Introduction

San Diego is well known for great weather, fun filled attractions, shopping, and more.

Most of these attractions are spent outside in sunny San Diego. The San Diego Zoo, Sea World,

Seaport Village, and Petco Park, are just a few fun in the sun activities families can enjoy.

Spending time on the San Diego beaches and parks are other ways to have a great time outdoors

too. Some parents even encourage their kids to get out of the house, take a break from using their

electronic devices and “play”, enjoy the weather, and exercise outside. Usually, summer weather

brings teenagers out of their rooms to bask in the sun for a perfect tan, however being exposed to

the sun without protection can be drastically life changing.

Phase 1: Quality of life: Social Diagnosis

Teens have a perception that sun bathing is a great way to have perfect skin or even

going to the Tanning Salon. Most teens are not aware of the future damages that the sun may

cause them; it can alter their image in a negative way and even become dangerous and deadly.

When there is an abnormal growth of cells in the body this disease is called, Cancer (CDC,

2014). Skin cancer is when the cancer cells start in the skin (CDC, 2014). This disease does not

favor any race, culture, age and/or gender; it can affect anyone (CDC, 2014). Skin Cancer is a

topic that not many teenagers are aware of. Teens may be talked to or lectured on in regards to

drinking/texting and driving or safer sex, and/or a healthier diet. A subject like cancer is not easy

to teach in high schools, although informing high school students of what they can do now can

prevent them from developing skin cancer later may be accomplished in several ways. This

health education program will target the age group between 15 to 19-year-old high school

students attending Otay Ranch High School of the high risk for the most common skin cancer.

The following pages will explain the data collection and analysis found in skin cancer at a

SKIN CANCER AWARENESS 2

national, state, and local level. Describes the genetic, behavioral, and environmental risk factors

associated with skin cancer, and express the need of a program focus. The intervention strategies

will be later discussed, as well as the process and outcome evaluation of the health education

program.

PHASE 2: EPIDEMIOLOGICAL ASSESSMENT

Epidemiology of Skin Cancer

Skin Cancer is the most common form of cancer and also the fastest growing cancer.

There are three types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and

melanoma. According to the American Cancer Society there are 3.5 million of cases of basal and

squamous cell skin cancer, and 73,000 of melanoma in 2015 (ACS, 2015). The latest data

gathered by the EPA, states that in California, melanoma makes up 75% of all skin cancer in the

state (2009). The same report states that in California, there are 800 deaths a year which is about

2 deaths per day (2009), making it a health problem that requires more awareness than it has

been receiving. The determinants of Skin Cancer may be due to genetic, behavioral or

environmental risk factors.

Genetic Risk Factors

Genetics plays a big role in determining an individual’s chances of getting Skin Cancer.

The Center for Disease Control and Prevention 1999- 2011 surveillance of the incidence rate and

death rate of Skin Cancer reveals just how Caucasians are disproportionately affected by skin

cancer, compared to other races. White men and white women have the highest rates of

incidence and deaths due to Skin Cancer (CDC, 2014). Nine of ten who are diagnosed with the

most dangerous form of skin cancer, melanoma are White (CDC, 2014). Even when the rates of

SKIN CANCER AWARENESS 3

incidence for Asians/Pacific Islander, Hispanics, Blacks and American Indians/Alaskan Natives

are combined, they are still at a lower rate compared to the white population. The results are also

the same when comparing the death rates. The race with the lowest rates or incidence and deaths

was the African American population.

An article in a periodical for genetics refers to different studies conducted that would

explained that the reason for this disparity is due to pigmentation. People with pigmentation

traits such as: fair skin, blue or green eye color, red and blonde hair and freckles are at a higher

risk of getting skin cancer (Vogan, 2008). Darker pigmentation, which is determined by

chromosomes, according to the same article, has the ability to protect the skin from the sun

damage (Vogan, 2008).

Behavioral Risk Factors

Genetics is a risk factor for skin cancer that no one can control, and is determined by

nature. Fortunately, a change in behavior can help lower the risk of getting skin cancer. The

behaviors linked to skin cancer are over exposure to the sun, use of indoor tanning, not wearing

sun-protective clothing, and lack of sunscreen usage. By reducing sun exposure, not using indoor

tanning, wearing proper clothing and using sun screen before exposure can dramatically reduce

the chances of getting skin cancer.

