SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
1

Sun Protection Habits Among Adolescent Athletes
Alexandra Kayla Ryan
DNP 704: Principles Evidence-Based Care
Arizona State University Edson College of Nursing and Innovation

Author Note
Alexandra Ryan is a registered nurse at Phoenix Children’s Hospital in the PeriOp Department
She has no known conflict of interest to disclose.
Correspondence should be addressed to Alexandra Ryan, Edson College of
Nursing and Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd
Street, Phoenix, AZ 85287-3020.
Email: akryan2@asu.edu

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Introduction: Most melanoma cases are directly related to harmful ultraviolet exposure (UV).
An adolescent athlete spends close to four hours per day outdoors, which equates to over one
thousand hours of sun exposure every year. Athletes are typically unaware that extended periods
of UV exposure can cause melanoma and therefore an education regarding sun safety is needed.
The Social Cognitive Theory depicts the studied behaviors for this project showcasing external
factors that may contribute to an adolescent not using proper sun protection.
Methods: Athletes on the swim team at a Phoenix High School (n=6) were surveyed to
determine their current sun protection habits. An education intervention about sun safety and
melanoma risk/identification was then implemented. The student athletes were then re-surveyed
two weeks post intervention to determine if their sun protection habits and melanoma knowledge
had changed. Descriptive statistics were run to compare the pre- and post-survey results.
Results: There was no change between baseline and post-intervention sun safety/melanoma
knowledge when descriptive statistics were run. Amongst the six athletes, sun safety habits and
knowledge identifying melanoma did not change after the education intervention.
Discussion: Adolescents are unaware of the consequences their lack of safe sun habits can cause
on their skin. Most adolescents do not have the proper education from schools or sporting teams
to teach them about the dangers of poor sun safety practices. Education alone cannot serve as the
sole influence as to whether adolescent athletes increase sun protection habits.
Keywords: sun, sun safety, melanoma, athletes, ultraviolet radiation

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Sun Protection Habits Among Young Adult Athletes: Background and Significance
Adolescents participating in outdoor sports embody a group of individuals at increased
risk for excessive exposure to harmful ultraviolet (UV) radiation. According to the Skin Cancer
Foundation (SCF) (2021), 86% of all melanoma cases are directly related to harmful UV
exposure. A college athlete spends close to four hours per day outdoors, which equates to over
one thousand hours of sun exposure every year (Bagatti et al., 2016). There is a seven-fold
increase in the risk of being diagnosed with melanoma between 15 and 19 years of age (Bagatti
et al., 2016). Daily sunscreen use decreases the risk of sun damage and can significantly reduce
the risk of melanoma, especially in those adolescents who are outdoors for an extended period
(SCF, 2021). Children and teens can use sunscreen at school, but the number of student-athletes
that use sunscreen before a sporting event or practice outdoors is often unknown.
Problem Statement
During childhood and adolescence, the risk for melanoma increases with every
overexposure to UV radiation and sunburn (Centers for Disease Control [CDC], 2020). On
average, a person can increase their risk of melanoma by having had more than five sunburns in
their lifetime (SCF, 2021). One of the best defenses to UV radiation is sunscreen use, preferably
a sun protection factor (SPF) of 15 or higher (CDC, 2020). Young athletes did not report
increased sun protection measures, such as SPF, hats, and shade, during their time outdoors at
practices or games (Orsimarsi, 2019). Most young athletes did not apply sunscreen before
participating in outdoor sports, and those that do, fail to reapply in an appropriate time frame
(Orsimarsi, 2019). In a study conducted by Bagatti et al. (2016), 83.3% of female athletes at a
college in Pennsylvania, did not report any skin-related care while outdoors. According to the
Arizona Department of Health Services (ADHS), younger age groups are more likely to be

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diagnosed with invasive forms of melanoma and are at the greatest risk for a late-stage
melanoma diagnosis (ADHS, 2017). Arizona’s invasive melanoma rates have also increased to
19%, which surpasses the United States age-adjusted rate of a 2% increase in invasive melanoma
cases (ADHS, 2017). Specifically, to those under 18 years old, education is an important first
step in promoting sun safety precautions and bringing awareness to melanoma risks in the
pediatric population.
Purpose and Rationale
In the U.S., more people are diagnosed with skin cancer than all other cancers combined
(SCF, 2021). In the adolescent athlete population, proper education regarding sun safety should
be delivered to equip young adults with the tools to protect themselves against harmful UV
radiation. The purpose of this paper is to review the current literature and data to establish the
need for sun safety education for young adult athletes who practice and play sports outdoors to
reduce their risk of melanoma.
Background and Significance
The SCF 2021 has defined skin cancer as an atypical uninhibited growth of skin cells.
Taking the appropriate measures to protect oneself, such as wearing sunscreen with an SPF of 15
or higher, is one of the first steps in reducing the risk of all types of skin cancers (CDC, 2020).
Pediatric melanoma has unique clinical presentations and can often be overlooked by a primary
provider (Moustafa et al., 2020). In the pediatric population, invasive cancers in those 15-19
years of age make up 79% of all skin cancer cases (Moustafa et al., 2020). A melanoma may
present in a pediatric patient as an amelanotic macule, papule, or nodule, and therefore there
have been many delays in diagnosing melanoma in the pediatric population (Merkel et al., 2018).

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Skin cancer focused programs and campaigns are needed to help change the culture of
sun protection and raise awareness of the harmful effects of UV overexposure (Bagatti et al.,
2016; Orsimarsi, 2019). In a study conducted by Bagatti et al. (2016), female athletes were given
a pre-test, education, and post-test about their knowledge of skin cancer facts, definitions of
melanoma and related skin terms, harmful effects of UV overexposure, prevention methods to
UV radiation, and skin self-examination techniques. After this study, it was reported that 79.2%
of female athletes would start using sunscreen before going outside compared to the 23.6% that
reported using sunscreen before the education was given (Bagatti et al., 2016). Student-athletes
are at the highest risk for UV overexposure due to their long hours in the sun for sports and
school hours in peak sunlight (Ally et al., 2020; Carter et al., 2016).
The Clever in the Sun and Shade Program (CSSP) was created in a study to help
encourage positive attitudes towards UV protection in schools (Stolzel et al., 2020). This
program was developed to provide teachers and coaches with education regarding beliefs over
risk factors for skin cancer, barriers to prevent UV radiation, and stigmas towards sun protection
(Stolzel et al., 2020). CSSP created videos, posters, and lectures to teach young athletes about
skin cancer and had many of their participants favor fondly towards the education (Stolzel et al.,
2020). The state of Arizona has also begun a sun safety program called SunWise which provides
training on UV protection and how to reduce skin cancer risk for those students kindergarteneighth grade (ADHS, 2020). Adolescents are often more receptive to education in
communication forms that they use most often, such as text messaging, e-mail, and video
(Horsham et al., 2020; Hubbard et al., 2020). In a controlled trial that was conducted among
teenagers 13-15 years old, smartphone technology was used to deliver text message reminders to
students about sun safety measures for seven weeks after an in-person education program to try

