Adolescence is a critical period for reducing the risk for skin cancer, which has risen in incidence over the past several decades more rapidly than any other cancer [1]. In 2021, melanoma, the most severe form of skin cancer, was the fifth most common form of cancer in the USA [2]. Although largely preventable through limiting exposure to ultraviolet (UV) radiation [2], melanoma carries a profound social and economic burden [3] and is increasingly impacting adolescents and young adults [4].

Adolescence brings increasing independence from parental control, pressure to conform to social norms, intense focus on appearance, and experimentation with new experiences [5]. This developmental period, more than any other, leads to increased risk behaviors, including excessive UV exposure [6]. Effective prevention programming for adolescents is imperative to reduce risk factors and to reinforce and sustain recent declines in indoor tanning [6].

The development of evidence-based interventions for improving UV risk and protective behaviors among adolescents has lagged behind programing for younger children [4]. Although schools are a logical and efficient venue to reach large numbers of adolescents with skin cancer prevention messages, programs for middle and high school students have generally been brief and focused exclusively on educational information, and evidence of effectiveness has been limited to short term changes or greater gains in knowledge than behavior [7,8,9,10,11].

School-based peer leader programs that engage older adolescents in developing and delivering skin cancer prevention messages to younger adolescents are poised to effectively address this gap. Such approaches are grounded in the Theory of Active Involvement, which posits that the process of developing prevention messages for one’s peers (or “near peers”) can give rise to self-reflective processes, which in turn, can bring about changes in relevant attitudes, norms, intentions, and behaviors among peer leaders [12]. Peer leaders can ensure that prevention messages are relevant, reflective of youth culture, and tailored to local preferences and learning styles [13]. They also capitalize on the power of social networks to shape behavior; young adolescents are likely to identify with peers (especially slightly older, “aspirational” peers) and perceive them as credible. As such, they are more likely to change attitudes, normative beliefs, intentions, and behaviors in response to messages developed and delivered by peers than by teachers, parents, or other adults [13].

Peer leader programs also simultaneously provide a mechanism for sustainably integrating prevention programming into educational curricula while supporting schools in their academic mission. The latter is especially important as schools are under increasing pressure to focus on core academic subjects and mandates such as 21st Century Skills [14], project-based learning (PBL), and service learning. Promising empirical support for this approach comes from studies demonstrating the effectiveness of peer leaders in developing and/or delivering skin cancer [15, 16], tobacco [17], and substance use [18] prevention messages to the same age or younger youth.

Other evidence demonstrates the effectiveness of narrative videos for conveying prevention messages to peers. The narrative approach was pioneered by Hecht and Miller-Day in the “keepin’ it REAL” program, which was shown to be effective in reducing youth substance use and selected as a model program by SAMSHA [18]. Stories map to the way individuals naturally process and store information; they engender less reactance than traditional health messages; and elicit more emotional arousal, making them more memorable and impactful [19, 20].

In this study, we designed, implemented, and evaluated the YES-CAN! program, a peer leader program in which high school students are supported in developing short narrative skin cancer prevention videos and delivering them, along with additional educational information about skin cancer and skin cancer prevention, to middle school students in the same school community. We evaluated the program’s effectiveness in improving skin cancer-related attitudes, perceived norms, and behavioral intentions both among the middle school students exposed to program materials and among the high school students who developed them.

