Skin cancer continues to be the most common cancer in Vermont and the United States. About one in five Americans will develop skin cancer in their lifetime. Vermont currently ranks second highest in the country for melanoma skin cancer rates. Rates continue to rise and skin cancer is impacting patients at younger and younger ages. Although several factors play into development of melanoma, a large risk factor for developing skin-cancer in one\u27s lifetime is UV exposure. One way to combat this is to encourage regular sun-safe practices, such as daily sunscreen use, seeking shade, and wearing sun-protective clothing. The aim of this project was to assess barriers to sunscreen use and evaluate current skin cancer statistics and sun-safe practices to create a SmartPhrase. Because providers only mention sunscreen in 0.9% of visits, the hope is that this SmartPhrase will be an easy and efficient way for providers at Colchester Family Practice to encourage sun-safe practices for their patients.https://scholarworks.uvm.edu/fmclerk/1613/thumbnail.jp

Benner, Joy A

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University of Vermont ScholarWorks @ UVM Family Medicine Clerkship Student Projects Larner College of Medicine 2020 Sun-Safety: Assessing Barriers and Promoting Sun-Safe Practices for Vermonters. Joy A. Benner UVM Larner College of Medicine Follow this and additional works at: https://scholarworks.uvm.edu/fmclerk  Part of the Medical Education Commons, and the Primary Care Commons Recommended Citation Benner, Joy A., "Sun-Safety: Assessing Barriers and Promoting Sun-Safe Practices for Vermonters." (2020). Family Medicine Clerkship Student Projects. 543. https://scholarworks.uvm.edu/fmclerk/543 This Book is brought to you for free and open access by the Larner College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion in Family Medicine Clerkship Student Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contact donna.omalley@uvm.edu. Sun-Safety: Assessing Barriers and Promoting Sun-Safe Practices for Vermonters.Joy BennerFamily Medicine Clerkship, January 2019Colchester Family Medicine Mentor: Benjamin Clements, MDProblem Identification and Need• Skin cancer is the most common cancer in the U.S. and in Vermont[1][2].• Although non-melanoma skin cancer rates are much more common, melanoma rates in Vermont, including Chittenden county, are some of the highest in the U.S. [2].• Estimates show that 1 in 5 Americans will develop some form of skin cancer in their lifetime [1].• Rates of skin cancer continue to climb.• The average annual number of adults with skin cancer in 2007-2011 was 4.9 million, which increased from 3.4 million in 2002-2006[6].• It is estimated that UV radiation causes about 90% of skin cancer [3]. • Having one blistering sunburn or more than five lifetime sunburns doubles the risk for melanoma [3].• 37.1% of U.S. adults and 55.8% of U.S. youth report 1 sunburn in the past year [6].• About 80% of sun damage occurs before the age of 21. • Using broad spectrum sunscreen with at least SPF 15 (although AAD recommends use of SPF 30) and above can reduce non-melanoma skin cancer rates by 40% and melanoma skin cancer rates by about 50% [3].• Sunscreen is mentioned at 0.9% of visits.• Currently, it is estimated that only about 15% of men and 30% of women in the U.S. use sunscreen for every hour of UV exposure [1].• Use was lowest among men, people with skin of color, adolescents, less physically active, and people with lower socioeconomic status [1]. 2Retrieved from: https://www.healthvermont.gov/sites/default/files/documents/pdf/stat_cancer_incidence_mortality_tables-2012-2016.pdfProblem Identification and Need• 35% of Vermonters and 63% of Vermont adolescents, including within Chittenden county, experience at least one painful sunburn yearly [4].• Only 16% of Vermont high schoolers, and 27% of Vermont middle school students use sunscreen regularly [2].• A 2018 study done by impactmelanoma.org in conjunction with the Vermont Department of Health, showed that while Vermonters have good sunscreen practices in the Summer, they do not regularly use sunscreen in the Winter, Fall, or Spring [4].• This study demonstrated these main barriers to sunscreen use in Vermonters[4]: 1. Forgetting to use sunscreen (61%) 2. Not worried about getting sunburn (45%) 3. Too messy (15%)4. Too expensive (10%)5. Not sure if it does any good (9%)6. Irritates skin (7%)7. Other (8%)• Values add up to more than 100% due to more than response option Study done in Canada (Boggild & From, 2003): frequently cited barriers to sun safety include inconvenience (34% of respondents), forgetting to use sun safety measures (49%), a desire to be tanned (33%), and protective clothing being too hot to wear (56%). High compliers were notable for their great likelihood of being counseled by a physician about sun safety (P < 0.025) and their slightly higher mean knowledge scores3Retrieved from:https://impactmelanoma.org/wp-content/uploads/2019/07/Vermont-Sunscreen-Use-2018.pdfRetrieved from:https://impactmelanoma.org/wp-content/uploads/2019/07/Vermont-Sunscreen-Use-2018.pdf4Retrieved from https://www.healthvermont.gov/sites/default/files/documents/pdf/stat_CancerDataPages_Cancer_Related_Risk_Factors_and_Preventative_Behaviors.pdfThese graphics depict melanoma rates, adult sunburn rates, and adolescent sunburn rates in various counties in Vermont.Public Health Cost• Given that skin cancer is one of the most commonly diagnosed cancers annually, it has huge implications as a public health concern. • The average annual number of adults with skin cancer in 2007-2011 was 4.9 million, which increased from 3.4 million in 2002-2006 (up 136%).