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The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/121/5/e1074
aICF International, Washington, DC; bCenter for Risk Analysis, Harvard University, Boston, Massachusetts; cDepartment of Dermatology, Henry Ford Hospital, Detroit,
Michigan; dDepartment of Dermatology, Boston University School of Medicine, Boston, Massachusetts; eUS Environmental Protection Agency, Washington, DC; fCenter
of Excellence in Climate Change Communication Research, Department of Communication, George Mason University, Fairfax, Virginia; gLaboratory of Photobiology and
Photoimmunology, Department of Environmental and Occupational Health, School of Public Health and Health Services, George Washington University Medical Center,
Washington, DC
Financial Disclosure: Dr Lim is a consultant for several sunscreen manufacturers (La Roche-Posay, Orfagen, Dow Pharmaceutical Sciences) and has received research grants from Johnson and Johnson; the
other authors have indicated they have no financial relationships relevant to this article to disclose.
Although a number of studies have evaluated the behavioral impacts of school-based To our knowledge, this study is the first to assess the net benefits of a school-based
and community sun safety education programs, few have evaluated the economics of skin cancer prevention program. This study shows that modest behavioral changes
skin cancer prevention programs. Some studies have analyzed the economics of other resulting from SunWise may result in significant reductions in skin cancer incidence
school-based health programs. and mortality.
ABSTRACT
OBJECTIVE. The SunWise School Program is a school-based sun safety education pro-
gram that was developed by the US Environmental Protection Agency and aims to
teach children how to protect themselves from overexposure to the sun. The objec- www.pediatrics.org/cgi/doi/10.1542/
peds.2007-1400
tives of this study were to assess the health benefits of the SunWise School Program
and use economic analysis to determine the program’s net benefits and cost-effec- doi:10.1542/peds.2007-1400
tiveness. The views expressed herein are solely
those of the authors and do not represent
METHODS. Standard cost/benefit and cost-effectiveness analysis methods were used. the official opinion of the US EPA.
Intervention costs were measured as program costs estimated to be incurred by the Key Words
skin cancer, prevention, environmental
US government, which funds SunWise, using 3 funding scenarios. Health outcomes
health, school health, cost/benefit analysis,
were measured as skin cancer cases and premature mortalities averted and quality- cost-effectiveness, schools
adjusted life-years saved. These health outcomes were modeled using an effective- Abbreviations
ness evaluation of SunWise based on pretest and posttest surveys administered to UV— ultraviolet
students who participated in the program and the Environmental Protection Agen- EPA—Environmental Protection Agency
QALY— quality-adjusted life-year
cy’s peer-reviewed Atmospheric and Health Effects Framework model. Costs averted AHEF—Atmospheric and Health Effects
were measured as direct medical costs and costs of productivity losses averted as a Framework
result of SunWise. Net benefits were measured as the difference between costs BCC— basal cell carcinoma
averted and program costs. SCC—squamous cell carcinoma
CMM— cutaneous malignant melanoma
RESULTS. Economic analysis indicated that if the SunWise School Program continues SPF—sun protection factor
SCUP-h—Skin Cancer
through 2015 at current funding levels, then it should avert ⬎50 premature deaths, Utrecht-Philadelphia– human
nearly 11 000 skin cancer cases, and 960 quality-adjusted life-years (undiscounted) HRQoL— health-related quality of life
among its participants. For every dollar invested in SunWise, between approximately Accepted for publication Oct 18, 2007
$2 and $4 in medical care costs and productivity losses are saved, depending on the Address correspondence to Mark C. Wagner,
funding scenario. SB, ICF International, 1725 Eye St, NW, Suite
1000, Washington, DC 2006. E-mail:
CONCLUSIONS. From a cost/benefit and cost-effectiveness perspective, it is worthwhile to mwagner@icfi.com
educate children about sun safety; small to modest behavioral impacts may result in Address reprint requests to Luke H. Hall-
Jordan, BA, Stratospheric Protection
significant reductions in skin cancer incidence and mortality. Division, Office of Atmospheric Programs,
US Environmental Protection Agency, 1200
Pennsylvania Ave, NW (6205J),
S KIN CANCER ACCOUNTS for more than half of all cancers diagnosed in the United
States, and ⬎1 million new cases of nonmelanoma skin cancer are expected to
occur in 2008.1 Incidence rates of melanoma are rising in most of the world.2 More PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2008 by the
Washington, DC 20460. E-mail: hall-jordan.