It is a well-known fact that sun exposure has many benefits including mood

enhancement, and providing the body with vitamin D, but too much exposure can harm the skin

due to the suns’ ultraviolet radiation. Ultra violet radiation has been linked to premature aging,

eye damage, a suppressed immune system, and other skin damage (WHO, 2015). Using

sunscreen can reduce damage done to the skin, and prevent skin cancer growth. Unfortunately,

SKIN CANCER AWARENESS 4

not everyone uses sunscreen. According to a study, sunscreen usage in the general population has

fallen rapidly and only 30% actually use sunscreen (Johnson, 2011). The study suggest that it

may be due to the perceived susceptibility being low, and the lack of skin cancer knowledge

(Johnson, 2011). Some people who get skin cancer do not get it from the sun, instead they get it

from an alternative way of tanning with the use of tanning bed/booths. There are thousands of

tanning salons all across the United States, and over a thousand in California alone. These

bed/booths are used to achieve a darker complexion without sun bathing. A study in Europe

found that artificial UV lights from these tanning beds/booths increases the risk of melanoma by

75%, if expose to it before the age of 35 (Benmaharnia, 2013).

Environmental Risk Factors

The environment an individual is in has an influence on their risk of getting Skin Cancer.

Due to the fact that California has such beautiful weather, and the sun is out majority of the year

increases the risk of developing a skin cancer later in life. Since the weather is so beautiful in

California, most individuals find themselves enjoying activities outdoors. Any injury to the skin

can result in abnormal skin cell growth, which can happen outdoors during these activities.

Phase 3: Educational and Ecological Assessment

Predisposing factors may include lack of education, as the main reason individuals do

not protect themselves against skin cancer. Bringing awareness to the topic may help parents in

teaching, and practicing healthy ways to protect their skin. Since some skin cancer do not

develop until later in life, protecting your skin is important at younger ages. Some parents may

feel that applying sunscreen takes too much time, and they do not want to keep reapplying even

if they initially put it on their children. Of course this becomes more difficult if society deems

SKIN CANCER AWARENESS 5

tan skin to be fashionable, and in style. Individuals may also have a low perception that skin

cancer can happen to them, and that may prevent themselves from protecting themselves.

Enabling factors would be the individual’s accessibility to proper protection from the

sun’s ultra-violet (UV) light. Along with being uneducated about the risk of skin cancers, some

individuals might not know where or just cannot afford sunscreens. Wearing sunscreen is one of

the main steps to protecting your skin, however, proper hats, and UV protective clothing is also

available. Once again this goes back to accessibility to these types of resources.

Reinforcing factors would be to not develop skin cancer in the future; this is the main

reward for protecting your skin. Protecting your skin from UV damage can also keep you

looking younger, and can slow the aging process. Over exposed skin, especially in the face can

result in wrinkles faster than aging alone. Protecting your skin can keep your youthful glow, and

wearing sunscreen is a major contributor to protection.

Program Focus

The health education program name that will be implemented is called, “Sun Safe:

SASSE”. SASSE stands for S: Sunscreen use, A: Avoid peak midday sun exposure, S: Stay in

the shade, S: Sun safe clothing, E: Exposure limitation. Health educators will visit one high

school campus from the Sweetwater High School District during the month of July, to educate

students of their risk, and inform them of preventative measures that can be taken.

Phase 4: Intervention Strategies

SKIN CANCER AWARENESS 6

Program Goal and Objectives

Goals Statement:

 To promote skin cancer awareness to students in Otay Ranch High School.

Process Objective:

 Before beginning the program, program planners will secure a speaker with skin cancer

to discuss their experience with the cancer.

 Before beginning the program, the program planners will contact sunscreen companies to

help provide free samples of sunscreen for the students.

Learning Objective:

 By the end of the presentation, a majority of the Otay Ranch High School students be

aware of sun safety practices.

 After the Sun Safe: “SASSE” health awareness program, the majority of the students

from Otay Ranch High School will be able to identify abnormal skin spots.

 By the end of the program, at least 75% of Otay Ranch High School students will be able

to identify three risk factors for skin cancer.

Behavioral Objective:

 By the end of the presentation, the majority of Otay Ranch High School students will

intend to wear sunscreen daily between the hours of 10am- 2pm, when outdoors.

Environmental Objective:

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 By the middle of school year, at least 50 % of the lunch area at Otay Ranch High School

will be covered by shade structures.

 By the middle of the school year, all locker rooms at Otay Ranch High School will have

sun screen pumps installed.

Outcome:

 By the end of the school year, the majority of those who attended the “SASSE” health

awareness program will use sunscreen more than students from another high school who

did not participate in the program.

