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Examination of sun awareness behavior, knowledge, and attitudes before and after a sun awareness program in 4th to 8th grade students

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Examination of sun awareness behavior, knowledge, and attitudes before and after a sun awareness program in 4th to 8th grade students

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Content EXAMINATION OF SUN AWARENESS BEHAVIOR, KNOWLEDGE, AND
ATTITUDES BEFORE AND AFTER A SUN AWARENESS PROGRAM IN 4
TH

TO 8
TH
GRADE STUDENTS

by
Venessa Tavares

A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(BIOSTATISTICS)

August 2007

Copyright 2007 Venessa Tavares

ii
TABLE OF CONTENTS

LIST OF TABLES iii
LIST OF FIGURES iv
ABSTRACT v
INTRODUCTION 1
METHODS 7
Study Subjects 7
Intervention 7
Measures 8
Statistical Analyses 11
Demographic Characteristics 12
Sun Awareness Knowledge, Behaviors and Attitudes 12
RESULTS AND DISCUSSION 15
1. Examination of Sun Awareness Behavior Before and After a Sun Awareness
Program in 4
th
to 8
th
Grade Students at St. Vincent’s School 16
Weather Conditions 16
Time Spent During PE 20
Time Spent Outside in General 24
2. Examination of Sun Awareness Attitudes Before and After a Sun Awareness
Program in 4
th
to 8
th
Grade Students at St. Vincent’s School 27
3. Examination of Sun Awareness Knowledge Before and After a Sun Awareness
Program in 4
th
to 8
th
Grade Students at St. Vincent’s School 29
CONCLUSION 33
REFERENCES 35
iii
LIST OF TABLES

Table 1: Demographic Characteristics of 4th-8th Grade Participants of a Sun
Awareness Program at St. Vincent’s School, Spring 2006 15
Table 2a: Sun Awareness Behavior Before and After a Sun Awareness Program for
Time Spent During Lunch in 4
th
-8
th
Grade Students at St. Vincent’s School, Spring
2006 18
Table 3a: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for Sun
Protection Behavior Questions for Time Spent Outside During Lunch 20
Table 2b: Sun Awareness Behavior Before and After a Sun Awareness Program for
Time Spent During PE in 4
th
-8
th
Grade Students at St. Vincent’s School, Spring
2006 22
Table 3b: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for Sun
Protection Behavior Questions for Time Spent Outside During PE 24
Table 2c: Sun Awareness Behavior Before and After a Sun Awareness Program for
Time Spent Outside in General in 4
th
-8
th
Grade Students at St. Vincent’s School,
Spring 2006 25
Table 3c: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for Sun
Protection Behavior Questions for Time Spent Outside in General 27
Table2d: Sun Awareness Attitudes Before and After a Sun Awareness Program in
4
th
-8
th
Grade Students at St. Vincent’s School, Spring 2006 28
Table 3d: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for Sun
Protection Attitude Questions 28
Table 4a: Frequencies and Percentages of Questions Regarding Communication with
Others About Sun Protection 29
Table 2e: Sun Awareness Knowledge Before and After a Sun Awareness Program in
4
th
-8
th
Grade Students at St. Vincent’s School, Spring 2006 31
Table 3e: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for Number
of Correct Sun Protection Knowledge Questions. 32

iv
LIST OF FIGURES
Figure 1: Measures of Sun Protection Behavior for a Sun Awareness Program
in 4
th
-8
th
Grade Students at St. Vincent’s School, Spring 2006 9

Figure 2: Flowchart of Participants of a Sun Awareness Program in 4
th
-8
th
Grade
Students at St. Vincent’s School, Spring 2006 12

