Educational Action in Adolescents of a Public School about the Prevention of Skin Cancer

Introduction: Skin cancer is the most prevalent malignancy worldwide. It is necessary to intervene from childhood in its prevention. The lack of awareness of the population demands photoeducation activities, so that photoprotection habits are built. Goals: Compare previous and immediately acquired knowledge and attitudes of primary school students, participants in this educational action aimed at the prevention of skin cancer. Analyze student satisfaction with the educational program attended. Method: A semi-experimental, quantitative study was carried out, based on educational intervention. The teachers, mediators of the intervention, were guided by the researcher, with two dialogical workshops. The educational program was applied over ten weekly activities, based on an active method, to 32 students from the eighth year of a public school in a municipality in the countryside of São Paulo, who answered questionnaires before the beginning and after the end of the activities. Sociodemographic data and phenotypic characteristics of risk for skin cancer, as well as information about knowledge and practice of photoprotective attitudes were previously collected. At the end of the educational inter-vention, students answered a close-ended questionnaire on knowledge and attitudes and a questionnaire on their satisfaction with the program. Quantitative and comparative analysis was carried out between the questionnaires on pre-intervention and post-intervention knowledge and attitudes. Results: The educational program was evaluated satisfactorily


Introduction
Skin cancer is a worldwide public health issue and investing in its prevention, starting in our early years, is the best tool to change this scenario.
Malignant neoplasms of the skin can originate from different cell types, the most common being basal cell carcinoma and squamous cell carcinoma, constituents of the group called non-melanoma skin cancer, which among skin tumors is the one with the highest incidence, corresponding to more than 95% of skin cancer cases, and the estimate for Brazil for each year of the 2020-2022 triennium is about 177,000 new cases (Sampaio & Rivitti, 2018;Chinem & Miot, 2011;Lomas et al., 2012;Instituto Nacional do Câncer, 2020). Predominantly affecting individuals with low skin phototype and with aggressiveness attributed to their power of local invasion, it confers physical mutilation and significant psychosocial damage on the patient, as well as high financial costs to families and health institutions (Lomas et al., 2012;Chen et al., 2013;Fitzpatrick, 1988).
Melanoma skin neoplasms, in turn, originate from melanocytes and dermal nevus cells and have a high fatality rate due to the high likelihood of metastasis (Sampaio & Rivitti, 2018;Weyers, 2012;Almeida, 2020).
Higher skin phototypes are not without risk. One of the subtypes of melanoma, called acral lentiginous melanoma, is almost exclusively prevalent in blackskinned individuals, and ends up being late noticed and diagnosed (Ribeiro et al., 2016).
Both types of neoplasia correlate with exposure to Ultraviolet (UV) radiation.
It is assumed that acute and intermittent exposure to sunlight would be sufficient to cause melanoma, whereas, in basal and squamous cell carcinoma, chronic exposure to sunlight would be the mutagenic factor (Sampaio & Rivitti, 2018;Chen et al., 2013;Ribeiro et al., 2016). The association between tanning and melanoma in young patients is also described (Nilsen et al., 2016). Childhood sun exposure appears as the most harmful factor in the genesis of skin cancer (Bataille, 2013).
According to the World Health Organization (WHO), non-melanoma skin cancer is one of the most prevalent worldwide, and late diagnosis and inaccessible treatment are quite common (Folha Informativa Câncer, 2018).
In 2018, Brazil ranked seventh among the countries in the world with the highest incidence of non-melanoma skin cancer, and ninth in relation to the melanoma type (GLOBOCAN, 2018).
The geographic position of Brazil poses a higher risk to its population, in addition to the local culture of tanning that encourages many people to practice intentional and involuntary sun exposure, during daily and work activities (Schalka et al., 2014;Martinez et al., 2006;Szklo et al., 2007).
A study on the exposure of Brazilian workers to UV rays demonstrated a daily dose of UV rays 50 times higher than the safe dose of 108 J/m 2, recommended by the WHO 14. Therefore, the adoption of photoprotective attitudes is required (Ministerio da Saude, 2010;Instituto Nacional do Câncer, 2009).
Most studies on photoeducation are not Brazilian, consist of short-term interventions, use self-reports to assess habits and have short-term follow-up (Lower et al., 1998;Buller et al., 2011;Lin et al., 2011).
It is known that the effectiveness of these measures is dependent on their pedagogical capacity in health education and their potential for raising awareness, as it should, above all, lead people to changes in habits and attitudes (Alonso et al., 2020;Rodríguez-Zamorano et al., 2018;Rocha et al., 2018).
Children and adolescents should be encouraged to adopt photoprotection habits, since photoexposure in this early stage of life is an important risk of carcinogenesis. In addition to being more receptive to prevention information, supported by models represented by teachers, children and adolescents tend to develop consolidated habits in adulthood, and may also influence other family members (Rocha et al., 2018;Reynolds et al., 1996;Bastuji-Garin et al., 1999;Kouzes et al., 2017;Jha et al., 2017;Stölzel et al., 2014).
The traditional approach has a prescriptive educational attitude, while the active approach seeks to problematize and include the listener as a protagonist in the process of deconstruction and construction of knowledge, promoting greater engagement and transformation of habits; this includes, in the process of "health literacy", the movement of reflection and "teachback", Diverse teaching materials and language appropriate and facilitated to the target audience (Simmons et al.,, 2017;Souza et al., 2018;Thomson, 2006).
Thus, the valorization of educational health measures is fundamental for changing the profile: incidence, morbidity and mortality of skin neoplasms.
In face of the social representation of the teacher as a very present model in society and the potential of this role (Guimarães, 2003), this study proposes to prepare public school teachers, in an active method and health knowledge, for the application of an educational program aimed at health promotion and skin cancer prevention to primary school students.
It is hoped that the gains associated with active methods, based on meaningful learning and constructivist theories, as well as the involvement of teachers in the design and implementation of activities, can reinforce positive knowledge and attitudes related to precautions against neoplastic skin lesions (Guimarães, 2003;Eppinger et al., 2013;Guy et al., 2016;Lima, 2017).
Thus, this study, held in a typical Brazilian city, with hot temperatures and great sun exposure of the population due to the economic activity and lifestyle habits, seeks to compare previous and immediately acquired knowledge and attitudes of primary school students in relation to their participation in educational action aimed at the prevention of skin cancer and to analyze the students' satisfaction with the educational program attended.