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and determine the feasibility of educating adolescents about sun safety in a school setting
(Hubbard et al., 2020). This study proved that it is possible to implement education programs in
schools so that adolescents will respond to and learn from, rather than just a formal lecture
format for the material. Another group of authors evaluated at how to best deliver sun safety
information in a study using photoaged photographs to show future sun damage among female
adolescents. Female adults and adolescents both pose a greater risk of being diagnosed with
melanoma than males, revealing that a suntan may be more desirable to females than males
(Bagatti et al., 2016; Eastabrook et al., 2018). Adolescents between 16 and 17 years old were
interviewed before and after seeing their photoaged photograph. Most participants stated that
they did not realize the amount of damage they had already done to their skin by trying to change
their skin tone (Eastabrook et al., 2018). Not only does gender come into play when it comes to
sun protection knowledge, but where a person lives. In a study conducted by Nagelhout et al.
(2019), high school students in rural settings reported fewer sun protection measures than urban
students. Geography, gender, and information delivery methods should all be considered when
educating adolescents regarding the importance of skin cancer prevention.
Adolescent Athletes Risk for UV Overexposure
According to the Arizona Melanoma Profile, younger age groups are more likely to be
diagnosed with invasive melanoma and have the highest proportion of late-stage diagnosis cases
(ADHS, 2017). In a study conducted by Eastabrook et al. (2018), overarching themes among
adolescent participants between 16 and 17 years of age, were that “brown skin tone is nicer than
pale,” “people think darker skin is more attractive,” “I feel better about myself when I am tan,”
and “celebrities all have brown skin tone.” The adolescent demographic has a strong desire to be
bronzed, leading to harmful behaviors such as increased sunburns, indoor tanning, and a lack of

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sunscreen use (Bagatti et al., 2016; Eastabrook et al., 2018). Many high school athletes are
unaware of the damage they have already done to their skin, evidenced by the lack of knowledge
of skin protection measures, facts about melanoma, and harmful effects of UV radiation
overexposure (Orsimarsi, 2019).
Education Intervention for Sun Safety Awareness
Education regarding sun safety is lacking among the adolescent age group. Reports show
lack of knowledge regarding sun-safety habits, skin cancer risk factors, and skin selfexamination techniques (Bagatti et al., 2016; Eastabrook et al., 2018; Orsimarsi, 2019). When
provided with education, whether in the forms of lecture, poster, text-message, or photoaged
photographs, most adolescent age groups responded favorably towards the information with a
better understanding of skin cancer prevention statistics and prevention methods (Bagatti et al.,
2016; Eastabrook et al., 2018; Hubbard et al., 2020; Stolzel et al., 2020).
Current Educational Practice
The current practice for educating adolescents on sun safety allows each school to
determine how it wants to educate its students about UV protection (The World Health
Organization [WHO], 2020, as cited in Stolzel et al., 2020). For the state of Arizona, the
SunWise program is available to schools, coaches, and other educators at no cost (ADHS, 2020).
As evidenced by results from multiple studies, an education program given to adolescents to help
increase their awareness of skin cancer risks can significantly improve their sun safety health
promotion (Bagatti et al., 2016; Eastabrook et al., 2018; Hubbard et al., 2020; Nagelhout et al.,
2019; Stolzel et al., 2020).
Future State of Skin Cancer Awareness

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Changing the culture of skin protection to promote sun-safe habits is at the heart of sun
safety education. Lack of basic knowledge about skin cancer and UV prevention warrants the
need for education among the adolescent athlete population (Orsimarsi, 2019). Education
regarding improved behaviors, knowledge, and attitudes towards melanoma can help adolescent
athletes recognize their skincare deficits and improve sun safety awareness (Bagatti et al., 2016).
Melanoma is the most common skin cancer in the pediatric population and presents most
frequently in adolescents aged 15-19 (Moustafa et al., 2020). Adolescent athletes who participate
in sports outdoors spend around 10-15 hours per week in the sun, often without proper shade,
clothing, and sunscreen (Bagatti et al., 2016; Orsimarsi, 2019). Many education programs have
proven beneficial in teaching student-athletes about melanoma risk factors, sun protection
methods, and skin self-examination (Bagatti et al., 2016, Eastabrook et al., 2018; Orsimarsi;
Stolzel et al., 2020). Due to the lack of participation in protective measures by adolescent
athletes, education about sun safety is necessary for this age group to prevent harmful damage
that could cause skin cancer.
Internal Evidence
The Arizona Department of Health Services identifies melanoma as the fifth diagnosed cancer
in males and the seventh diagnosed cancer in females (ADHS, 2017). For those students in North
Canyon High School in Phoenix, AZ, there are currently no guidelines or education towards sun
safety for their student-athletes. According to Athletic Director Jacob Kluch, the student-athletes
at his school are not given any education regarding the importance of sun safety. Jacob Kluch
believes that most students participate in outdoor sporting events at an average of 2 hours per day
and close to 10 hours per week. This inquiry has led to the clinically relevant PICOT question,

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“In high school athletes who practice outdoors, does an education program regarding sun safety
compared to no education program in schools affect the use of sunscreen over an athletic
season?”
Search Strategy
An expansive review took place over three databases, PubMed, CINAHL, and PsychInfo,
to help answer the PICOT question. These databases were selected for their focus on healthcare,
nursing, psychological significance, and impactful contributions to the medical community. All
three databases were searched using key terms that addressed relevant areas of the PICOT
question. Key terms used in the search included: adolescents, sun, sun exposure, melanoma,
athletes, and sunscreen. Key terms also included specific sports with outdoor sun exposure, such
as football and soccer. The outcome was specified using terms education and program to narrow
down an intervention closely related to the PICOT question. Filters that were applied included a
publication date of within five years (2016-2021), English language, randomized controlled
trials, and systematic reviews. Boolean terms in the databases were used to expand the search.
The results yielded 94 articles in PubMed, 1751 in PsychInfo, and 1208 in CINAHL.
PsychInfo and CINAHL searches were narrowed down using specific terms to yield more
precise articles related to the PICOT. A more narrowed and filtered search specifying the
adolescent population were added to the CINAHL and PsychInfo searches. Narrowing of terms
in CINAHL and PubMed lowered the yield results to 64 and 445, respectively.
Reviewing the titles and abstracts of the articles yielded 32 relevant studies for the
PICOT questions. The studies were printed in full text, and a total of 15 studies were relevant to
the topic. A final ten articles were chosen using rapid critical appraisals, giving preference to
articles with higher levels of evidence.

