Adolescents’ Perception about Photoprotection Measures for the Prevention of Skin Cancer

Introduction: The prevention of skin cancer must be carried out from childhood, requiring educational actions to promote healthy habits. Goals: To analyze influencing elements in photoprotective attitudes and to develop pho-toeducational material for children and adolescents. Method: This was a semi-experimental, qualitative study of educational intervention on photoprotection, applied to 32 students from the eighth grade of primary school. Sociodemographic and phenotypic data related to risk for skin cancer and factors that influence the practice of preventive attitudes was analyzed. Results: The analysis showed the need for a differentiated approach to adolescents, including regarding issues such as acne, refractive errors in vision, vitamin D and tan culture. Conclusion: The results gave rise to an educational material that syn-thesizes photoprotection measures and encourages the practice of photoprotective attitudes.


tology (Sociedade Brasileira de Dermatologia-SBD), also recommends interaction between medical students and children/ adolescents, a more youthful and assertive language, and space for clarification of doubts and private conversations
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Few studies on the knowledge and habits of photoprotection in Brazil are available in the literature. Among these, a study carried out in the city of Porto Alegre, among adolescents, shows that, although well-informed, adolescents do not adopt photoprotection habits. Among boys, sun exposure is more frequent during the practice of physical activity, whereas in girls, sun exposure is more frequent during walks and swimming in the pool. Furthermore, the study shows that the main source of information are campaigns published in the media, and emphasizes the need for a discussion using different resources to incorporate these measures among children and adolescents (Rodriguez-

Innovative Strategies and Building New Habits
In the process of "health literacy", a term used by Simmon et al. and Rodriguez, in 2018, who defend the use of active methods and the encouragement of student proactivity in the acquisition of knowledge in an integral and interdisciplinary way, meaningful learning is sought, which is one of the pillars for changing habits (Reynolds et al., 1996;Bastuji-Garin et al., 1999).
Active methods such as problem-based learning and problematization methodology encourage students to actively seek solutions, developing creativity and autonomy (Simmons et al., 2017;Souza et al., 2018;Thomson, 2006). This is a strategy that generates motivation, which facilitates the resolution of these problems, and shows the ability of students to become responsible for their own successes and changes (da Rocha et al., 2018). The best way to invest in behavior is with repetitive training sessions, not short, intensive, or one-off experiences (Reynolds et al., 1996).
The effectiveness of educational measures is also dependent on the pedagogical capacity of the proposals developed in health education and its potential for raising awareness (Rodriguez-Zamorano et al., 2018). The student's motivation arises after being aware of his potential for contribution and resolution, and this engagement is necessary to change behavior and habits (Bastuji-Garin et al., 1999).
As young individuals have more ability to acquire new knowledge, develop and maintain new habits, the strong social representation of teachers as an example in society and their skills to contribute to this process is used (Eppinger et al., 2013;Guy et al., 2016).
Considering the effects of cumulative photoexposure, the potential of active health education (Lima, 2017), the awareness of young individuals and the social representation of educators as mediators, this study aims to develop an educational intervention aimed at promoting health and preventing cancer for primary school students through public school teachers previously oriented on the subject and qualified to use an active teaching-learning method. C. S. Deponte et al. Active and dialogical intervention must be able to engage teachers and students, enable joint construction of significant knowledge and lead to changes in habits and new attitudes aimed at preventing skin cancer (Eppinger et

Goals
This study seeks to understand the perception of adolescent primary school students about the influential factors in the practice of photoprotective attitudes, after an educational action aimed at the prevention of skin cancer; and develop educational material for children and young individuals on this topic, encouraging the adoption of new habits for the prevention of skin cancer.

Material and Methods
This was a quasi-experimental, descriptive study, aimed at the application of an educational intervention on the prevention of skin cancer, whose results were qualitatively analyzed. The intervention was aimed at students in the eighth grade of primary school at a public school in the countryside of São Paulo and was mediated by a teacher specifically prepared to act as a facilitator. The teacher's preparation was conducted by the CSD researcher through two dialogical activities, of

Data Collection Instruments
Two reports were used, answered by the teacher, to characterize the school environment regarding sun protection policy and another to characterize the teacher, named, respectively, R1 and R2.
The questionnaires answered by the students were: Q1 questionnaire, composed of closed questions of sociodemographic and phenotypic data related to risk factors for skin cancer and Q2 questionnaire, composed of open questions about influential factors in the practice of photoprotective attitudes.

Participants
A teacher participated in the dialogic meetings and concluded the educational program with 32 students from the eighth grade of a public primary school. The inclusion criteria for participating students was being able to read, write and understand in Portuguese, and the conclusion of the educational program taught by the teacher, previously trained by the researcher. Those whose guardians did not authorize data collection through the survey questionnaires and/or who did not participate in the activities proposed by the teacher were excluded from the study (Deponte et al., 2021).