Methods

Program Description

The YES-CAN! program uses a youth-researcher partnership approach and a project-based curriculum to support high school students in creating short narrative videos about skin cancer prevention. High school students are also guided in how to present their videos to middle school students during classroom-based educational sessions that incorporate related information and discussion activities. The 28-lesson curriculum was developed through a collaboration between public health researchers and secondary school teachers. The researchers developed content on the science of skin cancer, skin cancer prevention, and how to develop effective public health messages for adolescents. Secondary school teachers contributed to lessons on cell biology, storytelling, video production, and effective presentation and discussion strategies. They also helped to structure lesson delivery so that it was maximally engaging for high school students. The curriculum includes units on (1) the biology of skin cancer and recommended prevention strategies, (2) health communication and behavior change strategies for young adolescents, (3) narrative story development, (4) video production, and (5) developing and delivering presentations to young adolescents. Content covers skin cancer etiology, epidemiology, risk factors, detection and treatment, and prevention. It includes guidance for developing health messages that: (a) address key determinants of adolescent skin cancer risk behaviors (attitudes, perceived norms, and perceptions of control), (b) are based on relevant health behavior theories such as the Theory of Planned Behavior (TPB) [21] and the Theory of Normative Social Behavior (TNSB) [22], (c) are tailored to diverse peer groups in the school, and (d) are engaging to young adolescents. Program lessons promote 21st Century Skills (e.g., collaboration, creativity, and problem solving) [14] and incorporate active learning strategies (e.g., independent research to correct false beliefs about skin cancer, reviewing scientific reports, and summarizing key points). Visits are scheduled from speakers such as melanoma survivors, dermatologists, melanoma oncologists, public health officials, and UV photography experts.

Throughout the program, students work in groups to develop concepts for short (3–5 min) videos that portray engaging stories about the use of sun protection or avoidance of excessive UV exposure. Each group develops one or more video ideas and presents their concept(s) to an audience of the public health research team, the class teacher, and fellow students during a “pitch” session. Based on audience ratings, 4 to 8 videos are selected, and groups work together to develop and produce them. Each group also prepares classroom-based presentations on skin cancer prevention for middle school students that feature their videos along with (1) guided discussions about the key messages conveyed in the video, (2) additional information about skin cancer or prevention, (3) extension activities such as written reflection assignments or self-directed internet research and/or (4) a social media campaign that reinforces key messages from video.

Program Implementation

The YES-CAN! program was implemented at a high school in the Denver metro area that serves a predominantly Hispanic/Latino student population of 360 9th–12th graders and has a 95% graduation rate. Approximately 60% of students receive free or reduced lunches, 8% are designated as gifted/talented, 10% are in special education, and 67% are English language learners. The school is based on an expeditionary learning model that engages students through PBL and integrates real-world problem solving, fieldwork, visits from outside professional experts, and authentic audiences. Classes are interdisciplinary, multi-grade level, and emphasize 21st Century Skills. The school created an in-person class in their usual format that meets 2.5 h per day for the delivery of this program and agreed to all other requirements of program implementation and evaluation, including helping to recruit a nearby middle school where the peer-led presentations could be made. The school received a small honorarium for its participation.

We provided the curriculum and tool kit to the science and video arts teachers who jointly led the class with a group of 26 10th–12th grade students that met for 10 weeks for 2.5 h per day during the fall of the 2018/2019 school year. Teachers were free to use or adapt the curriculum and toolkit in a way that aligned with student needs and their preferred teaching styles. Several guest speakers visited the class, including a young melanoma survivor, a melanoma oncologist, and a group of medical students who demonstrated how a UV camera is used to view skin damage invisible to the naked eye. Students received academic credit and a grade for completing the class. The teachers did not receive an incentive and used their own evaluation systems for student grading.

High school students produced 6 videos (https://www.youtube.com/channel/UCBKZoEScDnfGkyRtYG4vV8Q) and presented them to two 6th grade and two 7th grade science classes at a neighboring K-8 magnet school. Due to time constraints at the high school, only one 90-min peer-led session per middle school class was held, and no social media campaign was developed. One-quarter of the total K-8 school population received free or reduced lunches that school year; 57% of students were designated as gifted/talented, 3% were in special education, and 2% were English language learners. The 6th and 7th grade science classes were selected by the principal of the K-8 school based on the learning objectives for each class. High school students delivered presentations in individual classrooms comprised of approximately 30 students. They showed project videos, led discussions, answered questions, and shared educational information about skin cancer, the risks of UV exposure, and the benefits of sun protection.

Participants

All 120 students enrolled in the 6th and 7th grade classes that participated in the program were invited to complete pre- and post-program surveys. The students in those classes represented 67% of the 180 students enrolled in the 6th and 7th grades that year.