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Critical Appraisal and Synthesis of Evidence
Quality of studies was determined using the rapid critical appraisal (RCA) tool. Although
both quantitative and qualitative studies were applicable for this PICOT, qualitative studies
provided more in-depth knowledge into the sun safety habits of adolescent athletes (see
Appendix A, Table A1). Quantitative studies provided data regarding specific education plans
(see Appendix A, Table A2), however, did not often provide insight into reasons why sun safety
practices are lacking in the adolescent population. To compare both the qualitative insights
behind reasoning for lack of sun safety practices and specific education platforms, qualitative
and quantitative studies were compared using a synthesis table (see Appendix A, Table A3).
Among all studies, age groups ranged from school-aged children to college athletes and
most of the studies were performed in the US or Australia. Majority of the participants were
Caucasian. All the studies focused on either behavior leading to poor sun safety practices,
outcome of education on sun safety, pediatric skin cancer risk, or specific education protocols
that increase sun safety practices. Measurement tools among the studies involved interviews,
focus groups, and surveys. Majority of the studies had significant value in changing the attitudes
and behaviors of the participants in their sun safety practices. One study showed participants did
not believe sun safety was applicable based on the climate in which they lived.
Conclusions
The need for educating adolescents, especially those who spend a great deal of time
outdoors, is based off the high quality of evidence gathered from the literature search.
Adolescents are unaware of the consequences that their poor sun safety habits can cause on their
skin. Most adolescents do not have the proper education from schools or sporting teams to teach
them about the dangers that can occur from lack of sun safety practices. Education plans, in

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multiple forms, can bring awareness to the dangers of increased UV exposure and also change
habits related to sun protection. Reducing UV exposure and sunburns can significantly reduce
the risk of pediatric melanoma; therefore, strategic education programs should be implemented
to prevent early sun damage in the adolescent population.
Theory Application
A person’s beliefs about what society portrays as “attractive” and beautiful” can be
greatly influenced by others. The unique emphasis on social influence and external
reinforcement for this project directly relates to the social cognitive theory. Evidenced by the
number of articles that relate to an adolescent’s image of what their skin should look like, the
social cognitive theory is a theory that best depicts the behavior studied for this PICOT (see
Appendix B, Figure 1). The social cognitive theory considers the unique way in which an
individual acquires and maintains a behavior (LaMorte, 2019). The social cognitive theory also
considers a person’s past experiences, which also factors into whether a certain behavior will
occur (LaMorte, 2019). The cornerstone of the social cognitive theory is reciprocal determinism.
This key concept refers to the interactions of a person with their environment, past experiences,
and current behavior to achieve a goal (LaMorte, 2019). In the synthesis of research, the social
cognitive theory was most used (see Appendix, Table A3). From the literature review,
adolescents are under the assumption that tan skin is more desirable, and these thoughts often
come from their environment and peer groups. Looking at personal experiences, behavior, and
the environment, adolescent sun safety practices can be altered by providing education over the
dangers of these social beliefs that influence one’s actions. The social cognitive theory will guide
the focus of this project and help address behavior changes in the adolescent population.
Implementation Framework

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The model chosen to guide this framework is the Iowa Model. The Iowa model provides
guidance for clinicians to help them make clinical decisions that affect healthcare outcomes
(Melynk & Fineout-Overholt, 2019). For this project, the Iowa Model is the best choice since it
will help guide clinicians, coaches, and school administrators to identify opportunities for
education. Often, this model is used when clinicians want to highlight an opportunity for
questioning current practice standard and promote new initiatives (see Appendix B, Figure 2). In
the beginning of this model, a question is asked that clearly states the purpose of the project
(Melynk & Fineout-Overholt, 2019). This question should give clear purpose and boundaries.
This is often done with a PICOT question. The next step of the Iowa model is the topic priority,
meaning that the topic should include a high-risk, high-volume, or high-cost focus (Melynk &
Fineout-Overholt, 2019). After a topic is classified as a priority, assembling and appraising the
evidence is begun (Melynk & Fineout-Overholt, 2019). Sufficient evidence would be collected,
and an RCA tool would be used to determine high levels of research. Designing and piloting the
study would come after the appraisal of evidence and outcomes would be achieved in a
controlled environment (Melynk & Fineout-Overholt, 2019). This small pilot of an
implementation is key to determine if a project can be rolled-out into a larger scale without any
issues (Melynk & Fineout-Overholt, 2019). Piloting a project under this model also means
planning for implementation and evaluation. Evaluation of the structure, process, and the
outcomes all need to be completed before implementing a whole practice change (Melynk &
Fineout-Overholt, 2019). After the change has been determined as appropriate for practice, the
project is integrated and sustained and sustainability is often promoted by site champions
(Melynk & Fineout-Overholt, 2019). Once a project has been fully implemented, tracking and
evaluating results are key to promoting and adopting changes in the healthcare system. For this