luke@epa.gov
than 8400 Americans are expected to die in 2008 from melanoma, the most com- American Academy of Pediatrics
monly lethal form of skin cancer.3 Research has shown an association between
exposure to ultraviolet (UV) radiation and the development of melanoma and nonmelanoma skin cancers,4 and sun
e1074 KYLE et al
Downloaded from www.pediatrics.org. Provided by Mc Master University on November 8, 2009
exposure during childhood seems to be an important of school-based programs can provide a component of
risk factor associated with the development of mela- that validation, but few studies, to our knowledge, have
noma skin cancer.5–8 Stratospheric ozone depletion has analyzed the economics of school-based health pro-
exacerbated these health effects by allowing increased grams, and none has analyzed school-based sun safety
UV radiation to reach Earth’s surface.9 programs. For addressing this gap in the literature, the
Major skin cancer prevention strategies focus on reduc- objectives of this study were to assess the health benefits
ing overexposure to UV radiation through increasing of the school component of the SunWise Program and
knowledge and awareness, modifying sun safety practices, use economic analysis to determine the program’s net
and implementing policy measures and environmental in- benefits and cost-effectiveness.
itiatives.10 These strategies can lead to important reduc-
tions in future skin cancer incidence and mortality for
populations at risk. The Task Force on Community Pre- METHODS
ventive Services, supported by the Centers for Disease
Control and Prevention, found that there was sufficient Framework for Economic Analysis
evidence to support education and policy approaches in Standard cost/benefit and cost-effectiveness analysis
primary schools and recreational and tourism settings.11 methods were used to evaluate the costs and health
The SunWise Program, the first national health and outcomes of SunWise compared with a no-intervention
environmental education program for sun safety de- alternative. Intervention costs were measured as pro-
signed for children in elementary and middle schools, gram costs estimated to be incurred during a 17-year
was developed by the US Environmental Protection operation of the program (fiscal years 1999 –2015).
Agency (EPA) to teach children and their caregivers how Health outcomes were measured as skin cancer cases
to protect themselves from overexposure to the sun. and premature mortalities averted and quality-adjusted
SunWise aims to reduce the incidence of skin cancer and life-years (QALYs) saved. Averted costs associated with
other UV-related health problems by changing attitudes skin cancer cases and premature mortalities prevented
and behaviors concerning sun exposure. The SunWise were measured as direct medical costs and costs of pro-
School Program is the major programmatic component ductivity loss averted by SunWise. All costs are reported
of SunWise, and all public and private elementary and in 1999 dollars. Because there is a lag period between
middle schools in the United States are eligible to par- the intervention and averting skin cancer, health out-
ticipate. From its inception in 1999 through August comes, QALYs, and costs averted were calculated over
2007, ⬎15 600 schools registered to use SunWise, rep- the period 1999 –2100 and were discounted at a rate of
resenting ⬎12% of the ⬎123 000 US elementary and 3% as recommended by the US EPA16 and the Panel on
secondary schools.12 Registered schools receive a free Cost-effectiveness in Health and Medicine.17
SunWise tool kit with classroom activities for grades Health outcomes and averted costs were calculated
kindergarten through 8, a UV-sensitive Frisbee for under 3 intervention cost scenarios: (1) the current
hands-on experiments, story books, posters, videos, pol- funding scenario, in which funding for the SunWise
icy guidance, and other materials. School Program, including personnel costs, continues at
The cross-curricular, standards-based classroom les- its current levels from fiscal years 1999 through 2015
sons offered by SunWise were reviewed by an expert (approximately $926 000 per year, or 85% of the total
panel of educators, curriculum specialists, and skin can- SunWise Program budget); (2) an increased funding sce-
cer researchers before the program was launched to
nario, in which funding for the school component in-
ensure scientific accuracy, age-appropriateness, and
creases from current levels to $1.4 million per fiscal year
alignment with national education standards. Lessons
from 2008 through 2015; and (3) a low funding sce-
focus on 3 key areas: effects of UV radiation, risk factors
nario, in which no funding is provided from 2008
for overexposure, and sun protection habits. Each lesson
through 2015.