Health Communication Strategies/Health Education Strategies for Process Objectives

In order to have a successful health awareness program, program planners need to have

certain strategies in place to fulfill the programs process, learning, behavioral, and outcome

objectives. To complete the process objective program planners will need certain materials such

as age appropriate brochures, and visual aids. Program leaders will write a proposal to

Sweetwater High School District to allow our curriculum in the Otay Ranch High School. After

receiving approval from the district, program planners will then reach out to patients who are

willing to share their experiences living with skin cancer with students. After confirmation from

these patients, we will then schedule them as guest speakers for our presentations. Program

planners will contact several sunscreen companies in order to receive free sample to be

distributed to the students. Otay Ranch High School has about 2,750 students, they will be

divide by grade level in order to reach as many students as possible during the month of July.

The program will consist of eight presentation being conducted over a month long period of

time. The first week of July will be for the freshman class, second week for sophomores, third

week for juniors, and the fourth week for seniors. The presentations will be held in the

SKIN CANCER AWARENESS 8

gymnasium on Tuesdays, and Thursdays during the Extended Learning Period (ELP) at which

time we will divide each grade into two separate classes alphabetically.

There will be a list of student names, and a sign in sheet that a program planner will supervise to

ensure accuracy of attendance. Those who could not attend on Tuesday’s presentation can attend

Thursday’s presentation for make-up.

Health Communication Strategies/Health Education Strategies for Learning and Behavior

Objectives

Informal interviews with three students from Otay Ranch High School revealed that skin

cancer was not believed to be a major health issue concerning high school students. They

believed that there were much more important health concerns, such as teen pregnancy, under

age alcohol consumption, marijuana use, and obesity. Due to the fact that perceived

susceptibility to getting skin cancer is low, behaviors that can help prevent skin cancer is not

practiced. Therefore, the behavior change model that will be used to change the health behavior

of these students will be the Health Belief Model.

Students attending Otay Ranch High School currently have no form of skin cancer

awareness, nor has the school ever had a skin cancer awareness program. That means that there

are almost 3,000 students who are probably not informed on how to identify skin abnormalities,

risk factors of skin cancer, or sun safety practices that could help prevent it. In order to reach

these learning objectives, program planners will demonstrate the proper way to apply sunscreen,

and bring visual aids of clothing and accessories that can help protect the skin from sun

exposure. The program planners will also present pictures of skin abnormalities that indicate skin

cancer to provide a guide and be able to know what these abnormalities look like. All

SKIN CANCER AWARENESS 9

information provided in the curriculum will be researched based and distributed through power

point presentation, but a portion will be provided by a guest speaker who will be a young skin

cancer survivor. The guest speaker will be able to highlight risk factors through their personal

experience.

As stated earlier, the Health Belief Model (HBM) was used to confirm the need for this

awareness program. By using the HBM, getting someone to change his or her behavior may be

challenging, however with the in-depth presentation on Sun Safe: “SASSE” program, using the

Health Communication Strategy will be more effective. Especially, in the point made on “A”,

“A” is the acronym meaning to “Avoid” sun exposure during the mid-day peak hours of 10am-

2pm when outdoors. Thus, by end of the presentation the majority of Otay Ranch High School

students will intend to use sunscreen when outdoors specifically between the mid-day peak hours

of 10am-2pm.

Environmental Change Strategies for Environmental Objective

The step to full fill an Environmental Objective is using the Environmental Change

Strategy. By using this strategy, the goal will be met by having shade structures installed in the

lunch area at Otay Ranch High school. In addition to installing shade structures, hand pumps of

sunscreen will also be installed in the locker rooms for everyone to use in a quick and easy

application. The first step is to write a proposal to the Sweetwater High School District

requesting the need for an environmental change on the shade structure, and the installation on

sunscreen hand pumps at the Otay Ranch High School. The head coordinator of the Sun Safe:

SASSE program will write this proposal. This process may take a few weeks to a few months.

After getting the approval for both proposals by the district, the shade structures will be installed

SKIN CANCER AWARENESS 10

as well as the sunscreen hand pumps for Otay Ranch High School. The maintenance of the shade

structure will be included in the proposal for the general maintenance on high school premises to

take care of. To maintain each hand pump in the locker rooms of Otay Ranch High School the

Associated Student Body (ASB) or assistant student coaches will refill all hand pumps as

needed.

