Ozcan AYGUN*, PhD Ayse ERGUN*, PhD, RN, Assistant Professor Impact of a School-Based Sun Protection Program on the Sun-Protective Behaviors of Turkish Adolescent Ozcan AYGUN*, PhD Ayse ERGUN*, PhD, RN, Assistant Professor *Marmara University Health Science Faculty, Division of Nursing, Public Health Nursing Department, Istanbul, TURKEY 24th International Nursing Research Congress, Prague, Czech Republic, 22-26 July 2013

Bosphorus ISTANBUL/TURKEY I came from Istanbul. Istanbul is the largest city in Turkey, between the Sea of Marmara and the Black Sea. Bosphorus ISTANBUL/TURKEY

INTRODUCTION The incidence of skin cancers continues to increase The primary cause of skin cancer is chronic unprotected exposure to the sun’s ultraviolet light, as well as intense, intermittent exposures. A high level of sun exposure in childhood is a strong determinant of melanoma risk in adulthood

INTRODUCTION (continued) Sun protection programs may be particularly important during adolescence because this is a time of increased sun exposure and decreased parental influence.

AIM The purpose of this research was to investigate the effect of a Sun Protection Program (SPP) on the sun protection behavior of adolescents.

METHODS

Design A quasi-experimental design with pre-test, post-test and follow up and a control group.

Participants The study was conducted with 180 adolescents in the 6th and 7th grades at two private schools in Sakarya/Turkey during the academic year 2011- 2012. The schools were in the same district and the socioeconomic demographics of the students were similar.

Sakarya Province is a province in Turkey, located on the coast of Black Sea, It is closer to İstanbul. (Kaynak:http://en.wikipedia.org/wiki/Sakarya_Province) Sakarya

Participants (continued) A group from the schools was selected as the intervention group (n=96), and another group as a control group (n=84). The students in the intervention and control groups were in different schools. The study was completed with 147 students (intervention group: 76; control: 71) who participated in the pre-test, post-test and follow- up tests (participation rate, 81.6%).

Procedures Permission to conduct the research in the schools was also obtained from the school administrations and the local education authority. The ethics board approval was obtained from Marmara University.

Instruments The information sheet TTM sun protection and sunscreen stages Sun Protection Behavior Scale (SPBS) The Decisional Balance Scale (DBS The Self-Efficacy Scale (SES)

Intervention: Sun Protection Program The Sun Protection Program (SPP) had 3 basic objectives. These were to (1) give the participants an awareness of the effects of UV radiation on health and (2) the risk of extreme exposure to UV rays, as well as (3) encourage them to establish and practice sun protection behavior

Intervention (continued) The adolescents in the intervention group were provided the education for a period of 6 weeks in the period March-May 2011. The sun protection programs were accepted 6 posters, a 12-page family guidebook, a 12-page student handbook, 4 puzzles, educational videos and a UV-sensitive Frisbee game were among the tools prepared for and used in the education.

Data collection Data were collected in the students' classes during the hours advised by the school administration. The first author was present at the school in order to provide that the questionnaires were answered independently and confidentially and to help when necessary.

Data Analysis The chi-square, Repeated Measures ANOVA and MANOVA, the Paired Samples t test were used. Covariants were calculated in the pre-test scores and covariance analysis performed to measure the effect of the SPP on the intervention group. The impact of the intervention was evaluated using structural equation modeling (SEM).

Lake Sapanca-Sakarya/TURKEY Sapanca is a town and district of Sakarya Province. It is a touristic destination where closer to İstanbul.

RESULTS

Descriptive The average age of the students 12.10 ± 0.68. Students to 50.3% of girls and about 1/3's personal characteristics of the risk of skin cancer. No significant difference was found in the study between students in the intervention and control groups in terms of grade, gender, family economic status, hair color, eye color, skin color or skin type (p>.05).

TTM stages of change Table 1. Intervention effect on groups Stage Baseline Post test Follow-up p η2 Means±SD Sunscreen use Intervention 2.52±1.69 3.14±1.47 2.13±1.52 .037 .023 Control 2.30±1.42 2.25±1.46 1.85±1.40 Sun protection 2.35±1.57 2.71±1.44 2.14±1.43 .336 .008 2.35±1.53 2.26±1.48 2.01±1.43 Note: Sample size with complete data at baseline, post and follow-up points included in analyses, N =147, repeated measures ANOVA (Intervention n=76, control n = 71) In the post-hoc analyses, the fact that the stage of change of the intervention group in terms of sunscreen use on the post-test was more advanced than that of the control group was statistically significant (F=13.51, p=.000, η2=.085). (Table 1). In terms of the stages of change in sun protection in the intervention and control group, group-time interaction was not seen to be significant (p= .314, η2= .008). (Table 1).