Figure 3: Weather Conditions for Self-reported Days of Sun Protection During a Sun
Awareness Program in 4
th
-8
th
Grade Students at St. Vincent’s School, Spring
2006 17

v
ABSTRACT
Sun exposure is a potential risk factor for skin cancer and melanoma. Since
most sun exposure during one’s lifetime occurs during childhood, sun protection at a
young age may be an effective method of primary prevention. It remains unclear
how to effectively instill sun protective behaviors in children.
In this study, a sun awareness intervention program was conducted to see if
there were significant changes in sun awareness before and after the intervention.
Based on a study of 143 subjects, this thesis examines sun awareness behavior,
knowledge, and attitudes before and after the sun awareness program.
Results show that sun awareness knowledge increased after the intervention,
but smaller changes were observed for attitudes towards sun protection and sun
protective behaviors. This indicates that our intervention program increased
children’s awareness of skin cancer, but it didn’t appear to impact their behavior, and
therefore may not reduce their risk of skin cancer.
1
INTRODUCTION
It is estimated that in the United States, 62,190 people will develop
melanoma, which will also account for 7,910 deaths in 2006 (Jemal et al., 2006). In
California alone, it is estimated that there will be 6,290 new cases of melanoma in
2006 (Jemal et al., 2006). Furthermore, the incidence and mortality rates of
melanoma continue to rise (Rigel et al, 1996).
Skin cancer and melanoma are caused in part by severe sun exposure
(Armstrong and Kricker, 2001). Therefore, practicing sun protective behaviors may
be an effective method of primary prevention of skin cancer. The American Cancer
Society recommends the following sun protection measures: limiting midday sun
exposure, wearing protective clothing, wearing a hat, using sunscreen with sun
protection factor (SPF) of 15 or higher, and avoiding tanning beds and sunlamps
(American Cancer Society, 2006). Since sun exposure most relevant to the
development of melanoma appears to occur during childhood (Weinstock et al.,
1989), it is important to encourage sun safety in children. Although sun protection
measures are greatly important at a young age, less than one- third of U.S.
adolescents age 11-18 practice sun protection (Cokkinides et al., 2001). These sun
protection practices are defined as the following six behaviors: staying in the shade,
wearing sunglasses, wearing a wide-brimmed hat, wearing a long sleeve shirt,
wearing long pants, and applying sunscreen lotion on a sunny day (Cokkinides et al.,
2001).
2
Educational interventions could be useful in encouraging sun protective
behaviors in children. Primary prevention of skin cancer is of particular importance
in Los Angeles County because of the high levels of sun exposure (Mack and
Floderus, 1991). Schools may be providing information on sun safety based on their
particular needs and by accessing publicly available education material. However, to
our knowledge, there are no educational sun protection intervention programs in Los
Angeles for children in a school-based setting.
Most skin cancer prevention programs have focused on improving sun
protection in children by increasing the following three areas: knowledge of skin
cancer including risk factors and prevention strategies, favorable attitudes towards
sun protection, and sun protection behaviors (Buller and Borland, 1999).
Furthermore, one of the most important aspects of all intervention programs would
be to incorporate elements that are more likely to produce behavior change. These
intervention programs may also be divided into two subcategories. One being a
multi-unit program in which lectures are given many times, or a single unit program,
which oftentimes consists of one lecture or a one-time intervention strategy.
Girgis’ study was one of the first to examine sun protection interventions in
elementary schools given by a single lecture compared to “more intensive”
interventions (Girgis et al., 1993). Teachers in the intensive intervention group were
given booklets, which contained background information, objectives, and teaching
strategies for the program. They were given 4 weeks to incorporate the program into
their curriculum and were not informed of a set number of hours to dedicate to the
3
program. Control groups received no intervention while standard intervention
groups received a single 30-minute lecture on sun protection. Surveys were used to
obtain information about the students’ measures of sun protection from an education
officer of the New South Wales Cancer Council. Post-tests were completed 5 weeks
(post-test1) and 8 months (post-test2) after the pre-test. Students in the more
intensive intervention group were 2.45 times as likely at post-test1 and 3.06 times as
likely at post-test2 to have used high protection when compared to the control group
[OR = 2.45, 95% CI = 1.37, 4.38; OR = 3.96, 95% CI = 1.33, 6.99 respectively].
Students in the single lecture group were 1.18 times as likely at post-test1 and 0.85