The 26 high school students who participated in the program were invited to complete pre- and post-program surveys. Eighteen (69%) were in 11th grade, six (23%) were in 12th grade, and two (8%) were in 10th grade.

Instrumentation

Middle and high school participants completed identical pre- and post-program surveys measuring intentions to engage in sun protection and UV behaviors. Surveys also measured constructs from the TPB [21] and TNSB [22] as applied to sun protection and tanning (L.A. Crane et al. unpublished data, 2021; see Tables 2 and 3). We assessed normative beliefs about sun protection and/or tanning, including perceived friend norms, motivations to comply with friend norms, referent norms for tanning, group communication about tanning, injunctive norms, and personal norms related to tanning. We also assessed attitudes about tanning and sun protection, as well as perceptions of control. Responses to all items were recorded on 5-point Likert scales, with higher scores representing more of the construct being assessed. Phenotypic and demographic characteristics were also assessed (see Table 1). The Flesch–Kincaid reading level of the survey was estimated at 4.7.

Table 1 Demographic, phenotypic, and behavioral characteristics of middle school (N = 97) and high school (N = 13) students who completed pre- and post-surveys
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Procedure

Passive consent procedures were used in both schools prior to survey administration. No parents opted their child out. Research staff sent a unique survey link to the school email addresses of participating middle school students approximately one week before (pre-survey) and one week after (post-survey) the video-based skin cancer prevention presentations, in mid-November 2018. Those students completed the 20–30 min pre- and post-surveys during class time.

Participating high school students also received unique links to the online surveys in their school email. The pre-program survey was administered on the first day of class in early September 2018. The post-program survey was sent during the last week of the session, after the presentations were delivered, about 10 weeks after the pretest. High school students completed the pretest survey during class time and the post-test survey at a time of their choosing. Students received up to eight email reminders to complete post-surveys. The teachers who led the program also encouraged them to complete surveys. Survey data were collected and managed using the Research Electronic Data Capture (REDCap) system, a secure, web-based application hosted at the University of Colorado Anschutz Medical Campus that supports data capture for research studies, including online surveys [23].

Students received a $5.00 e-gift card each time they completed a survey. The expedited study protocol was reviewed and approved by the Colorado Multiple Institutional Board and by the Research and Accountability Office in the participating school district.

Data Analysis

Analyses evaluated pre- to post-program change in study outcomes. Analyses were conducted on individual survey items so we could identify the specific attitudes and beliefs that were impacted by the intervention. Middle school students who completed both pre- and post-surveys were included in the analysis regardless of their participation in the video-based classroom session. We used SPSS for Windows v. 25 [24] to compare the characteristics of participants who did and did not complete post-program surveys, compute descriptive statistics on the analysis sample, and conduct paired t-tests to assess program-related change. Listwise deletion was used for missing data, which was minimal.

Results

Middle School Students

Of the 120 middle school students enrolled in participating classes, 106 completed a pretest survey, 105 completed a posttest survey, 6 completed neither, and 97 (81%) completed both. No differences were found in the baseline demographic characteristics of students who did and did not complete posttest surveys. Among students who completed both surveys, 56% were female, 55% were in the 6th grade, and most (89%) were between 11 and 12 years old (Table 1). Just under half (48%) described themselves as white, 26% identified as Black, and 18% as Asian. Almost one-quarter (22%) reported Hispanic ethnicity. Students were approximately evenly distributed across the four levels of skin sensitivity to sun exposure, and approximately half described their skin as very fair or fair. A majority reported often or always using sunscreen and wearing a shirt with sleeves when outside in the summer during the mid-day hours; fewer reported consistently staying in the shade or wearing a sun protective hat. None reported ever indoor tanning, and few (5%) reported regular outdoor tanning.

Table 2 presents the results of paired t-tests that compare pre- and post-survey means on study measures among the 97 middle school students who completed both waves of data collection. Compared to pre-program, students reported at post-program they were significantly less likely to engage in outdoor tanning or get a sunburn in the next 12 months, and significantly more likely to use sunscreen, wear a hat, and wear a shirt with sleeves. Intentions to use indoor tanning were rare at pre-program and showed no change over time.