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project, the priority topic is adolescent athletes that practice outdoors. The design/pilot program
will be an education program over sun safety conducted at a local Arizona high school. The data
from this project will help create process improvements and promote change regarding sun
safety in local area high schools and among adolescent sporting programs.
Implications for Practice Change
The evidence has shown the need for adolescent education over sun safety is necessary to
help prevent pediatric melanoma rates. Adolescent athletes, who spend their time being exposed
to excessive UV radiation, are lacking proper sun safety practices before being educated (Bagatti
et al., 2016; Orsimarsi, 2019). Often, adolescents have an idea of beauty as bronzed skin, leading
to spending long hours in the sun to achieve a tan (Bagatti et al., 2016; Eastabrook et al., 2018).
To implement change, education over sun safety for the adolescent population should begin with
those who spend the most time outdoors, such as athletes. Those who teach high school athletes
are at the forefront of educating their students over proper sun safety practices. Student athletes
at a local high school in Phoenix, AZ currently do not have an education program in place that
educates athletes over sun safety when practicing outdoors. The project would consist of a presurvey, education program regarding safe sun practices, and a post-survey. The data collected
would give insight into whether an education program would impact sun safety practices for
student athletes. Pre and post survey data would confirm or deny the evidence that states
adolescents are more inclined to participate in sun safety practices after being educated over the
effects of harmful UV radiation.
Potential Outcomes
The potential outcome for the proposed study is an increase in sunscreen use among
adolescent athletes who practice outdoors. With an education program designed to teach

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adolescents about the dangers of UV radiation and potential melanoma risk, an increase in sun
protective behaviors is a hopeful outcome. This education program can be given by a school
nurse, athletic coach, athletic trainer, or athletic director. Adolescent athletes who practice
outdoors represent a vulnerable population that are not properly educated on the harmful effects
of sun damage. With a proper education program given to student athletes before a season
begins, sunscreen use will increase to help protect their skin from UV damage.
Setting and Stakeholders
The setting of this project is a high school in Arizona that has student-athletes that
participate in outdoor sporting events. The main stakeholder for this project is the athletic
director for the high school. The athletic director ensures that all student-athletes are supported in
all aspects of athletics including academics, health, safety, and sport-related concerns. The other
main stakeholder in this project is the athletes, who will benefit from this project. The athletes
will likely decrease unhealthy sun behaviors and increase sun protection methods. This will
prevent sunburns and decrease the chances of developing pediatric melanoma. Pediatric primary
care providers and pediatric dermatologists are important stakeholders in this project due to the
nature of educating this special patient population most at highest risk for sun damage. These
providers are often tasked providing initial sun safety education to patients in their office and this
program will augment that information in an additional setting. Last, the parents of the athletes
will also benefit from this project. Parents will be able to trust that their children are participating
in sun safety behaviors at school while engaging in sporting events outdoors.
Project Description
This project evaluated whether an educational program, developed to teach safe sun
habits, directly impacts increased sun safety habits and melanoma awareness among high school

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15
athletes during their fall sports season. Internal Review Board acceptance was obtained before
starting the project through Arizona State University. Once approval for the project had
occurred, consent was obtained by the athlete and their parent before project implementation.
The athletes were chosen during the fall sports season and participated in a pre-survey at the
beginning of their season to determine their baseline knowledge of sun safety measures. The
athletes then engaged in an education program using a PowerPoint presentation that contains
specific data related to sun safety protocols and pediatric melanoma rates. This educational
PowerPoint included multiple forms of learning such as written text, audio, photos, and graphics.
The athletes were then followed up with two weeks later and provided a post-survey to
determine if the education tool increased their use of sun safety habits while playing outdoors as
well as increasing knowledge over melanoma. With an education program designed to teach
adolescents about the dangers of UV radiation and their potential melanoma risk, an increase in
sun-protective behaviors was a desired outcome.
Participants and Recruitment
The participants in this project were high school athletes on the varsity swim team. The
fall sports season was chosen due to the hot climate of Arizona during this season. The fall sports
season is played during some of Arizona’s hottest months and athletes are easily overexposed to
UV radiation in a short amount of time. The participants identified as female or male. If the
participant played on multiple teams, the participant engaged in the survey and education
program once. The athletic director helped facilitate meeting times with the swim coach and
during these meeting times, the coaches will have the entire team be introduced to the project
idea, by myself, and the athletes can decide if they would like to obtain consent from their
parents and sign consent themselves. Inclusion was screened by the coaches to ensure that the

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athlete is a member of the sports team and the only exclusion criteria included being a non-fall
athlete, a participant that does not want to consent, a child of a parent who does not sign a
consent, and a participant who has been diagnosed with melanoma currently or in the past.
Exclusion was screened by listing exclusions on the consent form to be read by both the
participant and their parent or guardian. Once consent was obtained by a parent, the athlete could
also sign consent.
Data Collection and Analysis
Analysis of the athletes’ surveys took place after the conclusion of the project. All
surveys were kept in a secure location until data analysis was started. The baseline pre-survey
was compared against the post-survey to determine if any sun safety or melanoma knowledge
had increased. The demographic information was also analyzed to conclude if certain genders or
grade levels responded to the education more than others. The pre- and post-survey were the
same questions to better compare answers from before and after the education. Descriptive
statistics were used to compare pre- and post-surveys to determine which categories were
statistically significant. The Intellectus Statistics program was used to input data and run
descriptive statistics on the pre- and post-surveys. No funding was given for this project.
Results
This project showed that adolescent athletes on a fall sports team did not have a good
understanding of sun safety habits at baseline. The students spent an average of four hours per
day in the sun for their respective sport and a majority of the students did not practice sun safety
habits, such as wearing sunscreen, finding shaded areas, and wearing hats. The majority of
students were also unable to distinguish a melanoma skin lesion from a benign one in the presurvey. The post survey did not show a statistical significance in the sun safety habits of the

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
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athletes across the two-week post education period. The post survey also showed no statistical
significance in identifying melanoma lesions. The post survey did show that after the education,
all student athletes were able to identify that sunscreen was the best way to protect against UV
radiation and melanoma was the deadliest form of skin cancer. This project did not have the
intended outcome of increasing sun safety habits among adolescent athletes; however, it did
show that student athletes are able to be educated about UV overexposure and pediatric
melanoma. The intervention can be sustained by creating an education program that is taught at
all grade levels for all sport seasons. Repetitive education might be better digested by the
students than a one-time education and coaches of sports teams can also encourage sun safety
behaviors with their athletes.
Discussion
This project has shown that adolescent athletes need proper education about sun safety
habits and melanoma risk. Although the athletes did not increase their sun safety habits, the
students’ understood sunscreen was the best defense to UV overexposure and melanoma is the
deadliest form of skin cancer. Different forms of education or repetitive education may be a
better solution to having athletes increase sun safety habits than a one-time education program.
Limitations to this project include small sample size (n=6), loss of a participant, and lack of
diversity among fall sports. A learning barrier for the students was the environment where the
education took place. The education was given outdoors before their swim practice began and it
may not have been the best place to conduct education due to many distractions. Challenges
included reminding students to obtain parental consent if they wanted to participate and
coordinating times to give the surveys and education. The findings of this project relate to
previous research in the areas of education and hours spent in the sun. According to Bagatti et al.