Activities to Prepare the Facilitating Teacher
There were two activities totaling six hours of duration, carried out in fifteen days. On the occasions, the researcher and the teacher organized the themes and their respective triggers, by an active teaching-learning strategy, to include several subjects in the school curriculum and value triggers that mobilized greater interaction for the construction of meaningful on skin cancer and its prevention (Deponte et al., 2021). The triggers and topics covered are summarized in the following Table 1.

Data Analysis
Qualitative analysis followed the steps for Content Analysis in the Thematic Modality proposed by Bardin (2011): pre-analysis: initial reading of texts to identify meanings and ideas, in a fluent way; exploration of the material, with organization and categorization of the main ideas; and inferences and interpretation of the categorized ideas.

Characterization of the School and the Teacher
The educational institution is a public primary and secondary school. It has 731 students enrolled. The classes have, on average, 40 students and 9 teachers each. The teaching method used is traditional, disciplinary, although there are some movements to integrate contents. Short courses on active learning methods for teachers were reported. The physical space has an extensive outdoor area for socializing and dining with proper physical and tree coverage to house students, in addition to covered and open multi-sport courts. Physical education classes are not restricted to the safest hours of sun exposure (before 10a.m. and after 4p.m.).
Regarding internal policies aimed at photoprotection of students and teachers, permission for the use of hats during breaks between classes was mentioned. There was no mention of the effectiveness of sun protection measures or guidance and incentives given by teachers to parents or students.
In the primary school curriculum, solar radiation and specifically UV and its consequences are addressed in the ninth grade and in the Science subject.
The facilitating teacher of the intervention has a bachelor's degree in Biology, and has been teaching Science for 8 years. The teacher reported having participated in the training of active teaching methods and having already used instruments based on these methods in educational activities.
The most prevalent sociodemographic characteristics of the students participating in the study were represented in Table 2.
The phenotypic characteristics of students related to the risk for skin cancer are represented in the Figure 1 with the graphs below.
Low skin phototypes correspond to a minority of students, corresponding to Creative Education 35.48%; in a smaller percentage, there are still students with light-colored eyes and hair, in addition to freckles, not exceeding 20% of the total. Likewise, the number of spots and large spots are not prevalent factors in this student population, appearing in 7.52% and 13.27% of students, respectively. It is evident that a considerable portion of students had difficulty in answering and demonstrates lack of knowledge about such important physical characteristics, denoting little attention to this body segment. The same is true for family history of skin cancer and other cancers, in which more than 20% of students were unable to answer, again representing little concern with the topic.  Although physically the minority of students is at high risk for skin cancer, we have the opposite in terms of behavior. More than 60% of students report frequent sun exposures and episodes of sunburn, presenting high vulnerability.

Qualitative Study on Q2
The answers given to two open questions from the Q2 questionnaire were analyzed: 1) "Talk about the ease of carrying out the actions we must do every day to reduce the risk of skin cancer." 2) "Talk about the difficulties of carrying out the actions we must do every day to reduce the risk of skin cancer." Cursive answers were grouped into two broad categories: 1) access to strategies; 2) construction of habits. The "access to strategies" category encompasses the following subcategories: products, knowledge and care, which constitute the items for adequate photoprotection and its general meaning brings the idea of the ability to possess, enjoy or acquire the needs of photoprotection and daily care in the prevention of skin cancer; the "construction of habits" category, which includes the subcategories adherence, organization and weather, whose general meaning expresses limitations and ease of carrying out the necessary attitudes for daily care in the prevention of skin cancer, and are shown in Table 3.
Analyzing the cursive answers, it was identified that some students considered the skin cancer prevention measures simple and quick, which was categorized as "access to strategies" and subcategorized as "care". However, the superficial approach of the students was evident, inattentive to the proper adoption of the measure to ensure its effectiveness, as mentioned by Oliveira et al. (2019), among students of a surf school, with reference to the use of sunscreen, mentioned generically, as verified in the following answers: Table 3. Grouping into categories and subcategories regarding the meanings of the answers to the Q2 questionnaire.

Categories
Subcategories Senses "Access to strategies" Product Students have sunscreen, sunglasses, hat and caps at home. Students do not have the financial means to buy sunscreen. Students do not wear sunglasses because they wear prescription glasses.

Care
The ease of performing daily care: putting on sunscreen, wearing a cap, going to the doctor. Difficulty in providing care due to laziness or lack of time.

Knowledge
Everyone has enough knowledge to perform photoprotection. These are simple actions. Students do not do the actions because they believe acne or allergy would get worse, or because they have to produce vitamin D, or because family members say it is good to be exposed to the sun. Some people lack knowledge of how to prevent skin cancer.

Adhesion/appreciation
Students forget about the risk of developing skin cancer.

Organization
The day-to-day rush and lack of time prevent the performance of actions. Having to apply sunscreen or waking up earlier for this purpose.