Table 2 Results of paired t-tests comparing pre- and post-exposure scores on UV exposure and sun protection behavioral intentions, norms, attitudes, and perceptions of control among middle school students (N = 97)
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The perceived number of close friends who engaged in indoor and outdoor tanning was significantly lower at post-program compared to pre-program. Middle school participants were less likely to report at post-program that they would join close friends who wanted to tan indoors or outdoors and more likely to report that they would use sunscreen and wear protective clothing and hats if their friends did. They reported significantly less frequent communication with close friends about outdoor tanning. In addition, beliefs that close friends would approve of indoor tanning, that celebrities look better when they are tan, and that both indoor and outdoor tanning “were right” significantly decreased from pre- to post-program. None of the injunctive norms about parental disapproval of tanning or friend disapproval of sun protection showed significant pre- to post-program changes.

Regarding attitudes, participating middle school students were significantly less likely to report at post-program that they look better with a tan, they feel healthy with a tan, kids their age do not have to worry about skin cancer, it is too hot in the summer to wear a hat, and they cannot wear their hair the way they want if they wear a hat. In addition, compared to pre-program, students were significantly more likely to report post-program that sunburns can cause skin cancer; tanning booth lights are dangerous; tans from salons do not look good; tanning salons are bad for skin, and wearing a sun-protective shirt makes them look good.

High School Students

Among the 26 high school students enrolled in the video class, 18 completed a pretest survey, 15 completed a posttest survey, 6 completed neither, and 13 (50%) completed both. No differences were found in the baseline demographic characteristics of students who did and did not complete posttest surveys. Among the group that completed both surveys, 62% were female, approximately 85% were between ages 16 and 17, and 77% were in the 11th grade (Table 1). Nearly 90% described themselves as white; just under two-thirds described their ethnicity as Hispanic. Forty-six percent reported that they would get a painful sunburn and either no tan or a light tan one week later if they were in the sun without sun protection (sensitivity levels 1 and 2); 54% described their skin as fair and 39% as light brown. Close to one-third (31%) reported that they spend 4–6 h outside during midday on summer weekends. Approximately one-quarter reported that they often or always use sunscreen and 54% reported often or always wearing shirts with sleeves during the summer. Only 15% consistently wear hats, fewer than half stay in the shade. None reported outdoor or indoor tanning.

Results of paired t-tests among the 13 high school students who completed both waves of data collection are shown in Table 3. Compared to pre-program, high school participants reported at post-program being significantly less likely to get a sunburn in the next 12 months and significantly more likely to wear a hat outside in the summer. They were significantly less likely to report on the post-test that they want to be as tan as their close friends and significantly more likely to report they would wear sun-protective clothing if their friends did. In addition, personal norms about the acceptability of outdoor tanning significantly declined from pre- to posttest. A similar pattern occurred for norms about indoor tanning, but the difference did not reach statistical significance. Scores on several attitudinal measures also showed statistically significant pre- to post-test declines, including feeling: healthy with a tan, that it is worth getting a sunburn to get a tan, and that it is too hot in the summer to wear a hat. A statistically significant increase was seen in the belief that sunburns can cause skin cancer.

Table 3 Results of paired t-tests comparing pre- (T0) and post-exposure (T1) scores on UV exposure and sun protection behavioral intentions, norms, attitudes, and perceptions of control among high school students (N = 13)
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Discussion

After exposure to a single classroom session where high school students presented short narrative videos and other skin cancer prevention information and discussion activities, middle school students reported positive changes in future intentions to engage in sun protection and UV exposure behaviors, and on numerous measures of related normative beliefs and attitudes. High school students who created the skin cancer prevention videos and led the middle school presentations also reported positive changes, but fewer differences reached the threshold of statistical significance, and with a sample size of only 13, the findings should be interpreted with caution. Overall, study results add to a growing body of evidence about the promising effects of youth-participatory, peer-led approaches to adolescent risk reduction in general [17, 18] and to reducing skin cancer risks specifically [15, 16]. In doing so, they suggest that this approach may help to fill the gap in effective skin cancer prevention strategies for middle and high school youth [4, 7].

