Economic Evaluation Policy

Economic Evaluation of the US Environmental Protection Agency's SunWise Program: Sun Protection Education for Young Children Jessica W. Kyle, James K. Hammitt, Henry W. Lim, Alan C. Geller, Luke H. Hall-Jordan, Edward W. Maibach, Edward C. De Fabo and Mark C. Wagner Pediatrics 2008;121;e1074-e1084 DOI: 10.1542/peds.2007-1400

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/121/5/e1074

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2008 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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ARTICLE

Economic Evaluation of the US Environmental Protection Agency’s SunWise Program: Sun Protection Education for Young Children Jessica W. Kyle, BAa, James K. Hammitt, PhDb, Henry W. Lim, MDc, Alan C. Geller, RN, MPHd, Luke H. Hall-Jordan, BAe, Edward W. Maibach, PhD, MPHf, Edward C. De Fabo, PhDg, Mark C. Wagner, SBa aICF International, Washington, DC; bCenter for Risk Analysis, Harvard University, Boston, Massachusetts; cDepartment of Dermatology, Henry Ford Hospital, Detroit, Michigan; dDepartment of Dermatology, Boston University School of Medicine, Boston, Massachusetts; eUS Environmental Protection Agency, Washington, DC; fCenter of Excellence in Climate Change Communication Research, Department of Communication, George Mason University, Fairfax, Virginia; gLaboratory of Photobiology and Photoimmunology, Department of Environmental and Occupational Health, School of Public Health and Health Services, George Washington University Medical Center, Washington, DC

Financial Disclosure: Dr Lim is a consultant for several sunscreen manufacturers (La Roche-Posay, Orfagen, Dow Pharmaceutical Sciences) and has received research grants from Johnson and Johnson; the other authors have indicated they have no financial relationships relevant to this article to disclose.

What’s Known on This Subject

What This Study Adds

Although a number of studies have evaluated the behavioral impacts of school-based and community sun safety education programs, few have evaluated the economics of skin cancer prevention programs. Some studies have analyzed the economics of other school-based health programs.

To our knowledge, this study is the first to assess the net benefits of a school-based skin cancer prevention program. This study shows that modest behavioral changes resulting from SunWise may result in significant reductions in skin cancer incidence and mortality.

ABSTRACT OBJECTIVE. The SunWise School Program is a school-based sun safety education pro-

gram that was developed by the US Environmental Protection Agency and aims to teach children how to protect themselves from overexposure to the sun. The objectives of this study were to assess the health benefits of the SunWise School Program and use economic analysis to determine the program’s net benefits and cost-effectiveness. METHODS. Standard cost/benefit and cost-effectiveness analysis methods were used.

Intervention costs were measured as program costs estimated to be incurred by the US government, which funds SunWise, using 3 funding scenarios. Health outcomes were measured as skin cancer cases and premature mortalities averted and qualityadjusted life-years saved. These health outcomes were modeled using an effectiveness evaluation of SunWise based on pretest and posttest surveys administered to students who participated in the program and the Environmental Protection Agency’s peer-reviewed Atmospheric and Health Effects Framework model. Costs averted were measured as direct medical costs and costs of productivity losses averted as a result of SunWise. Net benefits were measured as the difference between costs averted and program costs. RESULTS. Economic analysis indicated that if the SunWise School Program continues

through 2015 at current funding levels, then it should avert ⬎50 premature deaths, nearly 11 000 skin cancer cases, and 960 quality-adjusted life-years (undiscounted) among its participants. For every dollar invested in SunWise, between approximately $2 and $4 in medical care costs and productivity losses are saved, depending on the funding scenario.

CONCLUSIONS. From a cost/benefit and cost-effectiveness perspective, it is worthwhile to

educate children about sun safety; small to modest behavioral impacts may result in significant reductions in skin cancer incidence and mortality.

S

www.pediatrics.org/cgi/doi/10.1542/ peds.2007-1400 doi:10.1542/peds.2007-1400 The views expressed herein are solely those of the authors and do not represent the official opinion of the US EPA. Key Words skin cancer, prevention, environmental health, school health, cost/benefit analysis, cost-effectiveness, schools Abbreviations UV— ultraviolet EPA—Environmental Protection Agency QALY— quality-adjusted life-year AHEF—Atmospheric and Health Effects Framework BCC— basal cell carcinoma SCC—squamous cell carcinoma CMM— cutaneous malignant melanoma SPF—sun protection factor SCUP-h—Skin Cancer Utrecht-Philadelphia– human HRQoL— health-related quality of life Accepted for publication Oct 18, 2007 Address correspondence to Mark C. Wagner, SB, ICF International, 1725 Eye St, NW, Suite 1000, Washington, DC 2006. E-mail: mwagner@icfi.com

Address reprint requests to Luke H. HallJordan, BA, Stratospheric Protection Division, Office of Atmospheric Programs, US Environmental Protection Agency, 1200 Pennsylvania Ave, NW (6205J), Washington, DC 20460. E-mail: hall-jordan. [email protected]