times as likely at post-test2 to have used high protection when compared to the
control group [OR = 1.18, 95% CI = 0.6, 2.36; OR = 0.85, 95% CI = 0.36, 4.53
respectively].
The intervention program conducted by Hewitt and colleagues is an example
of a single unit program that was successful (Hewitt M et al., 2001). Schools were
divided into the following groups: computer based intervention, workbook
intervention, or no intervention. The computer-based intervention consisted of an
interactive computer program that took approximately 20 minutes for the children to
complete. The workbook intervention was somewhat like the computer program in
that it contained many of the same still images and focused on sun exposure and skin
cancer preventive behaviors. A questionnaire was given before, a day after, and 6
weeks after the intervention. Adjusted means from a mixed model analysis showed
that the workbook intervention group displayed significant increases in knowledge
4
scores when compared to the control group [mean difference = 1.43, 95% CI = .36-
2.5], but was not significant for the computer intervention group [mean difference =
0.81, 95% CI = -0.29, 1.90]. Significant increases in attitude scores were found for
both a computer-based and workbook intervention group when compared to the
control group [mean difference = 2.38, 95% CI = 0.70 – 4.06; mean difference =
1.93, 95% CI = 0.21 – 3.65 respectively]. In addition, the sun protection behavioral
intention scores were also significantly better for only the computer-based
intervention group when compared to the control group [mean difference = 1.03,
95% CI = 0.43, 1.63], and not significant for the workbook-based intervention group
[mean difference = 0.58, 95% CI = -0.02-1.18]. This study showed that one single
intervention allowed for improvements in knowledge, attitudes, and behavioral
intentions.
A review of 24 sun protection programs for children under the age of
fourteen indicated that most intervention programs improved sun protection
knowledge, but rates for improvement in attitudes and behaviors were much smaller
than those of knowledge (Buller and Borland, 1999). Multi-unit interventions also
improved sun protection behaviors more than short-term interventions.
Change in tanness in skin color before and after the intervention as well as
the daily sun protection behaviors and other general sun protection behaviors verified
that a multi-unit intervention program was unsuccessful in impacting sun protection
behaviors (Mayer et al., 1997). This study suggested that sun protection behaviors
5
may be somewhat harder to change than attitudes and knowledge of sun protection
(Mayer et al., 1997).
According to a review of sun awareness interventions in public schools,
children are capable of learning and carrying out sun prevention measures (Buller
and Borland, 1998). However, it still remains unclear how to effectively
communicate and encourage students to do so.
The Sunny Days, Healthy Ways Skin Cancer (SDHW) prevention program
was implemented in secondary school students in the Colorado, New Mexico and
Arizona areas (Buller et al., 2006). This multi-unit program consisted of six lessons
aimed to increase positive attitudes towards sun protection and educate children on
different methods of sun protection. Students completed surveys containing
questions on sun safety knowledge and attitudes. Surveys also contained self-
reported measures of sun protection and were completed by students before and
approximately two months after the intervention.
When considering use of shade, hat, sunscreen, clothes, and limiting time in
the sun, they found that children in the intervention schools reported more sun
protective behaviors than those in control schools (p = 0.0035). Children in
intervention schools also showed more knowledge of sun safety (p < 0.0001) and
less desire to have a tan than control schools (p = 0.0026). This was one of the few
studies to show significant improvements in sun protection behavioral intentions and
the first to show the positive effects of a multi-unit intervention program in
secondary schools.
6
The SDHW program described above was used as a model for our
intervention. In this study, we test to see if a sun awareness program was effective in
changing sun protection behaviors, knowledge, and attitudes in students in grades
four through eight living in Los Angeles. The intervention was conducted in a
school-based setting through a series of lectures. Outcome measures are almost all
identical to SDHW. Like most of the other sun intervention programs described
above, our focus was to increase sun protective behaviors in children by expanding
their knowledge of skin cancer and educating them on a variety of methods to
enhance sun safety.
7
METHODS
Study Subjects
The study subjects were fourth through eighth grade students from St.
Vincent’s School in Los Angeles, California. Their ages ranged from 9 to 15 and all
children took part in the intervention program. Six classes participated in total with
one class from each grade participating. .