consists of developmentally appropriate activities that
combine education about sun protection and the envi- For each funding scenario, the base-case analysis was
ronment with other aspects of students’ regular learning conducted in 6 steps: (1) effectiveness analysis of Sun-
in science, social studies, health, physical education, lan- Wise based on pretest and posttest surveys administered
guage arts, and mathematics. One advantage of SunWise to students who receive the intervention; (2) modeling
is that it requires relatively little classroom time to im- to translate sun safety behavioral changes reported by
plement; nearly 90% of nurses and teachers that have students into changes in lifetime UV radiation exposure;
led the program reported that lessons took 1 to 2 hours.13 (3) modeling using the US EPA’s peer-reviewed Atmo-
The SunWise School Program is an effective means of spheric and Health Effects Framework (AHEF) model to
improving students’ sun protection knowledge, atti- translate changes in lifetime UV exposure into an esti-
tudes, and behaviors.13–15 These improved behaviors can mated number of averted skin cancer cases and prema-
prevent future cases of skin cancer; however, because ture mortalities; (4) estimation of medical care and
resources for funding school-based health programs are productivity costs averted per skin cancer case and pre-
limited, as is the amount of curriculum time that school mature mortality prevented; (5) estimation of QALYs
administrators can devote to health-related topics, demon- saved; and (6) calculation of the net benefit of SunWise.
strating effectiveness may not be sufficient to justify pro- Sensitivity analysis was also conducted on key parame-
gram implementation. Evaluations of the cost-effectiveness ters to evaluate the robustness of base-case results.
e1076 KYLE et al
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UV exposure (baseline UV dose minus SunWise UV body surface area to which sunscreen is applied. Stu-
dose) to lifetime UV exposure, and (4) translating that dents who reported that they applied sunscreen to 6 to
percentage reduction in cumulative lifetime UV expo- 8, 3 to 5, and 0 to 2 body parts (eg, face, arms, legs)
sure to reduced incidence of skin cancer using the AHEF were assumed to be protecting 75%, 50%, and 10% of
model. Registered schools are assumed to implement the their body surface area, respectively. Each body part
program once per year from 1999 to 2015. Health out- was weighted equally.
comes are calculated for each year’s intervention on the Students are assumed to participate in SunWise only
basis of the number of schools registered and then cu- once in their lifetime and to retain the sun safety behav-
mulated to estimate the total number of skin cancer iors that they report learning at a decreasing rate over
cases and premature mortalities averted by implemen- the 3 years after the intervention. We assumed that in
tation of SunWise from 1999 through 2015. the first year after participation in SunWise, 100% of
For development of a model for estimating students’ students still practice learned sun safety behaviors; in the
baseline and SunWise UV exposure, ambient solar UV second year, 50% of students display these behaviors;
radiation at the Earth’s surface by latitude and month of 25% in the third year; and in the fourth year and be-
the year was first computed using the Tropospheric Ul- yond, students revert to sun safety behaviors practiced
traviolet-Visible radiation model (3.9a).21–25 The accu- before participation in SunWise.
