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Original Article
DOI: 10.1016/j.adengl.2019.08.002
Open Access
Available online 27 June 2020
Effectiveness of the SolSano Program on Sun Protection Habits, Knowledge, and Attitudes Among University Students
Efectividad del programa SolSano en los hábitos, conocimientos y actitudes en materia de fotoprotección de los universitarios
M.P. Sirera Rusa, J.R. Ipiens Serrateb, E. Ferrer Graciab, P. Teruel Meleroc, J. Gállego Diéguezb, Y. Gilaberted,
Corresponding author

Corresponding author.
a Medicina Familiar y Comunitaria, Centro de Salud Pirineos, Huesca, Spain
b Dirección General de Salud Pública, Gobierno de Aragón, Zaragoza, Spain
c Departamento de Psicología y Sociología, Facultad de Educación, Universidad de Zaragoza, Zaragoza, Spain
d Servicio de Dermatología, Hospital Universitario Miguel Servet, IIS Aragón, Zaragoza, Spain
Received 08 July 2019. Accepted 07 August 2019
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Figures (1)
Tables (3)
Table 1. Characteristics of the Study Sample.a
Table 2. Sun Protection Habits and Knowledge and Their Association With Having Attended a School Where the SolSano Program Was Run.
Table 3. Association Between Different Variables and Having Experienced Sunburn.
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Additional material (1)
Background and objective

The SolSano (HealthySun) project is a primary school sun education program that has been running in Aragon, Spain, since 2000. In the short term, it has proven to be effective at promoting sun protection behaviors and heightening awareness in childhood. The aim of this study was to evaluate the long-term effectiveness of the SolSano program.

Participants and methods

Retrospective, observational, analytical, cohort study of students at the University of Zaragoza between 2015 and 2016. The students answered a previously validated, purpose-designed, online questionnaire. We calculated descriptive statistics for all variables and performed bivariate and multivariate analyses to test for differences between students who had attended a primary school that ran the SolSano program and those who had not.


Data for 324 students were analyzed. Mean age was 22.9 years and 78% of the respondents were women. In total, 44% of the students had participated in the SolSano program at primary school. Half of the respondents (50.5%) had experienced 1 or 2 sunburn episodes the previous summer. Significant differences were only observed for some aspects addressed by the questionnaire between SolSano participants and nonparticipants.


This is the first study to evaluate the long-term effectiveness (15 years) of a primary school sun protection program. The absence of significant differences in our sample might be explained by non-continuation of the program into adolescence and the existence of sun protection campaigns outside the school.

Antecedentes y objetivo

El proyecto SolSano es un proyecto educativo escolar que se realiza en Aragón desde el año 2000 y que ha demostrado promover hábitos de protección solar y aumentar conocimientos en los niños a corto plazo. El objetivo de este estudio es valorar la efectividad del programa SolSano a largo plazo.

Sujetos y métodos

Estudio analítico observacional de cohortes retrospectivo realizado en alumnos de la Universidad de Zaragoza durante el curso 2015-2016. El instrumento de valoración fue un cuestionario validado y adaptado para nuestro objetivo al que accedían a través de Internet. Se realizó una descripción univariante, así como un análisis bivariante y multivariante para estudiar las diferencias entre los participantes que habían estudiado Educación Primaria en un centro escolar donde se realizaba SolSano o no.


Trescientos veinticuatro estudiantes universitarios participaron. La edad media fue 22,9 años, un 78% de respuestas procedieron de mujeres. El 44% había acudido a un centro donde se realizó el programa SolSano. El 50,5% de los estudiantes habían sufrido 1 o 2 quemaduras solares el verano anterior. Solo se observaron diferencias estadísticamente significativas en algunos aspectos entre los que asistieron a centros educativos donde se desarrolló el programa SolSano y los que asistieron a otros centros.


Es el primer estudio para valorar la efectividad de un programa educativo escolar en materia de fotoprotección a largo plazo (15 años). La falta de continuidad del programa en la adolescencia y la existencia de campañas de fotoprotección fuera de la escuela son posibles causas de la ausencia de diferencias en nuestra muestra.

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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.

Patients and MethodsDesign and Population

We performed an analytical retrospective study of a cohort of undergraduates at the University of Zaragoza during the academic year 2015–2016. Patients from other autonomous communities were excluded. Our aim was to obtain a cohort of students who had completed their primary education during the period 2000–2006, when SolSano was implemented in schools in Aragon.


In order to evaluate habits, knowledge, and attitudes with respect to the risk of solar radiation and sun protection, we used the validated questionnaire of Troya-Martín et al.,15 to which we added questions from the SolSano program (Supplementary Material). The questionnaire was designed in an online format using Google Forms and forwarded to the students via the Research Unit and the lecturers who participated in the project.