Intervention
A group of University of Southern California (USC) undergraduates participating
in the Joint Educational Project (JEP) served as teachers for the intervention. These
JEP teachers were instructed to design their own curriculum for their particular class
based on materials in the centers for disease control and prevention (CDC) brochure
(Glanz et al, 2002), and were guided by a medical student from the University of
California, Los Angeles (UCLA). The CDC’s “Guidelines for School Programs to
Prevent Skin Cancer” gave background on skin cancer and melanoma, risk factors of
skin cancer, and guidelines for school programs to prevent skin cancer. These
guidelines were to create policies to reduce sun exposure, provide environments to
support sun safety, establish family involvement, provide skin cancer prevention
education to school teachers and administrators, incorporate skin cancer prevention in
school health services, and consistent evaluation of skin cancer prevention programs at
schools. The CDC brochure also described the following sun protective behaviors:
using sunscreen, wearing protective clothing, using hats and sunglasses, limiting time
8
in sun, and spending more time in the shade. The intervention lasted about two to
three weeks, and consisted of 3 one-hour sessions. At the beginning of the first
session, the students received the pre-test survey and at the end of the last session they
were given a post-test. With an exception of a few questions, the post-test was
identical to the pre-test.

Measures
The surveys asked questions regarding sun protection behaviors, attitudes, and
knowledge of skin cancer. Questions were also asked about state of residence, age,
gender, and race/ethnicity in the pre-test, and additional questions regarding
discussing sun protection with family and friends were included in the post-test.
Students were asked to report on sun protection behavior measures they engaged in at
lunch and during PE on the previous day (Figure 1). However, the leg coverage
question was not asked for time spent during lunch.
9
Figure 1: Measures of Sun Protection Behavior for a Sun Awareness Program
in 4
th
-8
th
Grade Students at St. Vincent’s School, Spring 2006
1. How long were you outside during lunch yesterday?
(1=0 minutes, 2=1-10 minutes, 3=11-20 minutes, 4=more than
20 minutes)
2. When you were outside yesterday during lunch, were you?
(1=mostly in sun, 2=mostly in shade, 3=sun and shade the
same amount of time)
3. What were you wearing on your head when you were outdoors during
lunch yesterday?
(1=nothing, 2=sun visor, 3=cap, 4=wide-brimmed hat)
4. What were you wearing on your shoulders and arms when you were
outdoors during lunch yesterday?
(1=no shirt, 2=tank top, 3=short sleeve shirt, 4=3/4 length
shirt, 5=long sleeve shirt)
5. What were you wearing on your skin when you were outdoors during
lunch yesterday?
(1=sunscreen, 2=no sunscreen)
6. About how long were you outside during PE yesterday?
(1=I did not have PE yesterday, 2=0 minutes, 3=1-10 minutes,
4=11-20 minutes, 5=more than 20 minutes)
7. When you were outside yesterday during PE, were you?
(1=mostly in sun, 2=mostly in shade, 3=sun and shade the
same amount of time)
8. What were you wearing on your head when you were outdoors during
PE yesterday?
(1=nothing, 2=sun visor, 3=cap, 4=wide-brimmed hat)
9. What were you wearing on your shoulders and arms when you were
outdoors during PE yesterday?
(1=no shirt, 2=tank top, 3=short sleeve shirt, 4=3/4 length
shirt, 5=long sleeve shirt)
10. What were you wearing on your legs when you were outdoors during
PE yesterday?
(1=short shorts or skirt, 2=knee length pants/shorts/skirt,
3=long pants)
11. What were you wearing on your skin when you were outdoors during
PE yesterday?
(1=sunscreen, 2=no sunscreen)
All grades were given their pre-tests on a different day except for 4
th
and 8
th