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18
(2016), the average athlete spends about 4 hours per day in the sun for their prospective sport.
This matched the survey data of the swim team athletes spending close to 4 hours per day in the
sun. The research also stated that forms of education for athletes might best be given in text
message format (Bagatti et al., 2016; Eastabrook et al., 2018). Recommendations for future
studies would be to include more sports teams in the project to get a better understanding of
baseline sun safety habits among multiple groups of athletes. Education in the forms of
photographs, audio, and reminder text messages may also be a better way to remind students to
engage in safety behaviors. Repetitive education would also be helpful in allowing the students
to better retain the information and more capable of identifying cancerous lesions. Sun safety
habits and melanoma identification among adolescent athletes is a vital way to prevent UV
overexposure and increase risk of melanoma in the pediatric population as well as adulthood.
Education should be in multiple formats and language of education should be easy to understand.
With more education and participation from schools and athletic coaches, impacts on decreasing
melanoma in the adolescent age group can be done.

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Carter, O. B. J., Mills, B. W., Mazzucchelli, G. N., & Carolan, C. W. (2016). Testing children’s
ability to correctly use the “shadow rule” for sun protection. International Journal of
Environmental Health Research, 26(3), 317–325.
https://doi.org/10.1080/09603123.2015.1111311
Centers for Disease Control and Prevention. (2020). Sun Safety.
https://www.cdc.gov/cancer/skin/basic_info/sun-safety.htm

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
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Eastabrook, S., Chang, P., & Taylor, M. F. (2018). Melanoma risk: Adolescent females’ perspectives
on skin protection pre/post-viewing an ultraviolet photoaged photograph of their own facial sun
damage. Global Health Promotion, 25(1), 23–32. https://doi.org/10.1177/1757975916639871
Horsham, C., Ford, H., & Hacker, E. (2020). Promoting sunscreen use in adolescents playing outdoor
sports using UV detection stickers. Preventive Medicine Reports, 19, 101166.
https://doi.org/10.1016/j.pmedr.2020.101166
Hubbard, G., Cherrie, J., Gray, J., Kyle, R. G., Nioi, A., Wendelboe-Nelson, C., Cowie, H., &
Dombrowski, S. (2020). Sun protection education for adolescents: A feasibility study of a waitlist controlled trial of an intervention involving a presentation, action planning, and SMS
messages and using an objective measurement of sun exposure. BMC Public Health, 20.
https://doi.org/10.1186/s12889-020-8265-0
Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and
validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi:10.1111/wvn.12223
LaMorte, W. (2019, September 9). The Social Cognitive Theory.
https://sphweb.bumc.bu.edu/otlt/mphmodules/sb/behavioralchangetheories/behavioralchangetheories5.html
Merkel, E. A., Mohan, L. S., Shi, K., Panah, E., Zhang, B., & Gerami, P. (2019). Paediatric
melanoma: Clinical update, genetic basis, and advances in diagnosis. The Lancet. Child &
Adolescent Health, 3(9), 646–654. https://doi.org/10.1016/S2352-4642(19)30116-6
Melynk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare: A
guide to best practice (4th ed.). Lippincott, Williams & Wilkins

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Moustafa, D., Neale, H., & Hawryluk, E. B. (2020). Trends in pediatric skin cancer. Current Opinion
in Pediatrics, 32(4), 516–523.
Nagelhout, E. S., Parsons, B. G., Haaland, B., Tercyak, K. P., Zaugg, K., Zhu, A., Harding, G.,
Yancey, J., Jensen, J. D., Grossman, D., Wetter, D. W., & Wu, Y. P. (2019). Differences in
reported sun protection practices, skin cancer knowledge, and perceived risk for skin cancer
between rural and urban high school students. Cancer Causes & Control, 30(11), 1251–1258.
https://doi.org/10.1007/s10552-019-01228-5
Orsimarsi, G. (2019). Skin cancer knowledge and prevention practices among young adult athletes.
Journal of the Dermatology Nurses’ Association, 11(3), 113–128.
https://doi.org/10.1097/JDN.0000000000000468
Stölzel, F., Wolff, M., Fieber, V., Glausch, M., Wachs, C., Breitbart, E., Bornhäuser, M., & Seidel, N.
(2020). UV protection for young athletes: Using participatory program planning to develop a
sports schools program. Environmental Health and Preventive Medicine, 25(1), 39.
https://doi.org/10.1186/s12199-020-00872-7
Taylor, M. F., Westbrook, D., & Chang, P. (2016). Using UV photoaged photography to better
understand Western Australian teenagers’ attitudes towards adopting sun-protective behaviors.
International Journal of Adolescent Medicine and Health, 28(1), 45–53.
https://doi.org/10.1515/ijamh-2014-0071
The Skin Cancer Foundation. (2020). Skin Cancer Facts & Statistics.
https://www.skincancer.org/skin-cancer-information/skin-cancer-facts/

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
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SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES

23

Appendix A
Evaluation and Synthesis Tables
Table A1
Evaluation Table for Qualitative Studies
Citation

Theory/Conceptual
Framework

Design/
Method

Sample/Setting

Major
Themes &
Definitions

Measurement/
Instrumentation

Data
Analysis

Findings/Themes

Level/ Quality of
Evidence; Decision for
practice/ application to
practice

Bagatti et al., 2016

None listed but
unconscious thoughts
and ideas are brought
to subjects’ attention

Quasiexperimental
1-group
pretest/posttest
design

n= 72 female
college athletes
who represented
the rowing,
soccer, and
lacrosse teams.

Research
questions
were specific
to behaviors,
knowledge,
and attitudes
regarding
sun safety.

Pre-test
questionnaire and
post-test
questionnaire.

Descriptive
statistics

Pre-intervention
behaviors included
high sun exposure,
poor attitude and
concern over sun
safety, and no care
related to skin.

Level II

Assessing behavior,
knowledge, and
attitudes about
melanoma: An
educational
intervention for female
college athletes.

