after longer exposure was a result of more opportunities
to be exposed to the adult and peer role models or if it
took time for role models to change their own behavior.
It is likely that repeated advice and reinforcement are
needed over time to maintain sun protection during
adolescence.
There are certain limitations to our study. We were
not able to study a longitudinal cohort of students but,
rather, repeated cross-sectional observations of a beach/
pool population. We did not anticipate the finding that
fewer adolescents came to the beach or pool as they
became older. Thus, we are unable to tell if the adolescents
who continued to come to the beach or pool after
8th grade are teens with more tan-seeking behaviors
than their peers who no longer attend. Cancellations of
school events because of weather during 2 years made it
impossible to obtain a large enough sample of adolescents
to determine sun protection at other outdoor activities.
A parent could have received information from
their child’s coach or clinician, articles in the school
newsletter, or school health fairs or had sun protection
included on an outdoor-event permission form. However,
it was a limitation of our study that it was not
feasible to have a direct-intervention component for
parents, who remain important role models for their
early-adolescent children.30 Expanding the parent outreach
would be appropriate in future replications. Although
we promoted improved adult self-protection and
provided yearly information for adults, we were limited
in our ability to follow-up on adults and cannot tell how
much they changed their own personal protection. Finally,
we were limited in our ability to assess the relative
contributions of the intervention components.
We would have preferred to see adolescents increase
use of clothing, hats, and shade rather than sunscreen.
Our project promoted multiple methods of protection as
well as shade. Use of sunscreen can extend the total
length of time in the sun and increase overall UV-radiation
exposure. However, 68% of young adolescent sunburns
occur during water activities.31 Thus, better sunscreen
use when engaged in water activities is an
important step in preventing the high rate of sunburns
in adolescents.
CONCLUSIONS
We have found that a new approach to delivering sunprotection
messages in early adolescence has an impact
on sun-protection behaviors at the community level.
Consistent messages across a number of venues and
involving teens, as well as adults, in the effort are needed
in early adolescence. We recommend that skin cancer
prevention programs for youth need to begin early in
middle school, when they are making independent
choices, and create a community-wide environment that
supports appropriate sun protection rather than focusing
on classroom health education alone. Support of a collaborative
team that extends into the community from
the school is key to implementation. Implementation of
the national recommendations for school and recreational
environmental changes and formal sun-protection
policies11 would complement this intervention by
providing more shade and changing sun-protection expectations
of staff, parents, and teens at outdoor events
and sporting events.
Future research needs to address 2 types of adolescent
sun exposure: intentional and incidental sun-tanning.32
Girls are more likely than boys to be intentional tanners.
Tan seekers are also more likely to use artificial tanning
lights when they are older.33 Interventions and messages
may need to vary for these patterns of sun exposure
among boys and girls. Poor sun protection and tanseeking
are common in older adolescents. Evidencebased
interventions specific to the high school level are
lacking. Future interventions need to be developed that
are responsive to their activities, motivations, and developmental
stage.