graders who completed their pre-tests on the same day. This was also true for the post-
tests. Therefore when asked about their sun protection behavior at lunch and PE
during the previous day for pre-tests, each of the five classes reported on one of the
four different weather conditions. We checked the weather conditions for all 8 days.
10
Students also provided self-reports on the following sun protection behaviors
they engaged in when going outside to play: sunscreen use, wearing protective
clothing, wearing a hat, and staying in the shade when they are outside playing
(1=always, 2=often, 3=sometimes, 4=rarely, 5=never).
The measure of sun protection attitudes included an evaluation of the
importance of getting a suntan. This question was asked on a four-point scale (1=not
important, 2=somewhat important, 3=important, 4=very important). Additional post-
test questions asked if they had spoken with an adult in their household, sibling, or
friend about sun protection within the past 2 weeks (yes, no).
We included the following sun protection knowledge statements: “A sunscreen
with a sun protection factor (SPF) of 2 is better than a sunscreen with a sun protection
factor (SPF) of 15” (false), “I should put sunscreen on once in a day and then not
bother to reapply it” (false), “It is most harmful to your skin to be in the sun between
10:00 a.m. and 3:00 p.m.” (true), “You can get a sunburn on a cloudy day” (true),
“People with light-colored skin are less likely to get skin cancer than people with
darker-colored skin” (false), and “Getting a lot of sunburns increases your chances of
getting skin cancer” (true). These items were answered on a 3-point scale (true, false,
not sure).
A total body coverage score was computed for time spent outdoors during
lunch and during PE (Girgis, 1993). Points were assigned to a body region according
to how covered it was by a hat or clothing from the above sun protection measures
engaged in during lunch and PE. These regions were the face, neck, arm, shoulder,
11
and torso for time spent outdoors during lunch. These regions along with the leg
region were used to compute a total body coverage score during PE. The higher the
score the more protected the child was from the sun. The maximum total body
coverage score possible was 12 for lunch and 15 for PE. The maximum total body
coverage score during lunch is slightly lower because our survey did not include a
question on coverage of the leg region during lunch.

Statistical Analyses
Questions in our survey were grouped into 3 categories: knowledge, behavior,
and attitudes toward sun protection. Of the 143 students we started with in our study,
10 were excluded from all analysis because they did not complete the post-test (Figure
2). Ninety-two students reported that they had gone outside during lunch for both pre-
and post-intervention. Therefore, analysis of sun awareness behavior during lunch
was conducted on only these 92 students. Analysis of sun awareness behavior during
PE was completed for the 16 students that were outside during that time both before
and after the intervention. Students were eliminated only from a specific question if
they had not answered that question during pre- or post-intervention.
12
Figure 2: Flowchart of Participants of a Sun Awareness Program in 4
th
-
8
th
Grade Students at St. Vincent’s School, Spring 2006

143
completed the
pre-test
133
completed the
pre- & post-test
92 were outside
during lunch pre-
and post-
intervention
16 were outside
during PE pre- and
post-intervention

Demographic Characteristics
Distributions of the study population by age, gender, race/ethnicity, state of
residence for majority of life, and grade level were calculated (Table 1).