• The average cost of skin cancer treatment was $8.1 billion in 2007-2011 up from $3.6 billion in 2002-2006 (a total increase of 126%) [4].• In 2007-2011, the average cost for non-melanoma skin cancers was $4.8 billion and was $3.3 billion for melanoma skin cancers [4] • Actinic Keratosis account for 5 million dermatology visits each year totaling a cost of $920 million annually [5].• Estimates show that emergency room visits regarding sunburns accounted for $11.2 million in 2013 [6].5Community Perspectives Benjamin Clements, MD Colchester Family Medicine• Melanoma rates in Vermont are higher than we as providers would like, and it seems that Vermonters are not using sunscreen and sun-safe practices as much as we would hope. In busy clinic days, talking about sunscreen and sun-safe practices can fall to the wayside especially when you have to prioritize. It is likely not being discussed in wellness visits as often as it should. This is definitely an area of improvement, and we should try to bring up sun-safe practices more often. We can encourage providers to have this conversation in more wellness visits. The SmartPhrase is a great way to help providers do this in a time efficient way. Audrey Monroe, LICSW Colchester Family Medicine• I think the biggest barrier is finances for those in the lower socioeconomic range. If they see dermatology at UVMMC they could apply for the Patient Financial Assistance Program which helps income eligible patients with copays/deductibles – especially for screenings. One way to improve sunscreen access is maybe having dermatology or primary care work with the Vermont Department of Health to provide free sunscreen to those from lower socioeconomic backgrounds. 6Had the pleasure of engaging in interviews with multiple individuals from different disciplines to better understand Vermonters access to sunscreen, barriers to use, and how to better promote sun-avoidance and better sun-safety practices!Community Perspective Sharon Mallory, MPH Coordinator – Comprehensive Cancer Control ProgramVermont Department of Health • Vermont has the second highest melanoma rate in the US, behind only Utah. There are several hypothesis behind why: Vermont has arapidly aging population, and a population that is largely made up of fair-skinned individuals. Although, interestingly enough, we have found that even after adjusting for these factors, we still have one of the highest rates of skin cancer. It is also thought that Vermonters often get “short bursts“ of sun because of our short summer seasons. It is thought in cancer research that short bursts may actually be more harmful than long-term exposure because you don’t build up that melanin reserve. We are also not as good at wearing sunscreen all year round because we have long winters and cloudy days, so people may not be wearing enough sunscreen during these times. • We at the Vermont Department of Health are trying to increase awareness and use of sunscreen by placing dispensers in state parks around the state. This work is done with with impact melanoma. We also worked with impact melanoma to research why Vermontersaren’t using sunscreen. We also work with rec departments and summer camps to promote sunscreen use in adolescents. • To help reduce UV damage in adolescents, Vermont and several other states passed legislation to ban tanning bed use in anyone under 18. While it is hard to know exactly the impact this has had, using the Youth Behavior Risk Survey (YRBS), we did notice a dramatic reported decrease from use the year before the legislation to the year after. We are having difficulties because you don’t have to have a license to operate a tanning bed, so it’s hard to keep track of where adolescents might have access to tanning beds. We also think we might be missing high school seniors that turn 18, who might use tanning beds for say an event like prom, because the YRBS only surveys teens until age 17.• Because skin cancer develops years down the line and has a relatively low mortality, it can be harder to promote awareness in younger populations. We now know that people are getting a significant amount of their lifetime skin damage before the age of 21, so it is important to address this. Research has shown that providing education about this in elementary school has more impact than providing education about this later on, such as in middle or high school. 7Intervention & Methodology - Promoting Sun-SafetyProvided educational presentation to providers about skin cancer statistics and sun-safe practices.• Encourage use of SPF 30 or greater with broad spectrum coverage (covers both UVA and UVB). • UVA thought to lead to more photodamage – such as wrinkling. Can penetrate glass. • UVB thought to lead to more sunburn and skin cancers. • Promote everyday use of sunscreen on exposed skin, even in winter time.  • Snow and ice can reflect more damaging rays of sun • 80% of UV rays penetrate on cloudy days • Don’t forget the lips. • Encourage use as young as possible – 80% of sun damage occurs by age 21!• Avoid tanning beds – exposure to indoor UV with tanning beds before age of 45 has 75% increased risk of early melanoma [1]. • VT and a few other states have created a law that restricts tanning bed use to ages 18+.• Minimize sun exposure from 10 AM to 2 PM.• Seek shade.• Wear long sleeve shirts, pants, sunglasses, and wide brimmed hats when possible.