The Knowledge-Behavior Gap in Pediatric Sun Safety Gets New Data

A school-based sun safety program developed by Penn State Health Dermatology significantly improved elementary students' awareness of the link between UV exposure and skin cancer, but the knowledge gains did not translate into sustained protective behaviors at 6-month follow-up — a finding that mirrors outcomes from prior short-duration programs and points to a persistent gap in pediatric sun safety education.^1,2

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The study, conducted at a Title I urban public elementary school in Lebanon, Pennsylvania, enrolled 88 third- and fourth-grade students for a multi-component intervention called "Sun Protection Hero." The program launched with a kickoff event in which students watched an educational video co-created by a nurse practitioner and 2 pediatric dermatologists, followed roughly 14 weeks later by a school assembly featuring a brief educational segment, interactive quiz, and skit. A t-shirt design contest anchored the interval between events, with students submitting superhero-themed sun safety artwork; school voting identified 6 finalists, and Penn State's Dermatology Department selected the winner. Students completed pre-surveys, immediate post-surveys, and 6-month follow-up surveys (n = 67 at follow-up) using a 7-item yes/no instrument assessing sunscreen use, hat use, reapplication habits, sunburn history, and knowledge of sun exposure's role in skin cancer.

Immediate Gains in Knowledge and Reported Behavior

Between pre- and immediate post-survey, investigators said 2 outcomes reached statistical significance. Reported sunscreen use rose from 59.1% to 73.3% (p = 0.049), and sunscreen reapplication climbed from 23.9% to 45.3% (p = 0.003). Awareness that UV exposure can cause skin cancer increased sharply, from 55.7% to 82.6% (p < 0.001). Hat use trended upward but did not reach significance (38.6% vs. 50.0%, p = 0.131). Because pre- and post-surveys were administered on the same day, the authors note the behavioral changes likely reflect increased motivation or priming rather than actual behavior change — pointing toward "increased knowledge about protective methods and perhaps an initial motivation to adopt behaviors," per the study.

Behavioral Gains Do Not Hold at 6 Months

At the 6-month follow-up, no behavioral outcomes showed statistically significant improvement over baseline. Reports of sunscreen use dipped slightly below pre-intervention levels (55.2% vs. 59.1%, p = 0.631), and hat use was essentially unchanged (37.3% vs. 38.6%, p = 0.865). Sunscreen reapplication showed a modest nonsignificant increase (29.9% vs. 23.9%, p = 0.401). Reports of sunburn in the past year declined from 42.0% to 34.3%, but the difference was not significant (p = 0.327).

The sole durable gain was knowledge: awareness of the UV-skin cancer connection remained significantly elevated at 6 months compared to baseline (83.6% vs. 55.7%, p < 0.001), suggesting the educational content was retained even as behaviors reverted. The authors note that this pattern — improved awareness without lasting behavioral change — "aligns with prior studies evaluating short-duration, school-based programs and highlights the need for ongoing reinforcement."

Implications for Program Design

To close the gap between knowledge and practice, the investigators point to parental involvement as a critical and underutilized lever. "As parental behavior and attitudes influence children's sun safety habits through both direct guidance and observational modeling, future multi-unit interventions should actively engage caregivers and incorporate strategies to educate and motivate parents to adopt sun protective practices," the authors write. Peer-based strategies, including student "sun safety champions" who model protective behaviors, and technology-based outreach such as texts and multimedia messaging to families were also identified as feasible mechanisms for extending program reach without placing additional burden on school schedules.

The investigators also acknowledge that seasonal variation may have confounded behavioral outcomes — the intervention occurred in late May while follow-up surveys were collected in late November, a period when sun protection behavior is naturally lower. Future studies were encouraged to schedule follow-ups during comparable seasons and to consider an earlier intermediate survey at 3 months. Additional structural limitations include the absence of a control group, a modest sample at a single school, and the likelihood of social desirability bias in child self-report, particularly immediately following the intervention.

Given that experiencing 5 or more severe sunburns between ages 15 and 20 increases melanoma risk by approximately 80%, identifying effective pediatric intervention models remains a meaningful clinical priority. This study's design — combining interactive education, creative engagement, and structured follow-up — offers a foundation worth building on, though its authors are clear that reinforcement strategies will need to be considerably more sustained to move the needle on behavior.

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References

1. Moeckel C, Anderson R, Krnajic L, et al. Sun safety intervention for elementary school students. Peds Dermatol. 2026. doi:10.1111/pde.70234.
2. Baig IT, Petronzio A, Maphet B, Chon S. A Review of the impact of sun safety interventions in children. Dermatol Pract Concept. 2023;13(1):e2023066. Published 2023 Jan 1. doi:10.5826/dpc.1301a66