racy of this model has been demonstrated in several The difference between students’ UV exposure before
comparisons to direct measurements of UV at the Earth’s and after SunWise was compared with an estimate of
surface,26–29 and the model has been used in many sci- lifetime UV exposure to calculate a percentage reduction
entific evaluations of ozone depletion.30–37 in lifetime UV exposure associated with a one-time par-
Data from Godar et al38 estimating the percentage of ticipation in SunWise. Lifetime UV exposure was esti-
ambient UV exposure that children are exposed to by mated by first calculating annual UV exposure for girls
gender, season, and geographic region were used to and boys aged 1 to 18 years on the basis of (1) annual
extrapolate students’ potential UV exposure on the basis ambient UV radiation at the Earth’s surface by latitude,
of time spent outdoors. These data were based on the (2) the percentage of ambient UV exposure that children
National Human Activity Pattern Survey, which re- receive annually, and (3) sun protection behavior re-
corded the daily minute-by-minute activities of ⬃2000 ported in the SunWise pretest and posttest surveys. An-
young adults over 2 years.38 The demographics of Sun- nual exposure for ages 1 to 18 years was totaled, and
Wise students (geographic distribution and race) are data from Godar et al51 on the percentage of UV expo-
assumed to reflect those of the general US population sure received by 18 years of age was used to extrapolate
and to vary over time to reflect changes projected by lifetime UV exposure.
the US Census Bureau; these demographic changes The AHEF model was used to translate the cumula-
are built into the AHEF model used to predict health tive percentage change in UV exposure into skin cancer
outcomes. cases and premature mortalities averted. The AHEF is a
To develop a baseline for children’s UV exposure, we peer-reviewed model that is typically used to evaluate
made several assumptions to adjust the potential human health impacts associated with changes in emis-
amount of UV exposure from time spent outdoors to sions of ozone-depleting substances.52,53 For this analysis,
account for the frequency with which students reported only the AHEF module that translates changes in
practicing sun protection behaviors (wearing sunscreen, ground-level UV (in this case, changes in actual UV
hats, and long-sleeved shirts) and the effectiveness of exposure) into changes in health outcomes was used.
those practices in reducing UV exposure. The reduction This module applies calculated dose-response relation-
in UV exposure derived from each sun protection behav- ships to the baseline skin cancer incidence/mortality and
ior was combined to develop a total reduction in UV change in UV exposure to calculate averted incidence/
exposure, and the difference in this reduction on the mortality in each year through 2100.
basis of students’ reports before and after intervention The dose-response relationships used in the AHEF
formed the basis for the health effects analysis. model measure the degree to which changes in UV ex-
For calculation of these UV exposure reductions, it posure weighted by the appropriate action spectrum
was assumed that students who reported that they prac- cause incremental changes in health effects. An action
ticed a sun protection behavior “all of the time,” “some- spectrum describes the relative effectiveness of energy at
times,” or “never,” exhibited that behavior 75%, 50%, different UV wavelengths in producing a particular bio-
and 0%, respectively, of the time that they spend out- logical response. The AHEF relies on the Skin Cancer
side. For long-sleeved shirts39–41 and hats,42–44 Ultraviolet Utrecht-Philadelphia– human (SCUP-h) action spectrum
protection factors of 25 and 2 were selected, respectively. (derived on the basis of the induction of SCC in hairless
No measure of lower body coverage was included in the mice and corrected for human skin transmission) to
analysis. We assumed that students applied sun protec- predict incidence of SCC, BCC, and CMM (because a
tion factor (SPF) 15 sunscreen, but only at 25% of the mammalian action spectrum for CMM remains to be
recommended thickness (2 mg/cm2).45–49 On the basis of determined).52
the exponential relationship between SPF and the thick-
ness applied,50 an effective SPF of 2 was calculated. Ef- Costs Averted
fectiveness of sunscreen use was modeled as the prod- Averted costs of BCC, SCC, and CMM prevented were
uct of this protection factor and the percentage of calculated as the number of cases averted multiplied by
registers for the program in 1999 and continues to implement the program each year until 2015, that classroom is counted in this total 17 times.