KIN CANCER ACCOUNTS for more than half of all cancers diagnosed in the United States, and ⬎1 million new cases of nonmelanoma skin cancer are expected to PEDIATRICS (ISSN Numbers: Print, 0031-4005; occur in 2008.1 Incidence rates of melanoma are rising in most of the world.2 More Online, 1098-4275). Copyright © 2008 by the than 8400 Americans are expected to die in 2008 from melanoma, the most comAmerican Academy of Pediatrics monly lethal form of skin cancer.3 Research has shown an association between exposure to ultraviolet (UV) radiation and the development of melanoma and nonmelanoma skin cancers,4 and sun

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exposure during childhood seems to be an important risk factor associated with the development of melanoma skin cancer.5–8 Stratospheric ozone depletion has exacerbated these health effects by allowing increased UV radiation to reach Earth’s surface.9 Major skin cancer prevention strategies focus on reducing overexposure to UV radiation through increasing knowledge and awareness, modifying sun safety practices, and implementing policy measures and environmental initiatives.10 These strategies can lead to important reductions in future skin cancer incidence and mortality for populations at risk. The Task Force on Community Preventive Services, supported by the Centers for Disease Control and Prevention, found that there was sufficient evidence to support education and policy approaches in primary schools and recreational and tourism settings.11 The SunWise Program, the first national health and environmental education program for sun safety designed for children in elementary and middle schools, was developed by the US Environmental Protection Agency (EPA) to teach children and their caregivers how to protect themselves from overexposure to the sun. SunWise aims to reduce the incidence of skin cancer and other UV-related health problems by changing attitudes and behaviors concerning sun exposure. The SunWise School Program is the major programmatic component of SunWise, and all public and private elementary and middle schools in the United States are eligible to participate. From its inception in 1999 through August 2007, ⬎15 600 schools registered to use SunWise, representing ⬎12% of the ⬎123 000 US elementary and secondary schools.12 Registered schools receive a free SunWise tool kit with classroom activities for grades kindergarten through 8, a UV-sensitive Frisbee for hands-on experiments, story books, posters, videos, policy guidance, and other materials. The cross-curricular, standards-based classroom lessons offered by SunWise were reviewed by an expert panel of educators, curriculum specialists, and skin cancer researchers before the program was launched to ensure scientific accuracy, age-appropriateness, and alignment with national education standards. Lessons focus on 3 key areas: effects of UV radiation, risk factors for overexposure, and sun protection habits. Each lesson consists of developmentally appropriate activities that combine education about sun protection and the environment with other aspects of students’ regular learning in science, social studies, health, physical education, language arts, and mathematics. One advantage of SunWise is that it requires relatively little classroom time to implement; nearly 90% of nurses and teachers that have led the program reported that lessons took 1 to 2 hours.13 The SunWise School Program is an effective means of improving students’ sun protection knowledge, attitudes, and behaviors.13–15 These improved behaviors can prevent future cases of skin cancer; however, because resources for funding school-based health programs are limited, as is the amount of curriculum time that school administrators can devote to health-related topics, demonstrating effectiveness may not be sufficient to justify program implementation. Evaluations of the cost-effectiveness

of school-based programs can provide a component of that validation, but few studies, to our knowledge, have analyzed the economics of school-based health programs, and none has analyzed school-based sun safety programs. For addressing this gap in the literature, the objectives of this study were to assess the health benefits of the school component of the SunWise Program and use economic analysis to determine the program’s net benefits and cost-effectiveness. METHODS Framework for Economic Analysis Standard cost/benefit and cost-effectiveness analysis methods were used to evaluate the costs and health outcomes of SunWise compared with a no-intervention alternative. Intervention costs were measured as program costs estimated to be incurred during a 17-year operation of the program (fiscal years 1999 –2015). Health outcomes were measured as skin cancer cases and premature mortalities averted and quality-adjusted life-years (QALYs) saved. Averted costs associated with skin cancer cases and premature mortalities prevented were measured as direct medical costs and costs of productivity loss averted by SunWise. All costs are reported in 1999 dollars. Because there is a lag period between the intervention and averting skin cancer, health outcomes, QALYs, and costs averted were calculated over the period 1999 –2100 and were discounted at a rate of 3% as recommended by the US EPA16 and the Panel on Cost-effectiveness in Health and Medicine.17 Health outcomes and averted costs were calculated under 3 intervention cost scenarios: (1) the current funding scenario, in which funding for the SunWise School Program, including personnel costs, continues at its current levels from fiscal years 1999 through 2015 (approximately $926 000 per year, or 85% of the total SunWise Program budget); (2) an increased funding scenario, in which funding for the school component increases from current levels to $1.4 million per fiscal year from 2008 through 2015; and (3) a low funding scenario, in which no funding is provided from 2008 through 2015. For each funding scenario, the base-case analysis was conducted in 6 steps: (1) effectiveness analysis of SunWise based on pretest and posttest surveys administered to students who receive the intervention; (2) modeling to translate sun safety behavioral changes reported by students into changes in lifetime UV radiation exposure; (3) modeling using the US EPA’s peer-reviewed Atmospheric and Health Effects Framework (AHEF) model to translate changes in lifetime UV exposure into an estimated number of averted skin cancer cases and premature mortalities; (4) estimation of medical care and productivity costs averted per skin cancer case and premature mortality prevented; (5) estimation of QALYs saved; and (6) calculation of the net benefit of SunWise. Sensitivity analysis was also conducted on key parameters to evaluate the robustness of base-case results. PEDIATRICS Volume 121, Number 5, May 2008