Statistical Analysis

We performed a univariate analysis of the variables. We then evaluated the associations between attendance at a school were the SolSano program had been implemented and sun protection knowledge and habits. Qualitative variables were analyzed using the χ2 test and relative risk; ordinal variables were analyzed using the Mann-Whitney and Kruskal-Wallis tests. The same tests were used to evaluate risk factors and variables associated with sun protection. Lastly, we used logistic regression to analyze the role of significant variables in the bivariate analysis. The data were analyzed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp.). Statistical significance was set at P<.05.


The study was approved by the Clinical Research Ethics Committee of Aragon (PI16/0151), and all the participants gave their informed consent before participating in the survey.

ResultsSample Characteristics

Table 1 shows the main characteristics of the sample. We obtained 324 responses, of which 78% were from women (n=252) and 22% were from men (n=72). The mean age was 22.9 years (range, 16–59 years). The most common degree course was medicine (n=79, 24.5%). Of the students who responded, 83.9% (n=271) were from those whose primary education had been in Aragon, and 44% (n=142) had attended a school were the SolSano program had been run, although 89.8% (n=290) reported that they were not acquainted with it.

Table 1.

Characteristics of the Study Sample.a

  Frequency  Percentage 
Male  71  22.0 
Female  252  78.0 
Mean (SD) age, y  22.9 (6.10)   
University degree
Science  20  6.2 
Educational science  61  18.9 
Health and sports science  17  5.3 
Law  1.2 
Business studies, economics, and management  2.5 
Nursing  49  15.2 
Engineering  48  14.9 
Medicine  79  24.5 
Nutrition  0.9 
Other  34  10.5 
Do you know about the SolSano program?
Yes  33  10.2 
No  290  89.8 
Did you attend a school where the SolSano program was run?
Yes  142  44.0 
No  181  56.0 
While at school, did you receive any information on sun protection?
Yes  210  65.0 
No  113  35.0 
When did you receive it?
Kindergarten  36  11.1 
Primary school, first cycle  76  23.5 
Primary school, second cycle  97  30.0 
Primary school, third cycle  108  33.4 
Secondary school, first cycle  134  41.5 
Secondary school, second cycle  53  16.4 
Who provided the information?
Parents  213  65.9 
Pediatrician  65  20.1 
Dermatologist  93  28.8 
Nurse  12  3.7 
Teachers  137  42.4 
Media  163  50.5 
If you did receive information, what were you recommended?
Use creams  265  82.0 
Use a cap  200  61.9 
Use protective clothing  91  28.2 
Staying in the shade  132  40.9 
I received information about the dangers of the sun  182  56.3 
Which of the following best defines your skin color?
Very pale  57  17.6 
Pale  160  49.5 
Olive  61  18.9 
Dark  45  13.9 
How does your skin react the first time you are exposed to sunlight in summer for 1h at midday?
Sunburn, pain, no tan  62  19.2 
Sunburn, pain, and slight tan  51  15.8 
Slight burning and moderate tan  128  39.6 
No burning and good tan  82  25.4 
For how many days on average did you sunbathe?
None  30  9.3 
1 to 5 d  55  17.0 
6 to 15 d  99  30.7 
16 to 30 d  61  18.9 
More than 30 d  78  24.1 
For how many hours a day do you sunbathe?
<30min  83  25.7 
30min to 1106  32.8 
1 to 3101  31.3 
More than 333  10.2 
How many times were you sunburned last year?
None  119  36.8 
1 to 2 times  163  50.5 
3 to 5 times  35  10.8 
6 to 10 times  1.5 
More than 10 times  0.3 
Have any members of your family (grandparents, parents, siblings, uncles/aunts, cousins) had skin cancer?
Yes  34  10.5 
No  289  89.5 

The distribution of the replies to all of the questions on the questionnaire is provided in the supplementary material.

In 65% of cases (n=210), the students had received information on sun protection during their time at school, mainly during the secondary stage (41.5%, n=134), followed by the primary stage. A similar percentage of participants had received information on sun protection from their parents (65.9%, n=213) and the media (50.5%, n=163).

As for exposure to sunlight, 30.7% (n=99) sunbathe on between 6 and 15 days per year, and 24.1% (n=78) sunbathe on more than 30 days per year. The most frequent duration of exposure was 30 minutes to 1 hour (n=106, 32.8%), although when this was between 12:00 and 16:00, it usually lasted less than 1 hour (n=148, 45.7%). Slightly more than half (50.5% [n=163]) had been sunburned once or twice the previous summer, and 36.8% (n=119) had not.

The main sun protection habits were always using sunscreen (59.1% [n=191]) and sunglasses (34.7% [n=112]) and avoiding sunlight in the middle of the day (15.5% [n=50]). As for the least common sun protection habits, 24.5% (n=79) reported never using a sunshade and 60.1% (n=194) reported never using long sleeves or trousers (Fig. 1). Regarding secondary prevention of skin cancer, 72.4% reported not performing an annual skin self-examination.

Figure 1.

Frequency of sun protection habits.