e1078 KYLE et al
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TABLE 3 SunWise Program: Evaluation of Student Responses (All Ages), 1999 –2005
Parameter Pretest Posttest Difference, %
(n ⫽ 13 791), % (n ⫽ 10 299), %
Knowledge
Sun can hurt one’s skin 74 79 5a
Wearing hat and shirt are ways to protect one from 61 72 11a
the sun
Sun protection and UV index 25 49 24a
The right number SPF to use 49 73 24a
Attitudes
Suntan is good for my skin 29 22 ⫺6a
People look healthier with a suntan 41 38 ⫺3a
Practices
Wear sunscreen all the time 25 26 1
Apply sunscreen to ⱖ5 body parts 71 76 4a
Wear hats all the time 14 16 3a
Wear long-sleeved shirt all the time 3 4 1a
Wear sunglasses all the time 20 21 1b
Intended practices
Do you think you will put on sunscreen this summer? 45 49 4a
I will try to play in the shade instead of the sun 67 73 6a
All estimates have been independently rounded. As such, the posttest response minus the pretest response may not equal the difference. The
significance of the difference between pretest and posttest responses was tested by using the 2 test for 2 ⫻ 2 contingency tables.
a Level of statistical significance is P ⬍ .001.
Survey data source: Geller AC. The Environment Protection Agency’s SunWise Program (1999 –2005) [abstract]. In: Proceedings of the UICC World
Cancer Congress 2006. Bologna, Italy: Medimond; 2006.
TABLE 4 Averted Nonfatal Cases, Mortalities, and QALYs Associated With the SunWise Program, Fiscal Year 1999 –2015
Funding Scenario Nonmelanoma Skin Cutaneous Malignant Total Cases Total Premature QALY Losses Averted
Cancer Melanoma Averted Mortalities Averted
Cases Premature Cases Premature Undiscounted Discounted
Averted Mortalities Averted Mortalities at 3%
Averted Averted
Current funding scenario 10 696 19 264 33 10 960 51 960 159
Increased funding scenario 14 877 26 367 45 15 244 71 1335 217
Low funding scenario 3049 5 75 9 3124 15 274 52
These averted cases and mortalities are based on baseline rates from the AHEF model for light-skinned individuals and are blended across different age cohorts. Totals may not sum due to
independent rounding.
e1080 KYLE et al
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dren about sun protection behavior. Our results show Second, like any complex modeling framework, the
that small to modest behavioral effects can produce cost- AHEF model— used to estimate health effects in this
effective results; the sun safety education delivered by study— uses data inputs and computational procedures
the SunWise School Program translates into significant that introduce uncertainty to the results. Much of the
reductions in the risk for developing skin cancer, as well uncertainty in the AHEF model is associated with the
as averted costs to society. choice of the SCUP-h action spectrum, which was de-
To our knowledge, this study is the first to assess the rived on the basis of the induction of SCC in hairless
net benefits and cost-effectiveness of a school-based sun mice and corrected for human skin transmission. Past
safety intervention. Although a number of studies have peer reviews of the AHEF have agreed that SCUP-h is
evaluated the behavioral impacts of school-based and the best choice of action spectrum and found the uncer-
community sun safety education programs,13–15,60–67 our tainty to be in an acceptable range.52
study is 1 of few economic evaluations of skin cancer Third, not all health outcomes associated with re-
prevention programs, school-based or otherwise. Carter duced lifetime UV exposure, including reducing the
et al68 modeled the cost-effectiveness of a hypothetical incidence of cataracts and actinic keratosis, minimizing
national skin cancer prevention program in Australia, the effect of photoimmunosuppression,75–81 and mini-
based on the existing SunSmart campaign, and con- mizing the development of photoaging, are modeled in
cluded that such a program would provide excellent this analysis. Averted costs associated with reduced in-
value for money. cidence of these additional health outcomes were not
Complementing the assessment of sun protection considered, although the large majority of the health
habits reported in this study, Geller et al14 found that benefit associated with SunWise is believed to be cap-
children who participated in SunWise experienced an tured. Averted cataract incidence has accounted for
11% reduction in the sunburning rate (from 66% of ⬍1% of the total health benefits (ie, averted costs asso-
students reporting sunburns at pretest to 55% at post- ciated with cataracts and skin cancer cases/mortalities)
test). An 8% decrease from pretest to posttest in the rate in other studies.55
of frequent sunburning (ⱖ3 sunburns per summer) was Fourth, limitations of the analysis may have led to
also reported. This study followed ⬎500 of the same either overestimations or underestimations of its impact.