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Intervention Costs The cost of the intervention was measured as the operating costs of the SunWise School Program from the perspective of the US government as the funder of SunWise. The annual cost is based on current and projected program expenditures for infrastructure (Web site management, tool kit printing, school registration), outreach and communication (conference attendance, school recruitment), and evaluation and training, as well as 3 to 4 full-time employees, depending on the funding scenario. For the current funding scenario, the annual cost of the program was assumed to stay constant through 2015. For the increased funding scenario, certain components of the overall program cost (eg, Web site management, conference attendance) were considered fixed costs, whereas other costs (eg, tool kit printing, registration data entry) were estimated on the basis of the number of additional schools assumed to be registered each year and the per-school cost. In addition to the operating cost of the program, other social costs are incurred by the SunWise intervention; however, these costs are not included in this analysis. These social costs include private costs incurred by students to comply with SunWise recommendations, such as the cost to purchase sunscreen or sun-protective hats, and opportunity costs associated with teachers’ and students’ time spent on SunWise rather than other classroom lessons. Other social costs could include changes in participants’ happiness resulting from behavioral changes brought about by SunWise, such as a decrease in self-perception of beauty stemming from less tanned skin. Effectiveness Evaluation of the SunWise Program Children’s one-time participation in SunWise activities (1–2 hours spent on classroom lessons) includes a selfadministered pretest on students’ knowledge, attitudes, practices, and intended practices, followed by classroom teaching, and then a posttest. Pretest surveys are distributed in classrooms generally during September through March, and posttests are distributed generally in May through June, ⬃2 months after classroom teaching. For the posttests, teachers were instructed to tell students to report on their postteaching current practices, and the posttest survey instrument reflects postteaching practices. Teachers were asked not to have students complete the posttest unless they had completed the pretest. Surveys were administered and collected each calendar year from 1999 through 2005. Because different schools were part of the evaluation year to year, no student completed ⬎1 set of pretest and posttest. The survey was reviewed and edited by educational and child development experts, pilot tested by 9 children aged 6 to 7 for readability and length, and time-tested to ensure completion within 5 to 7 minutes. Age, gender, and hair color data were also collected. Of the nearly 12 100 schools registered as of December 2005, ⬃10% were randomly selected to participate in the survey process, and ⬃60% of these selected schools completed both the pretest and the posttest. A total of 13 791 pretests and 10 299 posttests were come1076

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pleted. Respondents were between the ages of 5 and 15 years (median: 10 years). Because students completed the surveys anonymously, linking individual students’ answers from both surveys was not possible. As a result, the measure of the effectiveness of SunWise is the difference between pretest and posttest for the percentage of students who provided specific responses (instead of the change in individual students’ responses). The significance of the difference between pretest and posttest was determined using the ␹2 test for 2 ⫻ 2 contingency tables. Data through 2002 were published elsewhere,14 and survey results through 2005 were presented at the 2006 International Union Against Cancer World Cancer Congress.18 Number of SunWise Program Participants The number of children who participated in SunWise in each fiscal year from 1999 through 2006 was calculated on the basis of the number of schools and classrooms that are registered with SunWise and the average class size for US elementary schools.19 The number of students who would participate in SunWise in each fiscal year from 2007 through 2015 was projected on the basis of historical participation plus projected future participation. It was assumed that 3000 additional schools would be registered in 2007 and 3500 schools in 2008. Under the current funding scenario, 3500 additional schools were assumed to be registered annually in 2009 through 2015. For the increased funding scenario, the number of schools registered was assumed to be twice the number of schools registered annually under the current funding scenario. The low funding scenario assumed that no new schools would be registered from 2008 through 2015 and that the number of already registered schools would decrease to 0 over 4 years (100% of schools implement SunWise in 2008, 50% in 2009, 25% in 2010, and 0% from 2011–2015). In each registered school, ⬃2 classrooms are assumed to implement SunWise each year, and only the students in those classrooms are assumed to participate. Because the same classrooms are assumed to implement SunWise every year, students are assumed to participate in SunWise only once over their lifetime. We also assumed that 74% of teachers in registered schools actually use the SunWise materials, based on teacher survey results.20 The total numbers of SunWise students from 1999 through 2015 under the low funding, current funding, and increased funding scenarios are 3.4 million, 12 million, and 17 million students, respectively. Health Outcomes Health outcomes were calculated for 3 types of skin cancers: basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and cutaneous malignant melanoma (CMM). Averted skin cancer incidences and premature mortalities were calculated in 4 steps: (1) modeling an annual baseline UV exposure dose for students before participation in SunWise, (2) modeling a SunWise UV exposure dose for students for the 3 years immediately after the intervention, (3) comparing that reduction in