Weather/climate Does not use physical measures such as clothing because of the heat, or only uses it on cold days.
"Just wear sunscreen, you just have to apply it" (E01), "Applying sunscreen every day is something that doesn't take long" (E04), "Very easy, just take care of yourself" (E02) Despite this apparent naturalness mentioned by some, most students consider photoprotective measures a difficult task to be performed, which generated the category "construction of habits". Whatever hinders the adoption of photoprotection was subcategorized into "adherence/appreciation" with statements that "Being lazy to apply sunscreen" (E17), "Wake up early to apply sunscreen" (E20), "Rushing and lack of time, thinking it is not important" (E12).
As well as speeches that referred to the subcategory "organization" focused on the use of time in everyday life: "Sometimes I just don't have time" (E15), Sunscreen is then cited many times as not the only but the most important measure of photoprotection. Such information is not similar to qualitative research carried out with workers exposed to the sun, which cite physical protection as the main measure, through appropriate clothing as the main measure. This is because this research was carried out in cold climate countries, probably highlighting a lack of qualitative research on this topic in our country and continent (Zink et al., 2017;Jopson & Reeder, 2006;Rodriguez et al., 2017).
The economic issue was also often cited as a difficulty in complying with photoprotective measures, whether for the acquisition of sunscreen or other measures, and were gathered in the category "access to strategies", in the subcategory "products", as mentioned below: "There are people who are allergic to sunscreen and they have to find a correct one, but it is more expensive." (E10) "People cannot afford good sunscreen" (E14), "Sometimes sunscreen is very expensive and some families cannot buy it" (E 25) It was also interesting to observe different statements citing the use of eyeglasses as an impediment to the use of sunglasses. From these statements we can infer that students are unaware of the possibility of adding prescription to solar lenses or that the economic factor would limit their acquisition. The category "access to strategies" was grouped as subcategory "knowledge":

"I don't wear sunglasses because I wear eye glasses." (E23)
Other difficulties that reflect misinformation were also identified in the same "knowledge" subcategory: "My doctor said I need vitamin D." (E25) "But with acne breakouts, I'm afraid to apply sunscreen and get worse." (E03) "My parents say it's good to sunbathe once in a while." (E19) "There is a lack of knowledge, information on prevention and some people may not care about the risks the sun can cause us." (E02) The need for vitamin D production and, therefore, for sun exposure, is a belief that also appears in other studies ( Finally, in the subcategory "weather/climate" identified in the students' answers as hindering factors in "construction of habits" for the prevention of skin cancer: "I wear a long-sleeved shirt in the cold" (E09), "They don't always wear a long-sleeved shirt because it's hot" (E02), "I don't like shirts or pants" (E09), "Because I don't like it" (E05) The high temperatures prevalent in all months of the year appear as an important factor that prevents the adoption of mechanical measures such as the use of long-sleeved shirts, pants and hats. There is a preference for shorter clothing, also due to the tropical climate and style of this age group of the population.
In summary, we did not observe the interference of religion or spirituality as a factor that negatively influences the performance of actions. We also did not see fear or worry of having skin cancer in the students' answers, because they did not have bad experiences related to skin cancer, as mentioned by some international qualitative research ( Students treat photoprotection measures with superficiality, without rigor and importance, demonstrate negligence and invulnerability against the risk of skin cancer. They demonstrate ignorance regarding other issues such as the use of sunglasses, influence on acne and the production of vitamin D. They also mention the difficulty with long clothes due to the heat, and the financial difficulty in acquiring sunscreen.
The analysis shows the need for a unique educational program for childhood and adolescence, involving family members and educators, focusing on all measures other than sunscreen, and that demonstrate the damage the sun causes to the skin, effectively sensitizing them from everyday situations. The participation of the educational system, the media and health professionals is essential for raising awareness in society, promoting its responsibility, abandoning ingrained harmful attitudes and practicing new conscious habits of photoprotection (  Based on the results presented, educational material was created, which synthesizes the educational action, using language aimed at children and adolescents, named "10 steps to understand what skin cancer is and how to protect yourself", represented in the Figure 2.

Conclusion
The research brings us relevant information that can be added to the educational program, addressing changes common to adolescence and health, such as acne, refractive errors in vision and vitamin D, which should be better clarified so that they are no longer cited as factors preventing photoprotection.
When working with adolescents, it is clear that it is important that the questionnaires are more succinct and that the benefits of participation are offered for greater adherence and commitment (Alonso et al., 2020; Deponte et al., 2021).
There is still little knowledge about the difficult reality of the treatment and prognosis of some skin cancers, electing this topic as very little discussed and disseminated and, therefore, an intervention that emphasizes these aspects would cause greater impact and perception of the risk of skin cancer by students (Deponte et al., 2021).
There is a need for a differentiated approach to a young audience, including biological and psychological changes inherent to adolescence, seeking to promote knowledge, awareness and healthy attitudes (

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