students over the course of 2 summers. Because a quan- Factors other than SunWise, such as community pro-
titative relationship between sunburn and development grams or parent influence, may have resulted in im-
of skin cancer is not known, it was not possible to use proved sun protection behavior from pretest to posttest.
these results in this analysis. The absence of a randomly selected control group makes
Our study shows that the medical costs and produc- it difficult to determine definitively whether the mea-
tivity losses averted by SunWise outweigh the cost of the sured changes in students’ sun protection behaviors are
program by between 2 and 4 times. These results are attributable entirely to the SunWise intervention; how-
comparable to those of economic analyses of other ever, Geller et al13,14 reported that comparably aged
school-based health education programs. For example, 1 children who served as non–randomly assigned control
study examined Safer Choices, a school-based sexually subjects to SunWise experienced no positive changes in
transmitted disease and unintended pregnancy preven- sun protection practices during the 1-year study period.
tion program for high school students, and calculated a Conversely, other assumptions may have led to conser-
benefit-cost ratio of 2.65.69 Another study evaluated vative estimates of the averted skin cancer incidence and
Planet Health, a school-based intervention designed to costs in this study. For example, in calculating UV pro-
reduce obesity in youth, and estimated averted medical tection resulting from children’s reported sun protective
and productivity costs equal to $40 991 and 2-year pro- behaviors, data were not available to adjust sunscreen
gram costs of $33 677, which translates to a benefit-cost coverage for clothing worn; thus, UV protection (and
ratio of 1.2.70 hence benefits) may be underestimated if, for instance,
Our study has several limitations. First, student self- children are wearing long-sleeved shirts but not sun-
reporting of sun protection behaviors forms the basis for screen on their arms. In addition, the program impact
the baseline and SunWise scenario UV exposure models. may be conservative because the full reach of SunWise
The sun protection practices reported in SunWise stu- (ie, on the sun protection behavior of teachers and
dent surveys, however, are consistent with those in school nurses teaching the program and participants’
other studies of US children, reported by either the child families) was not quantified, although it could be signif-
or the parent.71–73 Verbal reports are used most fre- icant. As of August 2007, 19 840 teachers had registered
quently in sun protection studies; for example, 76 of 81 to use SunWise. Teacher surveys undertaken for Sun-
skin cancer prevention studies cited in the Guide to Wise indicated that 77% of teachers have made sun
Community Services evidence review relied on verbal protection habit changes as a result of teaching the pro-
reports.11 Although moderate to high levels of agree- gram.20 Future efforts should focus on overcoming such
ment between self-report and objective verification of limitations to strengthen the cost-effectiveness evalua-
sunscreen use and protective clothing have been shown, tion of SunWise.
such assessment methods are impractical in school set- Fifth, private costs for participants to comply with
tings; correlations between self-report and dosimeter SunWise recommendations and for teachers to imple-
readings have been shown to be fair, although still sta- ment the Program were not included in this analysis. If
tistically significant.74 the private costs of students’ participation were in-
e1082 KYLE et al
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