Analysis of attitudes to sun protection revealed that 65.9% of respondents (n=213) thought their clothes looked better on them when they were tan, around 50% (n=160) considered tan people to be more attractive, 60.3% (n=195) did not find sun cream unpleasant, and the vast majority (82.4%, n=266) believed that it is worthwhile using cream, even if you do not tan (Supplementary Material).

Knowledge about sun protection was fairly good, and most participants identified solar radiation as the main cause of skin cancer (95.4%, n=308) and patches on the skin (98.1%, n=317). They also reported that avoiding exposure to sunlight during the middle of the day was the most effective way to protect oneself from the sun (86.4%, n=279) (Supplementary Material).

Sun Protection Habits and Knowledge Depending on Whether or Not the Participant Had Attended a School Where SolSano Was Run

Sun protection habits were quite similar in both groups, except for the use of sunscreen, which was more common in the group that had not attended a school where SolSano had been implemented (82.3% vs. 75.4%), although the differences were not statistically significant (Table 2).

Table 2.

Sun Protection Habits and Knowledge and Their Association With Having Attended a School Where the SolSano Program Was Run.

Knowledge  School Running SolSano  School not Running SolSano  Statistical Significance 
  (Responds in Accordance)  (Responds in Accordance)   
Sunscreen prevents aging of the skin caused by sunlight  80.3% (n=114)  73.5% (n=144)  P=.153 
Sunlight is the main cause of skin cancer  95.1% (n=135)  95.6% (n=176)  P=.829 
Sunlight causes patches on the skin  95.8% (n=136)  100% (n=181)  P=.007 
Avoiding sunlight in the middle of the day is the most effective way of protecting skin from the sun  85.9% (n=122)  86.7% (n=157)  P=.830 
Reducing exposure to sunlight before age 18 reduces the risk of skin cancer by 80%  59.2% (n=84)  67.4% (n=122)  P=.126 
The use of total protection sunscreen does not mean that exposure to sunlight is free of risk  90.8% (n=129)  88.4% (n=160)  P=.477 
Once my skin is tan, it is necessary to use sunscreen  97.9% (n=139)  100% (n=181)  P=.084 
Sunshade  32.4% (n=46)  37.6% (n=68)  P=.334 
Sunglasses  62.0% (n=88)  60.8% (n=110)  P=.826 
Cap or hat  15.5% (n=22)  16.0% (n=29)  P=.897 
Long sleeves and trousers  5.6% (n=8)  5.5% (n=10)  P=.966 
Avoiding exposure in the middle of the day  45.8% (n=65)  44.8% (n=81)  P=.854 
Use of a product with sun protection factor >15  75.4% (n=107)  82.3% (n=149)  P=.121 
Skin self-examination in the previous year  27.5% (n=39)  27.6% (n=50)  P=.975 

As for knowledge, students from SolSano centers scored higher for the item “Sunscreen prevents aging of the skin caused by sunlight” (80.3% vs. 73.5%) and “The use of total protection sunscreen does not mean that exposure to sunscreen is free of risk” (90.8% vs. 88.4%). The percentage of correct responses to the remaining questions was higher among students who had not attended a SolSano center, although the difference was only statistically significant for the item “Sunlight causes patches on the skin”.

Factors Associated With Sunburn

The multivariate analysis revealed a statistically significant association between having been sunburned at least once during the previous summer and having a pale skin tone, being male, thinking that the sun produced a pleasant sensation, and considering tanned people to be more attractive (Table 3).

Table 3.

Association Between Different Variables and Having Experienced Sunburn.

Variable  Coefficient  OR  95% CI  P Value 
Sex  0.630  1.878  1.027–3.432  .041 
Skin tone  0.929  2.532  1.509–4.247  .000 
Beliefs: tanned people are more attractive  0.508  1.661  1.020–2.705  .041 
Beliefs: sunbathing generates a pleasant sensation  0.609  1.838  1.068–3.164  .028 
Use of a sunshade  0.438  1.550  0.943–2.547  .084 
Knowledge of the SolSano program  0.102  1.107  0.496–2.472  .804 
Attending a center where SolSano was run  0.198  1.219  0.738–2.015  .440 

Abbreviation: OR, odds ratio.


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.

Conflicts of Interest

The authors declare that they have no conflicts of interest.


The study was performed as part of the Research Group acknowledged by the Government of Aragon, B18_17D. We are grateful to all of the lecturers at the University of Zaragoza who participated in the study.

Appendix A
Supplementary data

The following are the supplementary data to this article:

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Please cite this article as: Sirera Rus MP, Ipiens Serrate JR, Ferrer Gracia E, Teruel Melero P, Gállego Diéguez J, Gilaberte Y. Efectividad del programa SolSano en los hábitos, conocimientos y actitudes en materia de fotoprotección de los universitarios. Actas Dermosifiliogr. 2020.

Actas Dermo-Sifiliográficas (English Edition)

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