Sun Awareness Knowledge, Behaviors and Attitudes
Descriptions of the responses for each question are presented using frequency
tables. The percent differences were calculated by subtracting the percentage of
students that chose that particular answer in the pre-test from the percentage of
students that chose that answer in the post-test. A negative difference indicated that a
higher percentage of students chose that answer post-intervention than they had pre-
intervention. Therefore a positive difference for a sun un-protective answer suggested
13
an improvement from the intervention, while a negative difference suggested a
setback. A negative difference for a sun protective answer also suggested an
improvement from the intervention.
Estimates of relative risks were calculated by taking the ratio of the prevalence
of the sun protective answer post-intervention and the prevalence of the sun protective
answer pre-intervention to determine if sun protective measures were associated with
the intervention. The pre-intervention group served as the reference group and 95%
confidence intervals were also calculated for these relative risk estimates (Rothman,
1998).
Mean responses were calculated for amount of time spent outside during lunch
and PE, total body coverage score during lunch and PE, and importance of having a
suntan. A high mean indicated a higher amount of time spent outside, a higher total
body coverage score, and placing a higher importance on having a suntan. For sun
behavior questions for time spent outside in general, responses were (1=always,
2=often, 3=sometimes, 4=rarely, 5=never), therefore a higher mean value indicated
high unfavorable behaviors towards sun protection.
The statistical significance of the effect of the intervention from pre-test to
post-test was analyzed using paired t-tests for these behavior and attitude questions.
Effect sizes were used to examine the strength of the relationship between the pre-test
and post-test sun protection measures. They were calculated using the Cohen’s D
formula (Cohen, 1988), and therefore effect sizes were considered small for d = 0.2,
medium for d = 0.5, and large for d = 0.8.
14
All statistical analyses were performed in SAS version 9.1 (SAS Institute Inc.,
Cary, NC).

15
RESULTS AND DISCUSSION
Analysis of this study can be divided into three sections: examination of sun
awareness (1) behavior, (2) attitudes, and (3) knowledge before and after a sun
awareness program.
The mean age of the students was approximately 12-years-old (Table 1).
Fifty-four percent of the students were female and almost all were Hispanic (96.5%).
Furthermore, almost all students reported that they had lived in California most of
their life. A total of 143 children completed the pre-test and 133 completed the post-
test. Twenty-seven fourth graders completed the pre-test, and all but one completed
the post-test. Thirty-two fifth graders completed the pre-test and 26 students
completed the post-test. All 25 sixth graders completed both the pre-test and post-
test. Twenty-eight of the 30 seventh graders and 28 of the 29 eighth graders that
completed the pre-test also completed the post-test.
Table 1: Demographic Characteristics of 4th-8th Grade Participants of a Sun
Awareness Program at St. Vincent’s School, Spring 2006
Age (yr)

11.9 ± 1.4
9 6 (4.2)
10 17 (11.9)
11 38 (26.6)
12 26 (18.2)
13 36 (25.2)
14 13 (9.1)
15 4 (2.8)
Missing 3 (2.1)
Gender
Male 62 (43.4)
Female 77 (53.9)
Missing 4 (2.8)
Race/Ethnicity
Hispanic 138 (96.5)
16
(Table 1, Continued)
Non-Hispanic 2 (1.4)
Missing 3 (2.1)
State lived most of life
CA 131 (91.6)
Missing 12 (8.4)
Grade Level
4
th
27 (18.8)
5
th
32 (22.4)
6
th
25 (17.5)
7
th
30 (20.9)
8
th
29 (20.3)
Total participants 143
*
Mean ± SD for continuous variables
*
Frequency (%) for discrete variables

1. Examination of Sun Awareness Behavior Before and After a Sun Awareness
Program in 4
th
to 8
th
Grade Students at St. Vincent’s School
The students’ sun awareness behavior was examined for time spent the
previous day during lunch, PE, and general time spent outside.