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UV exposure (baseline UV dose minus SunWise UV dose) to lifetime UV exposure, and (4) translating that percentage reduction in cumulative lifetime UV exposure to reduced incidence of skin cancer using the AHEF model. Registered schools are assumed to implement the program once per year from 1999 to 2015. Health outcomes are calculated for each year’s intervention on the basis of the number of schools registered and then cumulated to estimate the total number of skin cancer cases and premature mortalities averted by implementation of SunWise from 1999 through 2015. For development of a model for estimating students’ baseline and SunWise UV exposure, ambient solar UV radiation at the Earth’s surface by latitude and month of the year was first computed using the Tropospheric Ultraviolet-Visible radiation model (3.9a).21–25 The accuracy of this model has been demonstrated in several comparisons to direct measurements of UV at the Earth’s surface,26–29 and the model has been used in many scientific evaluations of ozone depletion.30–37 Data from Godar et al38 estimating the percentage of ambient UV exposure that children are exposed to by gender, season, and geographic region were used to extrapolate students’ potential UV exposure on the basis of time spent outdoors. These data were based on the National Human Activity Pattern Survey, which recorded the daily minute-by-minute activities of ⬃2000 young adults over 2 years.38 The demographics of SunWise students (geographic distribution and race) are assumed to reflect those of the general US population and to vary over time to reflect changes projected by the US Census Bureau; these demographic changes are built into the AHEF model used to predict health outcomes. To develop a baseline for children’s UV exposure, we made several assumptions to adjust the potential amount of UV exposure from time spent outdoors to account for the frequency with which students reported practicing sun protection behaviors (wearing sunscreen, hats, and long-sleeved shirts) and the effectiveness of those practices in reducing UV exposure. The reduction in UV exposure derived from each sun protection behavior was combined to develop a total reduction in UV exposure, and the difference in this reduction on the basis of students’ reports before and after intervention formed the basis for the health effects analysis. For calculation of these UV exposure reductions, it was assumed that students who reported that they practiced a sun protection behavior “all of the time,” “sometimes,” or “never,” exhibited that behavior 75%, 50%, and 0%, respectively, of the time that they spend outside. For long-sleeved shirts39–41 and hats,42–44 Ultraviolet protection factors of 25 and 2 were selected, respectively. No measure of lower body coverage was included in the analysis. We assumed that students applied sun protection factor (SPF) 15 sunscreen, but only at 25% of the recommended thickness (2 mg/cm2).45–49 On the basis of the exponential relationship between SPF and the thickness applied,50 an effective SPF of 2 was calculated. Effectiveness of sunscreen use was modeled as the product of this protection factor and the percentage of

body surface area to which sunscreen is applied. Students who reported that they applied sunscreen to 6 to 8, 3 to 5, and 0 to 2 body parts (eg, face, arms, legs) were assumed to be protecting 75%, 50%, and 10% of their body surface area, respectively. Each body part was weighted equally. Students are assumed to participate in SunWise only once in their lifetime and to retain the sun safety behaviors that they report learning at a decreasing rate over the 3 years after the intervention. We assumed that in the first year after participation in SunWise, 100% of students still practice learned sun safety behaviors; in the second year, 50% of students display these behaviors; 25% in the third year; and in the fourth year and beyond, students revert to sun safety behaviors practiced before participation in SunWise. The difference between students’ UV exposure before and after SunWise was compared with an estimate of lifetime UV exposure to calculate a percentage reduction in lifetime UV exposure associated with a one-time participation in SunWise. Lifetime UV exposure was estimated by first calculating annual UV exposure for girls and boys aged 1 to 18 years on the basis of (1) annual ambient UV radiation at the Earth’s surface by latitude, (2) the percentage of ambient UV exposure that children receive annually, and (3) sun protection behavior reported in the SunWise pretest and posttest surveys. Annual exposure for ages 1 to 18 years was totaled, and data from Godar et al51 on the percentage of UV exposure received by 18 years of age was used to extrapolate lifetime UV exposure. The AHEF model was used to translate the cumulative percentage change in UV exposure into skin cancer cases and premature mortalities averted. The AHEF is a peer-reviewed model that is typically used to evaluate human health impacts associated with changes in emissions of ozone-depleting substances.52,53 For this analysis, only the AHEF module that translates changes in ground-level UV (in this case, changes in actual UV exposure) into changes in health outcomes was used. This module applies calculated dose-response relationships to the baseline skin cancer incidence/mortality and change in UV exposure to calculate averted incidence/ mortality in each year through 2100. The dose-response relationships used in the AHEF model measure the degree to which changes in UV exposure weighted by the appropriate action spectrum cause incremental changes in health effects. An action spectrum describes the relative effectiveness of energy at different UV wavelengths in producing a particular biological response. The AHEF relies on the Skin Cancer Utrecht-Philadelphia– human (SCUP-h) action spectrum (derived on the basis of the induction of SCC in hairless mice and corrected for human skin transmission) to predict incidence of SCC, BCC, and CMM (because a mammalian action spectrum for CMM remains to be determined).52 Costs Averted Averted costs of BCC, SCC, and CMM prevented were calculated as the number of cases averted multiplied by PEDIATRICS Volume 121, Number 5, May 2008

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TABLE 1 Total Cost per Case of Nonfatal Skin Cancer and Mortality (1999 $) Parameter Nonfatal skin cancer case BCC SCC CMM Skin cancer mortality