Sun protection behavior Table 2. Intervention effect on groups Scale Groups Baseline Post test Follow-up p η2 Means±SD SUN PROTECTION BEHAVİOR Intervention 24.91±7.62 27.49±6.59 24.26±7.05 .058 .039 Control 25.61±6.81 25.42±6.74 22.72±6.16 Sun avoidance behavior 9.48±3.22 9.70±3.17 .038 .044 10.03±3.07 9.20±2.46 Sunscreen use behavior 9.37±4.02 10.38±3.56 9.75±3.82 .192 .023 9.65±3.98 9.76±3.80 8.46±3.53 Hat use behavior 5.70±2.49 6.14±2.24 4.94±2.50 .324 .016 5.93±2.35 5.70±2.30 5.06±2.28 Note: Sample size with complete data at baseline, post and follow-up points included in analyses, N =147, repeated measures ANOVA (Intervention n=76, control n = 71) 10.79±2.69 9.96±2.84 In terms of the sun avoidance behavior mean scores, group (intervention vs control)-time interaction was significant (p=.047, η2=.044). The SPBS did not find a significant group-time interaction in sunscreen or hat use (p=.058, η2=.039; p=.192, η2=.023; p=.324, η2=.016, respectively) (Table 2). In the post-hoc analysis, the post-test scores for sun avoidance in the intervention group and the follow-up scores for sunscreen use were higher and more significant than in the control group (F=4.04, p=.046, η2=.027; F=4.78, p=.030, η2=.032, respectively).

Pros and cons Table 3. Intervention effect on groups Scale Groups Baseline Post test Follow-up p η2 Means±SD PROS Intervention 13.62±4.47 15.08±3.88 14.15±3.53 .007 .067 Control 14.97±3.85 14.06±3.53 13.76±4.04 CONS 11.00±4.58 8.99±4.44 10.65±4.24 .063 .038 10.04±4.24 9.66±3.65 9.72±3.75 Note: Sample size with complete data at baseline, post and follow-up points included in analyses, N =147, repeated measures ANOVA (Intervention n=76, control n = 71) Group-time interaction in terms of pros were found to be significant (p=.007, η2=.067) (Table 3). However, there was no difference between the intervention and control groups in terms of the pros scores on the post-test and follow-up test (F=3.62, p=.059, η2=.024; F=2.98, p=.086, η2=.020, respectively). The pros on the post-test compared to the pre-tests of the intervention group was found to be significant (t=-2.62, p=.011). Time-group interaction was not found to be significant in terms of cons scores (p=.063, η2=.038) (Table 3).

Self efficacy Table 4. Intervention effect on groups Scale and sub-scales Groups Baseline Post test Follow-up p η2 Means±SD SELF EFFICACY Intervention 26.03±9.43 29.92±7.89 26.96±8.89 .000 .109 Control 29.06±8.51 26.45±8.55 24.77±7.38 Sun avoidance self efficacy 8.06±3.53 9.55±3.10 9.23±4.75 .106 9.06±3.27 7.99±3.05 7.93±2.60 Sunscreen use self efficacy 11.96±4.60 13.85±3.74 12.44±4.38 .006 .068 13.52±4.32 12.66±4.90 11.72±4.32 Hat use self efficacy 5.55±2.68 6.39±2.20 5.58±2.51 .005 .072 6.48±2.40 5.80±2.05 5.13±2.14 Note: Sample size with complete data at baseline, post and follow-up points included in analyses, N =147, repeated measures ANOVA (Intervention n=76, control n = 71) Time-group interaction in self-efficacy in terms of self-efficacy, sun avoidance, sunscreen use, and hat use was found to be statistically significant (p=.000, η2=.109; p=.000, η2=.106;p=.006, η2=.068; p=.005, η2=.072, respectively; see Table 4). The SES scores of the control group on the pre-test and of the intervention group on the post-test were higher and significant (F=4.16, p=.043, η2=.028; F=6.54, p=.012, η2=.043, respectively). A significant difference was seen between the groups in the sun avoidance self-efficacy post-test and in the pre-test in sunscreen use self-efficacy (F=11.16, p=.001, η2=.071; F=4.23, p=.041, η2=.028, respectively).

Effect of the intervention The results of the analysis of covariance in this study showed that the SPP was effective in the intervention group in the post-test in terms of sun protection behavior, self-efficacy and perceiving pros; it was not effective in the follow- up test (Effect size= 0.29 and Z>1.96). X2= 75.53, P= .06; CFI= .97, RMSEA= .046; % 90 GA: .00 - .07

Effect of SPP on the boys and girls The results of the repeated measures analysis of variance carried out separately with girls and boys in order to evaluate sun protection behavior, pros and cons perceptions and the effect of the SPP on self-efficacy are presented in Table 5, 6 and 7.