Weather Conditions
The mean temperature pre-intervention was 57.8°F (range = 49.5°F, 65.3°F),
all days were overcast except for one that was sunny, and all had light rain during
lunch and throughout the day except for one day that was clear. The mean
temperature post-intervention was 61.3°F (range = 54.8°F, 66.8°F), all days were
either overcast or had scattered clouds, and none had rain during lunch or PE (Figure
3).
17
Figure 3: Weather Conditions for Self-reported Days of Sun Protection
During a Sun Awareness Program in 4
th
-8
th
Grade Students at St. Vincent’s
School, Spring 2006
Pre-test Mean
Temperature
1
Rain
Conditions
Cloudy/Sunny
Conditions
4
th
, 8
th
grade 56 (49, 62) Light rain Slightly cloudy
until 4:00 p.m.
5
th
grade 56 (49, 62) Light rain Overcast until 3:45
p.m.
6
th
grade 58 (47, 69) No rain Clear until 7:00
p.m.
7
th
grade 61 (53, 68) Light rain Overcast
Average 57.8 (49.5, 65.3)
Post-test Mean
Temperature
1
Rain
Conditions
Cloudy/Sunny
Conditions
4
th
, 8
th
grade 62 (55, 68) No rain Scattered clouds
5
th
grade 63 (57, 68) No rain Mostly cloudy
6
th
grade 60 (52, 67) No rain Overcast
7
th
grade 60 (55, 64) No rain Overcast
Average 61.3 (54.8, 66.8)
1
mean (range) °F

Time Spent During Lunch
There was a 50% decrease in students that reported that they stayed inside
during lunch post-intervention when compared to pre-intervention (RR = 0.5, 95%
CI = 0.26, 1.0). While this appears to be a large decrease it is not statistically
significant, so chance remains a reasonable explanation for this finding.
Furthermore, children might have been more inclined to stay inside pre-intervention
because of the mostly rainy weather when compared to the non-rainy days during
post-intervention.
Ninety-two students reported that they had gone outside during lunch for both
pre- and post-intervention. Therefore, further analysis of sun awareness behavior
18
during lunch was completed on only these 92 students (Table 2a). There was a 2%
increase in time spent in the shade after the intervention (RR = 1.02, 95% CI = 0.87 -
1.19). However, there was no difference in use of head coverage during lunch both
before and after the intervention. The students were 10% more likely to wear a long
sleeve shirt during lunch in post-intervention than pre-intervention (RR = 1.1, 95%
CI = 0.85 - 1.6). During post-intervention, the students were also 20% less likely to
apply sunscreen during lunch than pre-intervention (RR = 0.8, 95% CI = 0.23 - 2.8).
While these results suggest that the sun awareness program was successful with
teaching students about sun protective clothing during lunch, the estimates of relative
risk are quite small, and none are statistically significant, so chance remains a
reasonable explanation for these findings.

Table 2a: Sun Awareness Behavior Before and After a Sun Awareness Program
for Time Spent During Lunch in 4
th
-8
th
Grade Students at St. Vincent’s School,
Spring 2006
Pre Post

% Diff
(pre-
post)
RR 95% CI
How long were you outside
during lunch yesterday?

More than 1 min. (did
go outside)
102
(76.7)
114 (85.7) -9.0 1.0
0 minutes (didn’t go
outside)
24 (18.1) 12 (9.0) 9.1 0.5 (0.26,
1.0)
Missing either 7 (5.3)
Missing 7(5.3) 1 (0.8)
Outside during lunch
for both pre & post-
intervention.

Yes 92 (68.2)
No or missing 41 (30.8)
19
(Table 2a, Continued)
When you were outside
yesterday during lunch,
were you?

Mostly in the sun 12 (13.0) 11 (12.0) 1.0 1.0
Mostly in the shade/ in
sun and shade for same
amt of time
54 (58.7) 55 (59.8) -1.1 1.02 (0.87,
1.19)
Missing either 26 (28.3)
Missing 25 (27.2) 15 (16.3)
What were you wearing on
your head when you were
outdoors during lunch
yesterday?

Nothing 63 (68.5) 63 (68.5) 0.0 1.0
Sun visor/cap/wide-
brimmed hat
0 (0.0) 0 (0.0) 0.0 1.0
Missing either 29 (31.5)
Missing 28 (30.4) 14 (15.2)
What were you wearing on
your shoulders and arms
during lunch yesterday?