Medical Cost, $

Productivity Loss Cost, $

Total Cost per Case/ Mortality, $

825a 825a – –

959b 3698b – –

1785 4523 28 857c 6 100 000d

Totals may not sum due to independent rounding. a Chen et al,54 adjusted to 1999 dollars using the medical care component of the Consumer Price Index. b Calculated by authors, based on US EPA55 and US Bureau of Labor Statistics.56 c US EPA,55 adjusted to 1999 dollars using the medical care component of the Consumer Price Index. d US EPA,16 based on the central estimate recommended for benefits analysis from a review of 26 risk value of a statistical life studies.

the medical and productivity loss cost per case. Cost per case is for cancer care only and excludes the costs of unrelated care, such as increased costs for treating other medical conditions later in life that might have occurred after the predicted skin cancer mortality. Total averted costs were calculated over 1999 through 2100 and discounted to 1999 using a discount rate of 3%. The medical costs and productivity loss per case are shown in Table 1. Medical costs per case of BCC and SCC were based on Chen et al54; that study used data from the Medicare Current Beneficiary Survey (1999 –2000) to estimate medical treatment costs associated with BCC and SCC in different practice settings. To determine an average medical treatment cost per case, we calculated weighted averages on the basis of the percentage of episodes managed in each setting. Productivity loss costs were based on a US EPA analysis supporting the Regulatory Impact Analysis: Protection of Stratospheric Ozone.55 We calculated cost per case by multiplying EPA’s estimates of the loss of work as a result of illness and caregiving performed by others for

the patient for BCC and SCC by the national mean annual wage for 1999.56 For CMM, we used EPA’s estimate of the total medical cost and productivity loss per case. The value of a statistical life was based on US EPA’s Guidelines for Preparing Economic Analyses.16 QALY Losses Averted For estimation of QALY losses averted, total life-years saved were calculated and then adjusted to account for health-related quality of life (HRQoL). We assumed that the duration of each nonfatal case of skin cancer was 1 year. For premature mortalities avoided, the number of life-years saved was calculated by comparing the age at which each premature mortality was projected to have occurred (in the absence of the SunWise Program) with the average life expectancy for a person at that age.57 The life-years saved were weighted to consider HRQoL. For premature mortalities avoided, the average HRQoL at the age at which the mortality would have occurred (“without-condition” HRQoL, based on a scale from 0 to 1) was compared with the HRQoL associated with death (“with-condition” HRQoL, or 0). For nonfatal cases, the average HRQoL at the age at which the case would have occurred was compared with the HRQoL associated with having skin cancer. The difference between with-condition and without-condition age-specific HRQoL was multiplied by the duration of the morbidity to estimate QALY losses averted. The age-specific without-condition HRQoL was based on the mean EuroQol-5D index scores for US adults as derived from the 2000 –2002 Medical Expenditure Panel Survey.58 Because a EuroQol-5D index score was not provided for people who were younger than 18 years, we applied the mean index for adults aged 18 to 29 years for age cohorts aged 10 to 19 years. For the with-condition HRQoL for melanoma and nonmelanoma skin cancer, expert assigned values from Freedberg et al,59 as interpreted by the Tufts-New England Medical Center Institute for Clinical Research and Health Policy Studies (data are available from the corresponding author), were used.

TABLE 2 Sensitivity Analysis Upper and Lower Bounds Variable

Base-Case Value

Sensitivity Analysis Upper Bound

Behavioral retention rate

Total SunWise classrooms (1999–2015)a

Percentage of time spent on behaviors reportedly practiced “all the time” Percentage of lifetime UV exposure before age 18

7% discount rate, %

Lower Bound

Year0 ⫽ 100%, Year1 ⫽ 100%, Year2 ⫽ 50%, Year3 ⫽ 25%, Year4 ⫽ 0% Current funding ⫽ 766 798 Increased funding ⫽ 1 066 521 Low funding ⫽ 218 585 75

Year0 ⫽ 100%, Year1 ⫽ 100%, Year2 ⫽ 100%, Year3 ⫽ 50%, Year4 ⫽ 25% Current funding ⫽ 1 043 452 Increased funding ⫽ 1 451 312 Low funding ⫽ 297 448 100

Year0 ⫽ 100%, Year1 ⫽ 50%, Year2 ⫽ 25%, Year3 ⫽ 0%, Year4 ⫽ 0% NA

Northern girls ⫽ 23% Northern boys ⫽ 21% Southern girls ⫽ 23% Southern boys ⫽ 23% 3

Northern girls ⫽ 46% Northern boys ⫽ 43% Southern girls ⫽ 47% Southern boys ⫽ 46%

Northern girls ⫽ 12% Northern boys ⫽ 11% Southern girls ⫽ 12% Southern boys ⫽ 11%

50

7

All estimates have been independently rounded. As such, upper and lower bounds may not sum. NA indicates not applicable. a This value does not represent the number of unique classrooms that have registered, but rather, the total number of classrooms that have participated in the SunWise program. Thus, if a classroom registers for the program in 1999 and continues to implement the program each year until 2015, that classroom is counted in this total 17 times.