United States
No funding
Bias- convenience
sample of
predominately white,
college-age, females at
one university; no
established reliability
for the pre-test in

Evaluate the
knowledge,
behaviors, and
attitudes of
college
athletes
regarding skin
cancer

Study conducted
at a small,
private, liberal
arts university in
Western
Pennsylvania.

All subjects were
at least 18yo and
active in a
collegiate sport

Chi-square
Pre-test included
a 28-item
questionnaire to
assess risk,
knowledge, and
behaviors related
to sun safety.
Also included
four images of
normal and
abnormal nevi to
assess subject’s
ability to identify
abnormal skin
lesions.

Paired ttests

McNemar
test

Post-test results
showed significant
improvement in
behaviors,
attitudes, and
knowledge.

Changing the culture of
sun protection and
addressing college
athletes about the
problems with increased
sun exposure can help
reduce the burden of
melanoma on this
population

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
Citation

24

Theory/Conceptual
Framework

Design/
Method

Sample/Setting

Major
Themes &
Definitions

Measurement/
Instrumentation

Data
Analysis

Findings/Themes

Level/ Quality of
Evidence; Decision for
practice/ application to
practice

Social Theory

Determine
whether
viewing a
personal
photoaged
photograph
had the
capacity to
alter Western
Australian
teenagers’
pro-tanning
attitudes

Female n=10

Five
questions
were aimed
at eliciting
data on
participants
existing
attitudes on
sun
protective
behaviors

Interviews

Transcribed
interviews

Teenagers had the
existing attitude
that is important to
use sunscreen, but
they often forget

Level II

Americans. No validity
for post-test.

Taylor et al., 2016
Using UV photoaged
photography to better
understand Western
Australian teenagers’
attitudes towards
adopting sun-protective
behaviors
Australia
Funding- none
Bias- Small scale
sample size

Male n=5
N=15
All 15 years old
Lived in Perth,
Australia

Seven
questions on
how theses
perceptions
changed
once they
viewed their
UV
photoaged
photograph

Inductive
reasoning
to refine
interviews
into themes
and
subthemes

Greater effort needs to
be focused on increasing
teenagers’ understanding
of how sun-damage
occurs

After viewing their
photo, the results
did not alter their
desire to remain
tan

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES

25

Citation

Theory/Conceptual
Framework

Design/
Method

Sample/Setting

Major
Themes &
Definitions

Measurement/
Instrumentation

Data Analysis

Findings/Themes

Level/ Quality of
Evidence; Decision
for practice/
application to
practice

Eastabrook et al.,
2018

Social Theory

Interpretative
phenomenological
analysis

n= 10

Intentional
UVR
exposure is
known to
accelerate
the ageing of
skin

Interviews
(pre/post)

Interpretive
phenomenological
analysis using
coding of
recurring patterns
with the interview
data.

Four major
themes and nine
subthemes were
extracted from the
interviews

Level II

Melanoma risk:
adolescent females’
perspectives on skin
protection pre/postviewing a ultraviolet
photoaged photograph
of their own facial sun
damage

Australia

No funding

Bias- study limited to
small sample size of
specific, age, gender,
and race.

All participants
are female,
between 1617yo,
Caucasian,
resided in
Western
Australia

Study to
help
adolescents
understand
their won
perspectives
on sun
tanning and
attitudes
towards
adopting sun
safety
behaviors
both pre/post
viewing a
UV
photoaged
photo of
their face

1 normal flash
picture

1 photoaged
picture

Overarching
themes included:
having a tan and
looking good in
the short term is
okay, however, in
the longer-term
you can end up
looking far worse,
but still a tan is
worth it.

Skin protection
interventions that
lessen the belief of
invincibility around
adolescent females’
understanding of
their risk of
melanoma is vital to
lessen the incidence
of melanoma.

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES

26

Citation

Theory/Conceptual
Framework

Design/
Method

Sample/Setting

Major
Themes &
Definitions

Measurement/
Instrumentation

Data Analysis

Findings/Themes

Level/ Quality of
Evidence; Decision
for practice/
application to
practice

Carter et al., 2016

Piaget’s Theory of
Cognitive
Development

Questionnaire

n=76

The
“Shadow
Rule” is an
immediate
indicator of
sunburn risk
following
the
mnemonic
“short
shadow?
Seek shade!”

Education
session

One- sample t test

Children
experienced
greatest difficulty
judging their
shadows’ lengths
when they were
equal to their
height. At all
other angles they
demonstrated a
92% accuracy and
could correctly
interpret the SR

Level II

Testing children’s
ability to correctly use
the “Shadow Rule”
for sun protection.

Shadow Simulator
Estimate sun-cast
shadow length
relative to their
height and
whether this
meant they should
seek shade

Australia
No funding
Bias- Small sample
size; one age group

10-year-old
children in fifth
grade
48% were
female

Response sheet“longer, “same
length” or
“shorter”
Tested their own
shadow and
30cm tall doll

10-year-old children
are capable of
applying the SR.
Further education
needed to determine
if understanding the
SR would translate
into sun protection
behavior changes.

Questions
over a
person’s
ability to
discern
when their
shadows are
short vs long
Stozel et al., 2020

UV Protection for
young athletes: using
participatory program

Health Action
Process Approach
Social Learning
Theory

PPP groups were
conducted with
students, teachers,
coaches, and
school
administrators to

2 schools
Total:
Students n=
115

CSSP aims
at enforcing
positive
attitudes
toward UVR
protection

Interviews

Frequency of
adjectives were
collected- word
clouds

Less than 50% of
school
administrators
and coaches
expressed
positive attitudes

Level II
CSSP promotes
positive attitudes
towards UVR
protection. PPP is

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
Citation

Theory/Conceptual
Framework

planning to develop a
sports school program
Germany
Funding: German
Cancer Aid in the
campaign “Clever in
Sun and shade”;
Program for
development of
interdisciplinary
oncology centers of
excellence in
Germany
Bias: Small sample
size; may be biased
by social desirability

Design/
Method

Sample/Setting

Major
Themes &
Definitions

test CSSP
program
feasibility and
acceptance

Teachers n= 5

and
supporting
school sports
in establish
UVR
protection
strategies

School
administrators
n=4
Coaches n=5

27
Measurement/
Instrumentation

Data Analysis

Findings/Themes

Level/ Quality of
Evidence; Decision
for practice/
application to
practice

Positive vs
negative

toward UVR
protection, less
than 10%
reported
appropriate UVR
behavior. After
CSSP program,
80-86% of
participants
expressed
positive
adjectives to
describe the
importance of
UVR protection

valuable in allowing
tailored messages to
meet schools’ needs.