Methods
A descriptive and quasi-experimental, quantitative study was carried out in a public school in the countryside of São Paulo, with educational interventions in health for students in the eighth grade of primary school, through previously qualified teachers.
The study was approved by the Research Ethics Committee and its members signed the Free and Informed Consent Form (ICF) and/or Free and Informed Consent Form (TALE), in accordance with Resolution 466/2012 of the National Health Council (Conselho Nacional de Saúde, 2012).
The two moments of the research were: dialogical workshops with teachers and an educational program with students; both were carried out in a public primary school in a small city in the countryside of the State of São Paulo.
The program was proposed to 3 public schools in the Municipality, and to all of its teachers, but we only had one school and one teacher interested. The age range of students and the school year to be applied was decided by the authors and the school coordinator, according to the students' intellectual background.
The participants were a primary school teacher and 32 eighth grade students, literate and able to read, write and understand, in the Portuguese language participated in the whole study. Those who did not answer the questionnaires and/or who did not participate in all the activities proposed by the teacher were excluded. The teachers were the mediators of the educational program and the students, its participants.
The researcher made teaching materials available that were used by the teacher, who contributed with ideas and suggestions to the program, so that it was active, interdisciplinary and integrated. There were two workshops lasting three hours each, fortnightly, aimed at preparing the teacher to apply the photoprotective educational program and to facilitate students' learning about skin cancer.
Prior to the educational program, the sociodemographic questionnaires Q1 and Q2, the latter called Q2-pre, were applied on the theoretical content and habits of photoprotection and skin cancer prevention. A similar questionnaire, called Q2-post, was applied after the educational program, in addition to the Q3 questionnaire.
The following theoretical support materials were used: Primer on skin cancer prevention released by the Ministry of Health ( The activities of the educational program are summarized in the Table 1 below. The questionnaires used were: R1, R2, Q1, Q2-pre, Q2-post and Q3. The R1 and R2 instruments were descriptive, to characterize the school and the teacher. Q1 and Q2 were questionnaires translated and adapted from the SunSmart-School program, and from the Brazilian Society of Dermatology (Sociedade Brasileira de Dermatologia, 2017a; Nova Zelândia, 2019; Instituto Melanoma Brasil, 2013). Q2: Close-ended questionnaire to assess knowledge and attitudes of photoprotection and prevention of skin cancer.
Q4: Judges were invited to validate data collection tools according to the criteria: being a doctor with specialization in dermatology or plastic surgery, with a doctorate degree and being active in care or teaching. All instruments were applied to a pilot group with 15 eighth grade Primary School students in another school.
The reports were analyzed descriptively as well as the results of the questionnaires. The quantitative analysis was based on Wilcoxon and chi-square calculations with a 95% reliability index (SAS Institute, 2018).