Table 5. Intervention effect on groups at baseline and after post and folow-up tests of the girls and boys Scale Gender Groups Baseline Post test Follow-up p η2 Means±SD SPBS Girls Intervention 26.97±7.89 28.82±6.30 23.80±7.16 .624 .007 Control 27.06±5.38 28.06±5.84 24.90±6.20 Boys 22.61±6.68 26.00±6.66 24.77±6.97 .009 .064 24.34±7.68 23.13±6.68 20.81±5.52 SPBS: Sun protection behavior scale Note: Sample size with complete data at baseline, post and follw-up points included in analyses, N =147, repeated measures ANOVA (Girls: intervention group n =40, control group n = 33; Boys: intervention group n =36, control group n = 38). While no significant difference was found between the girls in the intervention and control groups in terms of their sun protection behavior mean scores, there was a statistically significant difference among the boys (p=.624, η2=.007; p=.009, η2=.064, respectively) (Table 5). In the post-hoc analysis, the SPBS scores of the intervention group were significantly higher than those of the control group in the follow-up test (F=7.38, p=.008, η2=.093).

Table 6. Intervention effect on groups at baseline and after post and folow-up tests of the girls and boys Variables Gender Groups Baseline Post test Follow-up p η2 Means±SD PROS Girls Intervention 15.20±3.85 16.62±2.61 14.25±3.36 .008 .066 Control 16.54±2.88 15.24±3.33 15.36±3.13 Boys 11.97±4.37 13.41±4.23 13.77±3.58 .054 .040 13.60±4.09 13.02±3.41 12.36±4.26 CONS 12.07±4.59 8.75±4.11 11.22±3.84 .014 .058 10.63±4.63 10.21±3.99 10.06±3.63 9.94±4.22 9.47±4.65 10.00±4.36 .969 .000 9.52±3.84 9.18±3.30 9.42±3.86 Note: Sample size with complete data at baseline, post and follow-up points included in analyses, N =147, repeated measures ANOVA (Girls: intervention group n =40, control group n = 33; Boys: intervention group n =36, control group n = 38). The sun protection pros and cons perception mean scores of the female students were found to be significantly different in terms of group-time interaction (p=.008, η2=.066; p=.014, η2=.058, respectively). Among the boys, there were no significant differences in the sun protection pros and cons perception mean scores in terms of group-time interaction (p=.054, η2=.040; p=.969, η2=.000, respectively) (Table 6). However, no significant differences were seen in the intervention and control groups in the post-hoc analysis of the pre-, post- and follow-up scores, in terms of the pros and cons perceptions of the girls (p=.102, p=.051, p=.151, respectively) or boys (p=.102, p=.663, p=.129, respectively). When the group was examined within itself, a statistically significant increase was seen in the post-test pro scores of the girls in the intervention group compared to the pre-test and a drop in the follow-up scores as compared to the post-test (t=-2.17, p=.036; t=3.34, p=.002, respectively). In terms of the cons, the drop in the scores of the intervention group girls in the post-test compared to the pre-test is significant and a positive indicator (t=4.64, p=.000). However, the increase in the cons of the intervention group girls in the follow-up test compared to the post-test was also found to be significant (t=-2.83, p=.007).

Table 7. Intervention effect on groups at baseline and after post and folow-up tests of the girls and boys Variables Gender Groups Baseline Post test Follow-up p η2 Means±SD SELF EFFICACY Girls Intervention 27.70±9.78 30.62±7.80 25.50±8.11 .111 .030 Control 30.63±7.65 29.03±7.82 27.36±7.29 Boys 24.16±8.79 29.13±8.02 28.58±9.53 .000 .106 27.68±9.05 24.21±8.62 22.52±6.78 Note: Sample size with complete data at baseline, post and follw-up points included in analyses, N =147, repeated measures ANOVA (Girls: intervention group n =40, control group n = 33; Boys: intervention group n =36, control group n = 38). While no significant differences were seen between the intervention and control groups in terms of the girls' SES mean scores, the boys' mean scores exhibited a significant difference between the intervention and control groups (p=.111, η2=.030; p=.000, η2=.106, respectively) (Table 7). In the post-hoc analysis, the SES scores of the boys in the intervention group were significantly higher both in the post- and in the follow-up test compared to those of the control group (F=6.46, p=.013, η2=.082; F=10.00, p=.002, η2=.122, respectively).

Maiden's Tower ISTANBUL/TURKEY

DISCUSSION Positive changes in intervention group sun protection behavior have been traced in the literature in TTM-based experimental research on adolescents and adults.

DISCUSSION (continued) The present study found the SPP to be effective in the post-test, but relapses were seen in sun protection behavior as well as in pros and cons perceptions and in self-efficacy in the follow-up period. Parallel to these findings, some study results in the literature.

LIMITATIONS This study is limited to a small sample of students at two private schools. Short-term intervention Non stage based intervention for TTM

CONCLUSION The study showed that a school-based SPP was effective in the short term in achieving progress in the TTM stages of change and in improving sun avoidance behavior and self-efficacy and that the program may be used in school to increase sun protection behavior

FUTURE DIRECTIONS School-based, nurse-led, short-term SPP's that encompass group interventions are successful in developing sun protection behavior and will be useful in the future in the context of school nursing activities. The SPP was more successful in male. It is for this reason that more advanced studies should be conducted to increase the impact of the SPP on girls. Future TTM-based studies with longer interventions may be more effective in developing sun protection behavior in adolescents.

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