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TABLE 3 SunWise Program: Evaluation of Student Responses (All Ages), 1999 –2005 Parameter

Pretest (n ⫽ 13 791), %

Posttest (n ⫽ 10 299), %

Difference, %

74 61

79 72

5a 11a

25 49

49 73

24a 24a

29 41

22 38

⫺6a ⫺3a

25 71 14 3 20

26 76 16 4 21

1 4a 3a 1a 1b

45 67

49 73

4a 6a

Knowledge Sun can hurt one’s skin Wearing hat and shirt are ways to protect one from the sun Sun protection and UV index The right number SPF to use Attitudes Suntan is good for my skin People look healthier with a suntan Practices Wear sunscreen all the time Apply sunscreen to ⱖ5 body parts Wear hats all the time Wear long-sleeved shirt all the time Wear sunglasses all the time Intended practices Do you think you will put on sunscreen this summer? I will try to play in the shade instead of the sun

All estimates have been independently rounded. As such, the posttest response minus the pretest response may not equal the difference. The significance of the difference between pretest and posttest responses was tested by using the ␹2 test for 2 ⫻ 2 contingency tables. a Level of statistical significance is P ⬍ .001. b Level of statistical significance is P ⬍ .05. Survey data source: Geller AC. The Environment Protection Agency’s SunWise Program (1999 –2005) [abstract]. In: Proceedings of the UICC World Cancer Congress 2006. Bologna, Italy: Medimond; 2006.

Sensitivity Analysis To test the robustness of the base-case results, we conducted a univariate sensitivity analysis over a reasonable range of values for key parameters: behavioral retention rate (the rate at which students retain learned sun safety behaviors over the years after the intervention), number of classrooms participating in SunWise, the percentage of time that students actually perform a behavior that they reported practicing “all the time,” and the percentage of UV exposure received before age 18.51 Table 2 presents upper and lower bound estimates for each of the key parameters. Upper and lower bounds for percentage of lifetime UV received before age 18 were based on a twofold increase and decrease in the basecase value. Because the number of classrooms that participate in SunWise may be underreported (because only teachers who also sign up to report UV measurements report the number of participating classrooms), only an upper bound was tested at a 50% increase in the basecase value.

RESULTS Evaluation of the SunWise Program As shown in Table 3, the greatest improvement between pretests and posttests was shown for the knowledge variables; changes in students’ attitudes, practices, and intended practices were less marked, but still statistically significant. Only the measures of sunscreen, hats, and long-sleeved shirts practices are used as inputs for modeling the change in children’s UV exposure associated with participation in SunWise. Economic Analysis Results As shown in Table 4, if the school component of the SunWise Program continues through 2015 at current funding levels, then it should avert ⬎50 premature deaths and almost 11 000 skin cancer cases among its participants. More than 70 premature deaths and ⬎15 200 skin cancer cases could be averted if funding for SunWise were increased to $1.4 million per year in 2008 –2015. In addition,

TABLE 4 Averted Nonfatal Cases, Mortalities, and QALYs Associated With the SunWise Program, Fiscal Year 1999 –2015 Funding Scenario

Nonmelanoma Skin Cancer

Current funding scenario Increased funding scenario Low funding scenario

Cutaneous Malignant Melanoma

Cases Averted

Premature Mortalities Averted

Cases Averted

Premature Mortalities Averted

10 696 14 877 3049

19 26 5

264 367 75

33 45 9

Total Cases Averted

10 960 15 244 3124

Total Premature Mortalities Averted

51 71 15

QALY Losses Averted Undiscounted

Discounted at 3%

960 1335 274

159 217 52

These averted cases and mortalities are based on baseline rates from the AHEF model for light-skinned individuals and are blended across different age cohorts. Totals may not sum due to independent rounding.

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TABLE 5 Base-Case Cost/Benefit Analysis Results (1999 $) Funding Scenario

Averted Costs

Intervention Costs

Net Benefit

Current funding scenario Increased funding scenario Low funding scenario

43 391 914 59 345 457 14 078 062

12 194 833 14 772 974 7 211 715

31 197 080 44 572 484 6 866 347

All estimates have been independently rounded As such, averted costs minus intervention costs may not equal net benefit.

between ⬃270 and 1300 QALY losses (undiscounted) could be averted by SunWise. Table 5 presents the results of the base-case cost/ benefit analysis. Net of program costs, SunWise could generate between approximately $7 million and $45 million in net savings, depending on the level of future funding provided to SunWise. For every dollar invested in SunWise, between $1.95 and $4.02 in medical care costs and productivity losses could be saved. Program costs include both fixed costs and variable costs that depend on how many classrooms are registered. In contrast, the benefits are nearly proportional to the number of classrooms enrolled. Consequently, the

incremental cost-effectiveness associated with moving from 1 funding level to a higher level is nearly constant, and the average cost-effectiveness for SunWise increases with the scale of the program. The results of the sensitivity analysis (Table 6) indicate that changes in the values of key variables affect health and economic benefits. All sensitivity cases result in positive net benefits, with the exception of the scenarios in which a 7% discount rate is used. Net benefits are also not achieved in the low funding scenario when a lower bound for percentage of lifetime UV exposure before age 18 is used. The results of the sensitivity analysis on other variables were found to have minimal influence on benefits. DISCUSSION We evaluated the net benefits and cost-effectiveness of a school-based intervention that educates children about how to protect themselves from overexposure to the sun to reduce the incidence of skin cancer and other UVrelated health problems. The results of our study suggest that from the perspective of a cost/benefit and costeffectiveness analysis, it is worthwhile to educate chil-