Descriptive aspects
Characterization of the HEI (R1) and the teacher (R1, R2 and Q1) The participating school is a public primary and secondary school, with 731 students, with an average of 40 students per class and 39 teachers. Each class has 9 different teachers.
The curriculum is subject-oriented. There is no sun protection policy in place or guidance, or incentives given by teachers to parents or students.
The measure adopted by the students during the breaks for photoprotection is the search for the shade and the use of a cap, which is allowed in the breaks. UV radiation and its harms are subjects studied in the Science subject, only in the ninth year.
The teacher has a degree in Biology, has taught Science for 8 years, and reports participation in training in active teaching/learning methodologies, using instruments based on these methodologies in educational activities.
Sociodemographic and phenotypic characterization of the studied population The population of participating students is 53% male and 47% female: the age ranges from 11 to 15 years, with an average of 14 years. 49.5% consider themselves white and 44%, brown, being a minority of blacks. The predominant family income is 1 to 3 minimum wages, and most parents have completed secondary school.
Regarding the risk factors for skin cancer: 35.48% consider their skin to be of a low phototype (phototypes 1 and 2); as for the eyes, light hair, and the presence of freckles, 10.75%, 20.43% and 11.82% have these characteristics, respectively. As for the presence of more than 50 spots and spots larger than 1 cm, 7.52% and 13.27% responded positively; however, an important portion of students who did not answer or did not know how to answer is noteworthy, showing low concern with the issue.
As for risky behavior, more than 60% report daily sun exposure and more than 70% report at least one sunburn episode.
As for the family history of skin cancer, only 11.82% report a positive history, and more than 30% did not know how to answer.
As for the family history of cancer, a larger proportion of 20% also did not know or did not respond, which again shows low awareness of the topic.

Quantitative Results
In total, 32 students answered the questionnaire Q2-pre, Q2-post and Q3, completing 100% the proposal of the educational program.
Presentation of comparative results, under quantitative analysis, of the questionnaires of knowledge and attitudes Q2 pre-intervention and post-intervention, showing the mean and median (Tables 2-4).
Analysis of the Educational Program Satisfaction Questionnaire (Table 5).

Discussion
Regarding the quantitative data of photoprotective attitudes, there was no statistically significant change due to a bias: the educational program was developed in the months of the spring and students did not go through the summer after the program, so that it was possible to compare this behavior.
Regarding the qualitative responses to the attitude's questionnaire, there was statistical significance for question number four, which demonstrates that the educational program sensitized 33.4% of students to the use of sunscreen, even if rarely.    Another statistically significant change was related to sun exposure for intentional tanning. There was a decrease in the number of students who responded that they never intentionally exposed themselves to the sun, and an increase in students who responded to intentionally sunbathing rarely. This symbolizes students' awareness of sun exposure, who have come to consider the answer "Never" as unlikely.
As for knowledge, the educational program caused statistically significant changes in two questions: question three, about glass photoprotection, which obtained 100% of success and understanding to answer correctly, and question eleven, whose percentage dropped from 73% to 26% of students who wrongly judged the correct amount of sunscreen. This shows that the educational program was assertive for this case.
Regarding the satisfaction questionnaire, more than 93% of students considered having the opportunity to discuss ideas and concepts during the educational program, which is an important matter in active teaching/learning methodologies, since the rescue of prior knowledge makes it possible to insert new concepts and knowledge reconstruction, which makes learning meaningful (Sousa et al., 2012;Sociedade Brasileira de Dermatologia, 2017b;Nova Zelândia, 2019;Likert, 1932).
The variety of materials presented, and the motivation generated were also items approved by more than half of the students, which effectively contributes to changing behavior and developing new habits (Sousa et al., 2012;Sociedade Brasileira de Dermatologia, 2017b;Nova Zelândia, 2019;Likert, 1932).
The active participation of students and the supportive environment were judged positively by more than 60% of students.
And the understanding of the objectives of the activities and their clarity and ease, were judged to be sufficient in 54.8% and 67.7%, respectively.
The students had difficulty in giving their opinion on: "The effectiveness of the methods", "space to present their own ideas" and "opportunity to clarify the objectives of the activities". In view of the satisfactory evaluation of the other items, it was considered that in this case, possibly, the questions were not very objective, generating difficulty in understanding.

Conclusion
We concluded that the educational program through active learning methodologies on skin cancer prevention sensitized students, promoted the use of sunscreen and the acquisition of new knowledge about photoprotection: the correct amount for applying sunscreen and the fact that glass does not protect against UV radiation.
The possibility of significant knowledge construction, based on interaction with peers and the teacher, using triggers, allows a positive influence on the development of healthy behavior (Alonso et al., 2020;Souza et al., 2018).
The strategies used in the educational program were evaluated as satisfactory by the students, promoting an opportunity for the construction of new knowledge, in a participatory way, in a welcoming environment, through motivating materials, following the precepts of active learning methods (Thomson, 2006;Guy et al., 2016;Lima, 2017); in addition to enabling greater student involvement and integration with the topic, raising awareness of new attitudes and the development of healthy habits in the prevention of skin cancer.
The potential of the educational program to provide knowledge and motivate the change of habits is a good justification for the inclusion of the proposed theme in the curriculum of schools in the city, or even in the nationwide, so that more engaged teachers and students could improve the program and obtain better results.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this paper.