Descriptive
Analysis

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES

28

Appendix A
Evaluation and Synthesis Tables
Table A2
Evaluation Table for Quantitative Studies
Citation
Nagelhout et al., 2019

Differences in
reported sun
protection
practices, skin
cancer
knowledge, and
perceived risk for
skin cancer
between rural
and urban high
school students.
United States

Theoretical/
Conceptual
Framework
None listed
but social
theory is
inferred

Design/ Purpose

Sample/Setting

Variables

Measure/
Instrument

Data
Analysis

Findings

LOE/ Application to
practice/Generalization

Survey

Total n=1570
students.

IV: Sun safety
information

QuestionnaireSun Habits
Survey using
Likert Scale

Descripti
ve
Statistics

US vs RS: Rural students
had lower odds of
wearing sunscreen (95%
CI, p= 0.022), reapplying sunscreen (95%
CI, p=0.002), wearing
long sleeves (95% CI,
p=0.004), and seeking
shade compared to urban
students (95%CI,
p=0.005).

Level II

Evaluate
differences in sun
protection
practices, skin
cancer
knowledge, and
perceived risks
between rural and
urban high school
students

Non-Hispanic
white (n=863)

Hispanic (n=
341)

Male (n= 735)

Female (n=
812)

DV1:
Adolescents in
rural areas
DV2:
Adolescents in
Urban areas

Assessing sun
protection and
intentional
tanning,
sunburn
occurrence,
skin cancer
knowledge,
perceived risk

Chisquared

Logistic
regression

GLMM

RS also had higher
number of reported
sunburns than US. RM in
rural areas had higher
odds of wearing pants,
hats, and sunglasses than
UM. RF had lower odds

Strengths: First study to
compare skin cancer
prevention knowledge
and risk factors between
rural and urban
adolescents.

Weaknesses:
Demographics were
mainly white nonHispanics.

Variability in
socioeconomic factors

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
Citation
Funding: Undergraduate
Research Opportunities
Program at the University of
Utah

Bias: Self-reporting may
cause bias

Theoretical/
Conceptual
Framework

Design/ Purpose

Sample/Setting

Variables

Family history
of skin cancer
(n=444)

for skin cancer,
and
demographic
information.

Attended rural
school (n=485)

Attended urban
school
(n=1085)

Rural vs Urban
High school
studentsfrequency of
sun protection
methods along
with skin
cancer related
knowledge

29
Measure/
Instrument

Data
Analysis

Findings
of wearing sunglasses
than UF. RS had lower
perceived knowledge of
skin cancer risks tanning
between RS and US.

LOE/ Application to
practice/Generalization

Use of sun protection
was self-reported and
may be biased
Application to Practice:
Geographical and gender
differences should be
considered when
developing skin cancer
prevention programs or
education for
adolescents.

All schools
based in Utah11 schools
participated
located in three
counties- one
urban and two
rural.

Mean age is
15.7

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
Citation
Hubbard et al., 2020
Sun protection education for
adolescents: a feasibility
study of a wait-list
controlled trial of an
intervention involving a
presentation, action
planning, and SMS
messages and using
objective measurement of
sun exposure

Theoretical/
Conceptual
Framework
Common
Sense Model
of Illness
Representati
on and Selfregulation
Health
Action
Process
Approach

United Kingdom

Promoting sunscreen use
and sun-protective practices
in NCAA athletes: Impact

Sample/Setting

Variables

Measure/
Instrument

Data
Analysis

Findings

LOE/ Application to
practice/Generalization

Mixed Methods

Males and
females ages
13-15 from 6
schools across
different parts
of Scotland

IV: Sun
protection
education

Mexameter to
measure
melanin and
erythema
levels

Descripti
ve
Statistics

Melanin increased

Level II

Erythema decreased

Paired
analysis

68% of students read the
booklet, 92% listened to
the presentation, and
39% received text
messages. 27% of
students did all three.

Strengths: Objective
measurements of
melanin is feasible in
schools and acceptable
in adolescents

Feasibility study
of a wait-list
controlled trial
with five schools
allocated to the
research team and
one school to a
wait-list control
group. The last
school recruited
was allocated to
the control group.

n= 487 students
intervention
group= 385

DV: Melanin
and erythema
measurements
Qualitativeadolescent
view of overall
education
programs and
value in sun
safety
protection
measures

Qualitativefocus groups

Crosstabulation
s

Qualitativ
e:
transcript
s

Focus groups:
Adolescents did not see
the relevance of sun
protection in the UK for
their age group

Assess the
feasibility and
acceptability of a
sun protection
education
intervention with
an additional
intervention-SMS

Bias- small number of
mainly Caucasian
adolescents; Study
conducted in a country with
inclement weather.

Ally et al., 2017

Design/ Purpose

Study was not
randomized

Funding- Chief Scientist
Office of Scotland

30

Social
Theory

Measure impact
of educational
intervention on
sun protection

Weaknesses: mainly
white adolescents; study
conducted in a country
with mostly inclement
weather
Application to practice:
Can objectively measure
erythema and melanin
levels in students before
and after a school
holiday.
Possible to implement
sun protection education
interventions

n= 846 NCAA
athletes
surveyed in
September 2012

IV: Sunsport
education

Survey

Wilcoxon
rank-sum
test

Significant increase in
sunscreen use 4 or more
days per week by student

Level II
Strength: further
confirmed previous
studies in which sun

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
Citation
of SUNSPORT educational
intervention for studentathletes, athletic trainers,
and coaches

Theoretical/
Conceptual
Framework

Design/ Purpose

Sample/Setting

Variables

31
Measure/
Instrument

DV: sun safety
and skin cancer
risk

beliefs and
practices of
student athletes

Data
Analysis

Findings

LOE/ Application to
practice/Generalization

Chisquare

athletes (26% to 39%,
p=.02).

safety behaviors increase
with education programs

Fisher’s

Increase in students
being spoken to by their
coaches about sun safety
(26% to 57%, p=.0001)

Weakness: One
university surveyed;
Some student surveyed
did not practice outdoors

Student athlete’s
recognition of higher
skin cancer risk (54% to
67%, p= .04)

Application to Practice:
Education for student
athletes, coaches, and
athletic trainers can
greatly impact sun
protective practices.

