According to the World Health Organization, skin cancer is the most common type of cancer in the world.1 In recent years, its incidence has been increasing, with that of melanoma increasing even more rapidly.2 Based on clinical and histological criteria and number of tumors rather than persons affected, the incidence rate for basal cell carcinoma in Spain is 253.23 (95% CI, 273.01–269.45) per 100000 persons per year, that of squamous cell carcinoma is 38.16 (95% CI, 31.72–39.97) per 100000 persons per year, and that of melanoma is 8.76 (95% CI, 7.50–10.02) per 100000 persons per year.3

Exposure to UV radiation is the main risk factor for skin cancer and is responsible for almost 65% of melanomas and 90% of nonmelanoma skin cancer.1,4 In addition, as it is the only modifiable factor, prevention and raising awareness among the general public are essential.

Exposure to sunlight during childhood and adolescence plays a key role in the development of skin cancers and is associated with an increase in the number of melanocytic nevi.5–7 Children and adolescents are more exposed than adults.8

Several educational programs have been aimed at children. The first was SunSmart, which was created in 1960 in Australia9 and aimed to reduce the incidence and morbidity and mortality of skin cancer, change personal attitudes, and control the disease.10 Using a series of questionnaires and activities, the program attempted to raise awareness about the importance of sun protection.7 Today, SunSmart has improved sun protection habits among the public and has even reduced the incidence of skin cancer.11 Similar programs include SunSafe and Sun Protection Fun.2,12

SolSano (HealthySun), which was started in Aragon in 2000, is the first sun protection program in Spain.13 It is aimed at primary school children (6–12 years) and is run in schools by teachers. The main objectives of SolSano are to educate and to influence sun exposure habits in children and their families. It also aims to show how to enjoy sunshine in a healthy way and to reduce the frequency of adverse effects of UV radiation in the short term (sunburn) and in the long term (skin cancer).14 Some 5000 children take part every year. SolSano was able to increase the use of sun protection methods, reduce the number of cases of sunburn, and diminish interest in tanning within only a few months of completing the program.13,14 However, it is essential to determine whether these improvements remain in force in the long term. This information is essential, since the main objective of the program is to reduce the incidence of skin cancer in the future. Therefore, our objective was to investigate sun protection habits and knowledge among university students in Aragon who had attended a primary school where SolSano was run and to compare our results with those of schools that did not implement the program.

The results obtained show that sun protection habits and, more particularly, knowledge about sun protection among the students surveyed are good. However, no statistically significant differences were observed between those who attended a school where the SolSano program had been implemented and those who had not. This absence of differences may be because SolSano is not the only means of providing training on sun protection; in fact, the main sources of information were parents and the media. Furthermore, the period between attending a school that ran the program and the survey was more than a decade.14 Programs do not usually evaluate their efficacy in the long term. Jones et al.16 analyzed the effectiveness of the SunSmart program after 5 years and identified a significantly greater use of hats and sunscreen. Olson et al.2 evaluated the SunSafe program 2 years after completion and found that significantly more participants used sunscreen. An evaluation of SolSano 5 months after completion revealed less frequent use of sunglasses, clothes, and staying in the shade as sun protection strategies, a greater incidence of sunburn, and a reduced desire to tan.14 In all cases, the comparison was made to determine whether the program improved the habits and knowledge of a group of children, although there were no comparisons with a control group that had not undergone the program, as in the present study.

One of the secondary objectives of our study was to know the sun protection habits of university students. The most widely used were sun cream and sunglasses. This finding is consistent with those of Ponce et al.17 for university students in the Canary Islands and of Murphy18 and Kirk and Greenfield19 for university students in Ireland and the UK. Sunscreens are thought to be the most widely used method because of marketing campaigns in the media.15 In fact, most respondents in our survey said that the information they receive on sun protection came from their families and from the media.

Slightly more than half of the students (50.5%) reported having been sunburned once or twice the previous summer. A similar finding was reported for the SunSmart program in secondary school students, i.e., 2 of every 3 students reported having been sunburned the previous summer.10 The results of the study show that findings for sunburn were statistically significant for specific student profiles, namely, males with pale skin who liked to sunbathe. These results are similar to those of Saridi et al.,20 who found that the desire to tan was a risk factor for sunburn, as well as going to the beach during the middle of the day. Another interesting result is that women were less frequently sunburned than men, as reported by Ponce et al.17 and Geller et al.21 This seems to be consistent with the finding that adolescent females develop better sun protection habits and knowledge than adolescent males after receiving a sun education program.

Only 27.6% of those surveyed reported self-examining their skin annually. Some studies indicate that the incidence of skin cancer is increasing in young people22; therefore, we should insist on self-examination in this age group. Nahar et al.23 highlight that 17.5% of young people examine their skin annually, although this is not a complete examination, since they overlook large areas such as the back.

One objective of educational programs on sun protection is for participants not to desire a tan and not to consider it attractive. In our study, 65.4% of the students wished to have a suntan. Kirk and Greenfield19 highlight that 80% of university students in Birmingham, UK wished to have a suntan. SunSmart reduced this percentage from 68% to 36% in 20 years and the percentage who consider tanned people more attractive from 61% to 35%. SolSano also reduced this desire for a suntan from 48.3% to 43.8%, although in the short term.14

Students from the University of Zaragoza are knowledgeable about sun protection. Our findings are similar to those of Rodriguez et al.,24 who found that 97% of Peruvian students acknowledge that solar radiation is the main cause of skin cancer. Furthermore, 92.7% of Brazilian university students are aware of the risks of UV radiation and the association with skin cancer,25 and most Saudi Arabian university students say that exposure to sunlight should be avoided in the middle of the day.26 One study performed among Spanish university students highlighted that 94.3% are aware of the risk of exposure to sunlight on the skin.27 However, knowledge is not the same as behavior, and the incidence of sunburn is high (50.5% in our study and 70.6% in the study by Ponce et al.17).

Our results indicate that the SolSano program does not seem to achieve its long-term objective, at least as far as reducing the frequency of sunburn is concerned. SolSano is run in primary schools. However, it seems necessary to implement other educational interventions in higher education cycles, since students are more aware of the risk of developing skin cancer in the future.10 In addition, extension of SolSano to areas outside schools (e.g., health care and sports) would ensure that the program had a greater impact.28

Our study is subject to limitations and biases. First, the number of participants was low (324). The University of Zaragoza has 27571 students, and since we do not know how many received the link to the questionnaire, we cannot calculate the response rate. Second, the fact that most respondents were studying medicine could lead to bias, although several studies performed in Spain found that while medical students are more knowledgeable in this area, their sun protection habits are no better than those of other students27 and their incidence of sunburn is not lower.17

It is also important to remember that the survey was carried out some 15 years after the respondents participated in the program; therefore, the results may be subject to recall bias (65% reported having received information on sun protection while at school, mainly during the first stage of the secondary cycle [41.5%]). The only program that has proven effective in the long term is SunSmart, which was implemented in Australia, not only in schools, but also in the areas of leisure, sports, and health care.28

In conclusion, students from the University of Zaragoza are aware of the main risks of exposure to sunlight and report having appropriate sun protection habits, although most experience sunburn, wish to be tan, and do not perform skin self-examination. While the SolSano educational program has proven effective at improving children's habits and knowledge in the short term, this effect does not seem to make a difference in the future. Further educational interventions are necessary in higher school cycles and areas other than school if we are to ensure that the changes promoted by SolSano remain valid over time and, more particularly, that the frequency of sunburn decreases among our university students.

The authors declare that they have no conflicts of interest.