TABLE 6 Sensitivity Analysis Results Variable Current funding scenario Behavioral retention rate Upper bound Lower bound SunWise classrooms Upper bound Percentage of lifetime UV exposure before age 18 Upper bound Lower bound 7% discount rate Increased funding scenario Behavioral retention rate Upper bound Lower bound SunWise classrooms Upper bound Percentage of lifetime UV exposure before age 18 Upper bound Lower bound 7% discount rate Low funding scenario Behavioral retention rate Upper bound Lower bound SunWise classrooms Upper bound Percentage of lifetime UV exposure before age 18 Upper bound Lower bound 7% discount rate

Total Cases Averted

Total Premature Mortalities Averted

Averted Costs, 1999 $a

Intervention Costs, 1999 $a

Net Benefit, 1999, $a

QALY Losses Averteda

14 945 6974

70 33

58 373 901 27 960 467

12 194 833 12 194 833

46 179 067 15 765 634

214 102

14 914

70

59 094 203

12 194 833

46 899 370

272

21 920 5480 10 960

103 26 51

86 783 827 21 695 957 4 571 495

12 194 833 12 194 833 9 042 975

74 588 994 9 501 124 ⫺4 471 480

318 79 24

20 787 9701

97 45

79 835 747 38 240 459

14 772 974 14 772 974

65 062 773 23 467 485

292 140

20 744

97

80 803 634

14 772 974

66 030 660

372

30 487 7622 15 244

143 36 71

118 690 915 29 672 729 6 107 119

14 772 974 14 772 974 10 599 436

103 917 941 14 899 755 ⫺4 492 317

434 109 33

4260 1988

20 9

18 938 815 9 071 487

7 211 715 7 211 715

11 727 099 1 859 772

69 33

4251

20

19 204 193

7 211 715

11 992 478

88

6248 1562 3124

29 7 15

28 156 125 7 039 031 1 733 926

7 211 715 7 211 715 6 034 593

20 944 410 ⫺172 684 ⫺4 300 667

103 26 9

All estimates have been independently rounded. As such, averted costs minus intervention costs may not equal net benefit. a Using a 3% discount rate, except where otherwise noted.

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dren about sun protection behavior. Our results show that small to modest behavioral effects can produce costeffective results; the sun safety education delivered by the SunWise School Program translates into significant reductions in the risk for developing skin cancer, as well as averted costs to society. To our knowledge, this study is the first to assess the net benefits and cost-effectiveness of a school-based sun safety intervention. Although a number of studies have evaluated the behavioral impacts of school-based and community sun safety education programs,13–15,60–67 our study is 1 of few economic evaluations of skin cancer prevention programs, school-based or otherwise. Carter et al68 modeled the cost-effectiveness of a hypothetical national skin cancer prevention program in Australia, based on the existing SunSmart campaign, and concluded that such a program would provide excellent value for money. Complementing the assessment of sun protection habits reported in this study, Geller et al14 found that children who participated in SunWise experienced an 11% reduction in the sunburning rate (from 66% of students reporting sunburns at pretest to 55% at posttest). An 8% decrease from pretest to posttest in the rate of frequent sunburning (ⱖ3 sunburns per summer) was also reported. This study followed ⬎500 of the same students over the course of 2 summers. Because a quantitative relationship between sunburn and development of skin cancer is not known, it was not possible to use these results in this analysis. Our study shows that the medical costs and productivity losses averted by SunWise outweigh the cost of the program by between 2 and 4 times. These results are comparable to those of economic analyses of other school-based health education programs. For example, 1 study examined Safer Choices, a school-based sexually transmitted disease and unintended pregnancy prevention program for high school students, and calculated a benefit-cost ratio of 2.65.69 Another study evaluated Planet Health, a school-based intervention designed to reduce obesity in youth, and estimated averted medical and productivity costs equal to $40 991 and 2-year program costs of $33 677, which translates to a benefit-cost ratio of 1.2.70 Our study has several limitations. First, student selfreporting of sun protection behaviors forms the basis for the baseline and SunWise scenario UV exposure models. The sun protection practices reported in SunWise student surveys, however, are consistent with those in other studies of US children, reported by either the child or the parent.71–73 Verbal reports are used most frequently in sun protection studies; for example, 76 of 81 skin cancer prevention studies cited in the Guide to Community Services evidence review relied on verbal reports.11 Although moderate to high levels of agreement between self-report and objective verification of sunscreen use and protective clothing have been shown, such assessment methods are impractical in school settings; correlations between self-report and dosimeter readings have been shown to be fair, although still statistically significant.74