• Bring up sunscreen regularly: barriers that Vermonters report to sunscreen use include forgetting to use it and not being concerned about sunburns. 8Intervention & Methodology - SmartPhrase9Created a SmartPhrase to help providers more efficiently and easily address sun-safety. Accessible by typing .SUNSCREENFAQSJBResponse• Gave a brief presentation on current skin cancer data and trends. Also provided information on current research around Vermonters sunscreen barriers and utilization to providers at Colchester Family Medicine. Discussed sun-safe practices. • Overall, feedback was positive and providers felt this was education and that they learned something new about skin cancer and sunscreen use. • Administered brief 5-point Likert Scale Survey to assess reaction to SmartPhrase after providers reviewed the SmartPhrase. • Only 5 providers were present at the presentation, and all responded to the survey. • All providers agreed or strongly agreed to use this SmartPhrase in their practice. • All providers agreed or strongly agreed that this SmartPhrase easy to use. • All providers either strongly agreed or agreed that this will be useful in their practice. • All providers either strongly agreed or agreed that this will be beneficial to their patients. • Overall very positive response toward the SmartPhrase and providers plan to use it in their everyday practice and feel that it will help their patients and promote better sun-safe practices.10Effectiveness and Limitations• Effectiveness: • Provided a brief survey for staff to complete regarding presentation and SmartPhrase use, which indicated that the presentation was educational and that the SmartPhrase will be useful in their practice. • A useful future evaluation would be to assess how often providers use this SmartPhrase in after visit communications. • Another useful evaluation would be to assess whether patients found the information in this SmartPhrase helpful and whether it impacted behaviors. • An interesting future project would be to do larger study to assess barriers to sunscreen use, as current research is limited.• Limitations: • Very limited research exists on barriers to sunscreen use, the one research study I could find had limited data information or study information. • Challenging to provide information on which particular patients would benefit from these materials. • Did not have time to evaluate whether patients find the materials helpful. • Limited information regarding sunscreen use and patterns specific to Chittenden county. 11Future Indications12• Benefit would be gained from more studies assessing Vermont patterns of sunscreen use and limitations. Only one study could be found, which contained limited information. Very few studies exist that look at sunscreen barriers in the United States. • Future studies could also assess whether the SmartPhrase had an impact on patients sunscreen use and knowledge about skin cancer. • It would also be beneficial to use this information to provide educational materials to schools in Vermont. Research indicated that many adolescents experience sunburns annually, and a large risk of later skin cancer comes from early life sunburns. School-aged population would greatly benefit from encouraged sunscreen use. After speaking with VT Department of Health this should be mostly focused in elementary schools.References1. CDC – Cancer Prevention and Control - Sunscreen Use Among Adults in the United States (August 15th, 2018).Retrieved 1/3/2020, from  https://www.cdc.gov/cancer/dcpc/research/articles/sunscreen-use.htm2. Vermont Department of Health – Cancer: Understanding the Risks (May 5, 2016). Retrieved 1/3/2020 from https://www.healthvermont.gov/sites/default/files/documents/pdf/stat_BTVPR_Cancer_Risk_050516.pdf3. American Academy of Dermatology Association – Skin Cancer (n.d.). Retrieved 1/3/2020 from https://www.aad.org/media/stats-skin-cancer.4. Impact Melanoma – Sunscreen Use Vermont Baseline Study – (June 2018). Retrieved 1/3/2020 from https://impactmelanoma.org/wp-content/uploads/2019/07/Vermont-Sunscreen-Use-2018.pdf5. Emily A. Weig, Rechelle Tull, Jina Chung, Zoe O. Brown-Joel, Rumbidzai Majee & Nkanyezi N. Ferguson (2019) Assessing factors affecting sunscreen use and barriers to compliance: a cross-sectional survey-based study, Journal of Dermatological Treatment, DOI: 10.1080/09546634.2019.15871476. Guy Jr, G. P., Machlin, S. R., Ekwueme, D. U., & Yabroff, K. R. (2015). Prevalence and Costs of Skin Cancer Treatment in the US, 2002− 2006 and 2007− 2011. American journal of preventive medicine, 48(2), 183-187.7. Kirby, J. S., Gregory, T., Liu, G., Leslie, D. L., & Miller, J. J. (2017). Variation in the Cost of Managing Actinic Keratosis. JAMA dermatology, 153(4), 264–269. doi:10.1001/jamadermatol.2016.4733.8. Guy, G. P., Jr, Berkowitz, Z., & Watson, M. (2017). Estimated Cost of Sunburn-Associated Visits to US Hospital Emergency Departments. JAMA dermatology, 153(1), 90–92. doi:10.1001/jamadermatol.2016.4231.9. Retrieved 1/4/2020 from https://www.healthvermont.gov/health-statistics-vital-records/surveillance-reporting-topic/cancer10. Boggild, A. K., & From, L. (2003). Barriers to sun safety in a Canadian outpatient population. Journal of Cutaneous Medicine and Surgery: Incorporating Medical and Surgical Dermatology, 7(4), 292-299.13Thank you!

Sun-Safety: Assessing Barriers and Promoting Sun-Safe Practices for Vermonters.

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Sun-Safety: Assessing Barriers and Promoting Sun-Safe Practices for Vermonters.

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