Health Communication Strategies/Health Education Strategies for Outcome Objective

To complete a successful awareness program, the outcome objective is to ensure that

majority of those who attended the “SASSE” health awareness program at Otay Ranch High,

will use sunscreen more than other high schools in the district. Program planners will conduct

surveys at the end of the school year, in order to measure how effective our curriculum was at

Otay Ranch High School compared to the district. Marketing this program will not be necessary,

due to the fact, after approval from the school district this program will be implemented into the

curriculum.

Phase 5: Implementation

The “Sun Safe: SASSE”, skin cancer awareness program will be implemented in the

month of July. Between the months of May and June, the pilot test and revisions will be

completed in time for full implementation of the program. All students of the Otay Ranch High

School will be in attendance for a 45 minute long presentation during the schools Extended

Learning Period on Tuesdays, and Thursdays. The students will be meeting in the school

gymnasium for an informative power point presentation on skin cancer, and an anecdotal

presentation from a young survivor of skin cancer.

SKIN CANCER AWARENESS 11

Phase 6: Process Evaluation

To assess the quality of the program content and implementation, the program planners

must conduct a process evaluation. The process evaluation will be used to measure how the

program was successfully implemented according to the programs process objectives.

Qualitative data collected via survey by the students who attended the intervention program at

Otay Ranch High School will be compared to the survey conducted at the comparison school. A

timeline checklist in the form of a Gantt chart provides a measurement of program status, in

which program planners will follow.

Gantt Chart

M a

r

A

p

r

M

a

y

J

u

n

Jul

1st

week

Jul 2nd

week Jul 3rd

week Jul

4th

week

A

u

g

S

e

p

t

O

c

t

N

o

v

D

e

c

J

a

n

F

e

b

M

a

r

Prepare curriculum – – Purchase supplies necessary for

presentation – –

Contact & secure possible

speakers for the presentation – –

Seek approval from district for

shade structure construction – –

Solicit sun screen samples – – Pilot test – Make revisions based on pilot

test evaluation –

Pre-test survey for ORHS and

comparison school –

Full implementation for

Freshmen students of ORHS —

Full implementation for

Sophomore students of ORHS —

Full implementation for Junior

students of ORHS —

Full implementation for Senior

students of ORHS —

Conduct post-test surveys for

all students of ORHS after the

presentations

—– —– —— —–

SKIN CANCER AWARENESS 12

Continue to check on

environmental objectives – – – –

Construction of shade structure

and sunscreen pumps should be

complete

Conduct surveys for all

students of ORHS on

effectiveness of new structure

and sunscreen pumps

Conduct a post-test survey for

behavior objective –

Conduct surveys for all

students of comparison school –

Evaluate the program – – – – — —- —- —- – – – – – – – –

Write final report –

The programs process objectives were to secure a skin cancer survivor speaker, whom

would attend the intervention presentations, and secure sunscreen samples provided by sunscreen

companies. The students via a post program survey will evaluate the programs expert speaker.

By completing this survey, this will measure how well or poorly the expert speaker reached the

students. Upon receiving free samples of sunscreen given by varies companies along with

sunscreen pumps provided by the school district, programs planners would observe usage by the

students.

Phase 7: Impact Evaluation

In order to determine the effectiveness of the intervention, an impact evaluation must be

conducted. Through this evaluation the program planners will be able to determine if the

learning, behavior and environmental objectives has been achieved. The evaluation design will

be based on quantitative data collected from students who attended the intervention, and students

from the comparison school who did not attend the invention.

SKIN CANCER AWARENESS 13

The learning objectives include teaching the students sun safety practices, identifying

abnormal skin spot and identifying risk factors for skin cancer. To determine if the intervention

was the cause of the students to new gain knowledge, a pre-test will be conducted a month prior

to the implementation of the program. The pre-test would give an insight of what students knew

prior to the intervention. By doing so, it would rule out any confounding variable that could

possibly have an effect on the validity of the results. A post-test would then be conducted soon

after the presentation to determine their knowledge on risk factors of skin cancer, identifying

abnormal skin spots and sun safety practices.

The behavior objective is to encourage Otay Ranch High School students to wear sunscreen

daily especially during peak hours while outdoors. The pre-test would include information on

their daily sun screen use. The post-test for the behavioral objective would be conducted later on

in the year to determine behavior change.

The environmental objective include the construction of a shade structure to provide

students protection from the sun while eating at the lunch area and sunscreen pumps in locker

rooms for all students especially those that play outdoor sports. Program planners will constantly

check on the status of construction to ensure the objective is achieved. One month after the

constructions has been completed, students at Otay Ranch High School will be surveyed on their

use of the new environmental change made in their school and also their satisfaction with the

change. This allows the program planners to determine if the environmental change served its

purpose and if it should be proposed to other high schools as a part of skin cancer prevention

measure for young adults.