Second, like any complex modeling framework, the AHEF model— used to estimate health effects in this study— uses data inputs and computational procedures that introduce uncertainty to the results. Much of the uncertainty in the AHEF model is associated with the choice of the SCUP-h action spectrum, which was derived on the basis of the induction of SCC in hairless mice and corrected for human skin transmission. Past peer reviews of the AHEF have agreed that SCUP-h is the best choice of action spectrum and found the uncertainty to be in an acceptable range.52 Third, not all health outcomes associated with reduced lifetime UV exposure, including reducing the incidence of cataracts and actinic keratosis, minimizing the effect of photoimmunosuppression,75–81 and minimizing the development of photoaging, are modeled in this analysis. Averted costs associated with reduced incidence of these additional health outcomes were not considered, although the large majority of the health benefit associated with SunWise is believed to be captured. Averted cataract incidence has accounted for ⬍1% of the total health benefits (ie, averted costs associated with cataracts and skin cancer cases/mortalities) in other studies.55 Fourth, limitations of the analysis may have led to either overestimations or underestimations of its impact. Factors other than SunWise, such as community programs or parent influence, may have resulted in improved sun protection behavior from pretest to posttest. The absence of a randomly selected control group makes it difficult to determine definitively whether the measured changes in students’ sun protection behaviors are attributable entirely to the SunWise intervention; however, Geller et al13,14 reported that comparably aged children who served as non–randomly assigned control subjects to SunWise experienced no positive changes in sun protection practices during the 1-year study period. Conversely, other assumptions may have led to conservative estimates of the averted skin cancer incidence and costs in this study. For example, in calculating UV protection resulting from children’s reported sun protective behaviors, data were not available to adjust sunscreen coverage for clothing worn; thus, UV protection (and hence benefits) may be underestimated if, for instance, children are wearing long-sleeved shirts but not sunscreen on their arms. In addition, the program impact may be conservative because the full reach of SunWise (ie, on the sun protection behavior of teachers and school nurses teaching the program and participants’ families) was not quantified, although it could be significant. As of August 2007, 19 840 teachers had registered to use SunWise. Teacher surveys undertaken for SunWise indicated that 77% of teachers have made sun protection habit changes as a result of teaching the program.20 Future efforts should focus on overcoming such limitations to strengthen the cost-effectiveness evaluation of SunWise. Fifth, private costs for participants to comply with SunWise recommendations and for teachers to implement the Program were not included in this analysis. If the private costs of students’ participation were inPEDIATRICS Volume 121, Number 5, May 2008

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cluded, then the net benefit of the program could decrease by approximately $5 million to $20 million during the period 1999 to 2015 (present value discounted at 3%); SunWise would still generate between $2 million and $24 million in net benefit. These calculations are based on the behavioral changes measured in the SunWise student surveys, assuming that sunscreen is reapplied every 2 hours spent outside, that 1 oz of sunscreen is used for every application, that an average 8-oz bottle of sunscreen costs $8, and that a sun-protective hat costs $10. Another private cost of the program may be the opportunity cost of teachers’ time spent on SunWise; assuming teachers spend 1 hour on SunWise at an average hourly wage of $33.19,82 these costs could range from approximately $2 million to $9 million during the period 1999 to 2015 (at a 3% discount rate); however, because 1 of the advantages of SunWise is that its activities are designed to be integrated into normal classroom lessons, we do not expect teachers to incur this opportunity cost. CONCLUSIONS This study suggests that, after participation in the SunWise School Program, students make small to modest behavioral changes that may result in significant reductions in skin cancer incidence and mortality, which, in turn, render the program cost saving. These findings have important implications for pediatricians, researchers, policy-makers, and educators. For pediatricians, communicating ways to reduce adverse sun exposure to patients and their parents could have sizable impacts on reducing future skin cancer incidence. For the research community, economic evaluation and assessment of behavioral modifications, along with development of UV studies for dose-response relationships and a CMM action spectrum, should continue to play a part in assessing school-based programs to help policy-makers determine which programs reduce student risk behaviors at what cost. For school administrators, the cost of SunWise is 0, the time commitment is ⬍2 hours, and, as this study has shown, the health benefits may be potentially substantial. Future evaluations of SunWise should seek to improve the quality of the evidence on the effectiveness of the intervention and could also consider the impact of other program components, namely the SunWise Cities/Communities Program, as well as investigate the change in impact if students receive SunWise lessons more than once. ACKNOWLEDGMENTS This study was prepared under US EPA contracts EP-W06-008 and EP-06-H-002787. We thank Drusilla Hufford, Margaret Sheppard, Ross Brennan, Jim Democker, and Linda Rutsch of the US EPA for insight regarding the operation of the SunWise Program and comments on early versions of the manuscript. We also thank David Berv of ICF International for research contributions to this study. e1082

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Economic Evaluation of the US Environmental Protection Agency's SunWise Program: Sun Protection Education for Young Children Jessica W. Kyle, James K. Hammitt, Henry W. Lim, Alan C. Geller, Luke H. Hall-Jordan, Edward W. Maibach, Edward C. De Fabo and Mark C. Wagner Pediatrics 2008;121;e1074-e1084 DOI: 10.1542/peds.2007-1400 Updated Information & Services

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