Most results showed that
young athletes do not
report an increased use of
sun protection methods,
such as sunscreen or
protective clothing,
although they are
frequently exposed to the
sun

Level II

United States
Funding: None
Bias: Recall bias

Orsimarsi, 2019
Skin cancer knowledge and
prevention practices among
young adult athletes
Funding: none
Bias: none

Health
Promotion
Model

Systematic
Review

PubMed
Science Direct
Within the past
five years
8 studies

Searched with
terms: skin
cancer,
melanoma,
prevention,
young adults,
athletes,
behaviors,
attitudes,
knowledge

Questionnaires
RCTs
Quasiexperimental
Surveys

Descripti
ve
statistics
t-tests

Young athletes
participating in outdoor
sports are at an increased
risk for developing skin
cancer due to excessive
UVR while practicing
and competing

Results from the 8
studies show that
frequent sun exposure
does not impact young
athletes use of protective

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
Citation

Moustafa et al., 2020
Trends in pediatric skin
cancer
USA
Funding- The Dermatology
Foundation and the Harvard
Medical School Eleanor and
Miles Shore Fellowship
award
Bias- none

Theoretical/
Conceptual
Framework

Design/ Purpose

None listed
but Health
Promotion
Model
inferred

Systematic
Review

Sample/Setting

Variables

32
Measure/
Instrument

Data
Analysis

Findings

LOE/ Application to
practice/Generalization
clothing or preventative
measures.

Identify
pediatric cancer
characteristics,
underlying
genetic drivers,
and options for
melanomas
arising in
childhood and
adolescence
66 studies

Key termsmelanoma,
oncology, skin
cancer,
pediatrics,
treatment

Case studies
Clinical Trials

Descripti
ve
Statistics

Melanoma in pediatric
patients differs from
conventional adult
melanoma. Pediatric
patients with melanoma
should be screened for
predisposing risk factors.
More research is needed
for treatments on those in
the pediatric population
that are used for adults.

Pediatric melanoma is
rare and can occur in a
variety of presentations.
More research is needed
on therapeutic
treatments.

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES

33

Table A3
Synthesis Table
Study

Ally et al.,
2017

Bagatti et
al., 2016

Carter et
al., 2016

Eastabrook et
al., 2018

Hubbard et
al., 2020

Moustafa et
al., 2020

Orsimarsi et
al., 2019

Nagelhout et al.,
2019

Stozel et al., 2020

Taylor et al.,
2016

Design/LOE

CT; II

QE; II

Qual; II

Qual; II

MM; II

SR; I

SR; II

MM; II

Qual; II

Qual; II

846

72

76

10

487

66

8

1570

115

15

USA

USA

Australia

Australia

United
Kingdom

USA

USA

USA

Germany

Australia

Sample
n subjects
Country
Measurement
Tools
Survey

X

X

X

Interview

X
X

Focus Group

X

X

X

X

X

Various

X

X

Framework
Social theory
Piaget’s
Theory of
Cognitive
Development
Common
Sense Model

X

X

X

X

X

X

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
Study

Ally et al.,
2017

Bagatti et
al., 2016

Carter et
al., 2016

Eastabrook et
al., 2018

Hubbard et
al., 2020

34

Moustafa et
al., 2020

Orsimarsi et
al., 2019

Nagelhout et al.,
2019

Stozel et al., 2020

Taylor et al.,
2016

of Illness
Representation
Health Action
Process

X

Health
Promotion
Model

X
X

X

IV
Sunsport
Education

X

Shadow Rule
Education

X

UV aged
photograph

X

Sun protection
education

X
X

Pediatric Skin
Cancer

X

X

X

X

X

X

DV
Sun safety and
skin cancer
risk
Melanin and
Erythema
Measurements

X

X

X

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

X

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
Study

Ally et al.,
2017

Bagatti et
al., 2016

Carter et
al., 2016

Eastabrook et
al., 2018

Hubbard et
al., 2020

Therapeutic
Pediatric
Cancer
Treatments

35

Moustafa et
al., 2020

Orsimarsi et
al., 2019

Nagelhout et al.,
2019

Stozel et al., 2020

X

X

Taylor et al.,
2016

X

Outcomes
Education
improves
knowledge of
sun safety
behaviors

X

X

Increase in
sunscreen use

X

X

X

Increase
knowledge of
skin cancer
risk

X

X

X

Coaches
educate
athletes

X

Ability to
know when to
seek shade
based on
shadow length
Screening is
necessary to
reduce

X

X

X

X

X

X

X

X

X

X

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

X

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES
Study

Ally et al.,
2017

Bagatti et
al., 2016

Carter et
al., 2016

Eastabrook et
al., 2018

Hubbard et
al., 2020

36

Moustafa et
al., 2020

Orsimarsi et
al., 2019

Nagelhout et al.,
2019

Stozel et al., 2020

Taylor et al.,
2016

pediatric skin
cancer risk
Themes
Sun safety
behaviors
increase with
proper
education

X

X

X

X

X

X

X

X

PreIntervention
included poor
sun safety
attitudes and
behaviors

X

X

X

X

X

X

X

X

Young female
adolescents
believe having
tan is a
measure of
beauty

X

X

X

Education
over sun
safety did not
change
tanning
behavior

Key Terms: CI- confidence interval; CSSP- Clever in Sun and Shade Program; CT- controlled trial; DV- dependent variable; GLMM- generalized linear mixed
modeling; h-hours; II- Level 2; IV- independent variable; N- total number of participants; n- number of participants; NCAA- National Collegiate Athletic
Association; PPP- participatory program planning; QE- quasi-experimental; Qual- Qualitative; RF-rural females; RM- rural males; RS- rural students; SMSshort messaging system; SR- shadow rule UF- urban females; UM- urban males; US- urban students; UVR- ultraviolet radiation

X

X

X

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES

37

Appendix B
Theory Application and Implementation Framework
Figure B1
Social Cognitive Theory

BEHAVIOR

PERSONAL FACTORS

ENVIORNMENT

SUN PROTECTION HABITS AMONG ADOLESCENT ATHLETES

38

Appendix B
Theory Application and Implementation Framework
Figure B2
The Iowa Model

(Iowa Model
Collaborative, 2017)