SKIN CANCER AWARENESS 14

Phase 8: Outcome Evaluation

While assessing the need of skin cancer, setting a goal, listing objectives, and

implementing a program including numerous intervention strategies are equally important in

program planning, the most crucial and critical phase is Evaluation. In following the Precede-

Proceed model, phase 8 is measuring the outcome evaluation. Having a beneficially health

awareness program that will improve the quality of life for the community is ultimately what

health program planners want to achieve.

The outcome evaluation includes a strong outcome evaluation design with rationale as to

why this design was chosen. A design that is worthy of its time and effort for a positive health

awareness program is Quasi-experimental design. This design is a pretest-protest design, which

includes an experimental group, and a comparison group. The experimental group in this

program is Otay Ranch High School, and the comparison group is Olympian High School. With

this chosen design the SASSE awareness program potentially will have a great impact on its

target population. A pretest will be conducted for both groups in June. In following the method

of collecting data for the quasi-experimental design, the program planners will create a survey

for the students at Otay Ranch High School, and at Olympian High School. After the

intervention, the posttest will be conducted for both schools. All data collected from the pre/post

test will ultimately provide necessary feedback to stakeholders to assess how well or poorly the

program was implemented. Program planners will coordinate with stakeholders to further

improve program design, and implementation.

SKIN CANCER AWARENESS 15

Conclusion

Skin Cancer is a serious health problem that affects millions of Americans, and thousands

of Californians. Skin cancer has claimed lives of Californians daily, and will continue to claim

lives unless preventative measures are being made. The best way to tackle this health problem is

to provide education on this issue to populations whom are at a great risk, for example the young

adults. The “Sun Safe: SASSE” program was created to do just that. It targets students from Otay

Ranch High School, and provide them with education on the topic of skin cancer prevention. The

program planners use the Health Belief Model to change the perception of the health problem

due to the student’s low level of perceived susceptibility. Program planners have learning,

behavioral, environmental, and outcome objectives that are intended to reduce the risk of skin

cancer in high school students. In order to achieve this goal, the program planners plan to use

Health Communication Strategies/Health Education Strategies. In order to ensure their objectives

have been met, program planners will use quantitative, and qualitative data collection to evaluate

the programs effectiveness. If the program proves to be effective, then the program planners will

propose a statewide implementation, and hopefully a nation wide implementation of the

program. With great optimism this program will be used as a model across the United States, in

reducing the incidence rate of skin cancer among 15 to 19 year olds.

SKIN CANCER AWARENESS 16

References

Benmarhnia, T., Léon, C., & Beck, F. (2013). Exposure to indoor tanning in france: A population

based study. BMC Dermatology, 13, 6. doi:http://dx.doi.org/10.1186/1471-5945-13-6

Center of Disease Control. (2014, August). CDC – Skin Cancer Rates by Race and

Centers for Disease Control and Prevention (CDC). (2014). Basic Information About Skin

Cancer. Retrieved May 12, 2015, from

http://www.cdc.gov/cancer/skin/basic_info/index.htm

Eastlake High School. (2015). Eastlake High School | About Us. Retrieved from

Johnson, M. M. (2011). A SKIN CANCER MODEL: RISK PERCEPTION, WORRY AND

SUNSCREEN USAGE. Economics, Management and Financial Markets, 6(2), 253-262.

Retrieved from

http://ezproxy.nu.edu/login?url=http://search.proquest.com/docview/884339020?accounti

d=25320

Otay Ranch High School. (2015). Otay Ranch High School | About Us. Retrieved from

Sweetwater Union High School District. (n.d.) School. Retrieved May 12, 2015, from

Vogan, K. (2008). Cancer genetics: Pigmentation and skin-cancer risk. Nature Reviews.

Genetics, 9(7), 502. doi:http://dx.doi.org/10.1038/nrg2409http://www.cdc.gov/cancer/skin/basic_info/index.htmhttp://elh.sweetwaterschools.org/about-ushttp://ezproxy.nu.edu/login?url=http://search.proquest.com/docview/884339020?accountid=25320http://ezproxy.nu.edu/login?url=http://search.proquest.com/docview/884339020?accountid=25320http://orh.sweetwaterschools.org/about-us/

SKIN CANCER AWARENESS 17

World Health Organization. (2014). WHO | Health effects of UV radiation. Retrieved from

http://www.who.int/uv/health/en/

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