 17.5%; year 2: 20%) (P .05 [year 1] and P
.0001 [year 2]). Recall of clinician advice did not differ
between study arms after 1 year but was more likely
after 2 years for teens in the intervention communities
(25.3% [intervention] vs 10.5% [control]; P .001).
DISCUSSION
The SunSafe in the Middle School Years project has
begun to address the challenge of rapidly declining sun
protection in the adolescent years. The 2 years of intervention
altered the marked decline in observed protection
seen in the control group. The difference in protection
was because of better coverage with sunscreen at a
water-activity location. Consistent with our SunSafe
model, adolescents in the intervention communities
were more likely to report multiple sources of adult
sun-protection advice than those in the control communities.
The middle school time period is particularly challenging
time for influencing adolescent’s sun protection.
Two school-based surveys have provided more detailed
sun-protection information within this age range. The
first survey in Australia showed declining sun protection
as adolescence progressed, with the greatest increases in
TABL