Among the few skin cancer prevention programs available for middle school students, the YES-CAN! program aligns most closely with the “Students are Sun Safe” (SASS) program, where university [16] and high school [15] students are trained to deliver a brief skin cancer prevention presentation and sun-safety activities to middle school and/or high school students during a single classroom-based session. Exposure to the SASS program has been associated with short-term improvements in skin cancer knowledge [15, 16], perceived susceptibility to skin cancer [16], attitudes toward tanned skin [16], and self-reported skin cancer behaviors [15, 16]. While similar, our program provides more intensive training for peer leaders in the science of skin cancer, including behavioral determinants of skin cancer risk behaviors among adolescents. Peer leaders also receive comprehensive instruction in health communication for adolescents, narrative story development, and video production. Moreover, they create their own skin cancer prevention videos, educational materials, and discussion activities instead of using existing resources developed by adult professionals. The latter component capitalizes on youths’ creativity, their voice, and their lived experience to enhance the degree to which prevention messages resonate with and deeply engage younger youth. In addition, our full curriculum recommends that the presentations of the videos and related educational material take place over a series of 4 to 8 classroom sessions with middle school students and are combined with social media campaigns to enhance their intensity and increase their effectiveness. This full implementation was not feasible within the context of the current study.

Limitations

These findings are limited by the use of a single school community setting, the lack of non-program comparison groups of middle and high school students, and the small size of the high school sample. We assessed change in numerous outcome measures but did not adjust for multiple testing and the resultant inflation of the type I error. This decision was made to represent all possible program changes in this initial study. Further, outcome measures were based on student self-report, which could be influenced by social desirability bias. Because of time constraints at participating schools, it was not possible for high school students to lead multiple educational sessions with middle school students or to implement the social media component of the program. We were also not able to follow students over a longer period, which would have allowed us to assess the longer-term impacts of the program on behavior. We expect that evidence of program effectiveness will be stronger and sustained over time among middle school students who receive a “higher dose” from repeated exposures to the peer-led sessions and reinforcing messages from other sources. When the program is maintained over a period of years, we anticipate that it will lead to a healthier normative environment related to UV exposure and skin cancer risk. Finally, it will be important in future evaluations of this program to collect feedback from participating middle and high school students about their overall experience in the program and their assessments of receiving information from and serving as peer leaders, respectively.

Conclusions

The previously described limitations notwithstanding, the results of this study provide support for the short-term effectiveness of the YES-CAN! program, a youth-participatory, peer-led approach to skin cancer prevention, and warrant ongoing evaluation efforts with a more rigorous study design and longer follow-up period. An important next step will be to implement the program over a longer time period that allows the inclusion of all planned program elements, including multiple sessions with middle school students and a companion social media component. This would include an evaluation of the effectiveness of the program in a randomized controlled trial that assesses key outcomes among middle and high school students over a longer follow-up period, including behavioral outcomes that go beyond self-report such as colorimeter-based skin color readings and/or UV photographic readings to verify levels of UV exposure. The findings reported here suggest that the program holds promise for addressing the current gap in effective and engaging skin cancer prevention programming for adolescents.

Implications and Conclusions

This youth-participatory, peer-led approach to adolescent skin cancer prevention provides a sustainable model of school-based health promotion that can be integrated into existing curricula at high schools and middle schools. The YES-CAN! program addresses a range of academic standards related to health, science, communication, visual arts and technology, and supports schools and teachers in addressing their academic mission. The youth-directed, skills- and project-based program provides an opportunity for students to develop 21st Century Skills, including creativity, leadership, initiative, collaboration, critical thinking, and media and technology literacy. It can be delivered by existing faculty across multiple subject areas with minimal training, equipment, and software. Moreover, it can be extended to address other adolescent health risks such as tobacco and vaping prevention or mental health. Although it was implemented in an expeditionary school for this study, it can be successfully delivered in more traditional school settings where PBL is used as a pedagogical method [25].