No shirt/tank top/short
sleeve shirt
31 (33.7) 26 (28.3) 5.4 1.0
¾ length shirt/long
sleeve shirt
34 (37.0) 39 (42.4) -5.4 1.1 (0.85,
1.6)
Missing either 27 (29.4)
Missing 26 (28.3) 15 (16.3)
What were you wearing on
your skin when you were
outdoors during lunch
yesterday?

No Sunscreen 59 (64.1) 60 (65.2) -1.1 1.0
Sunscreen 5 (5.4) 4 (4.4) 1.0 0.8 (0.23,
2.8)
Missing either 28 (30.4)
Missing 27 (29.4) 14 (15.2)
* Ten students did not complete the post questionnaire.
* Some students did not answer the questions.
A small increase was detected for mean time spent outside during lunch (d =
0.14, p = 0.23) and the mean total body coverage score during lunch decreased after
20
the intervention (d = -0.21, p = 0.89) (Table 3a). Although this suggests that it may
be more difficult to instill sun protective behaviors during lunch, neither of these
associations is statistically significant and so chance is a possible explanation for
these findings. These results suggest that there may be more barriers to achieving
sun protection in a school-based setting.

Table 3a: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for
Sun Protection Behavior Questions for Time Spent Outside During Lunch
Pre
2
Post
2
Effect
size
1
Pvalue
Amount of time spent outside
during lunch yesterday
2.77 (1.11)
n = 126
2.91 (0.92)
n=126
0.14 0.23
Total body coverage score during
lunch
6.58 (1.52)
n=72
6.54 (1.77)
n=72
-0.021 0.89
*
Maximum lunch total body coverage score is 12.
1
Effect sizes were considered small for d = 0.2, medium for d = 0.5, and large for d
= 0.8.
2
Mean (SD)
Time Spent During PE
There was a statistically significant 36% decrease in students that reported
that they stayed inside during PE before when compared to after the intervention (RR
= 0.64, 95% CI = 0.52, 0.77).
Analysis of sun awareness behavior during PE was conducted on the 16
students that were outside during that time both before and after the intervention
(Table 2b). Students were 20% less likely to stay in the shade during PE after the sun
awareness program (RR = 0.8, 95% CI = 0.44 - 1.45). However, this association is
21
not statistically significant, and therefore chance may be one explanation for this
finding.
In addition, there was no difference in wearing shirts that covered most of
the arms and shoulders during PE both before and after the program. However,
during post-intervention, students were 43% more likely to wear longer pants in PE
than during pre-intervention (RR = 1.43, 95% CI = 0.75 - 2.73). Although this
appears to be a considerable increase, this association is not statistically significant
and may be due to chance. Furthermore, one class reported about their sun
protection behavior on a sunny day for the pre-test, and all post-tests classes reported
about their sun protection behavior during PE on an overcast day. This could have
caused students to wear longer post-intervention.
Finally, students were 75% less likely to wear sunscreen during PE after the
intervention (RR = 0.25, 95% CI = 0.03 - 1.98). This suggests a great decrease in
sunscreen use, however this association is not statistically significant and so chance
may be an explanation for this finding. Since students were also less likely to wear
sunscreen during lunch, the sun awareness program may need to create new effective
methods for teaching the importance of sunscreen use and investigate possible
barriers to using sunscreen. Another explanation for the decrease in sunscreen use is
that there was one clear day pre-intervention and all were overcast post-intervention.
Perhaps the students did not use sunscreen because the post-intervention days were
all cloudy. However if that were the case, then we did not effectively communicate
the importance of wearing sunscreen on both sunny and cloudy days.
22
Table 2b: Sun Awareness Behavior Before and After a Sun Awareness Program
for Time Spent During PE in 4
th
-8
th
Grade Students at St. Vincent’s School,
Spring 2006
Pre Post % Diff
(pre-
post)
RR 95% CI
About how long were you
outside during PE
yesterday?

more than 1 min (did go
outside)
19 (14.3) 54 (40.6) -26.3 1.0
I didn’t have PE
yesterday / 0 minutes
(didn’t go outside during
PE yesterday)
95 (72.2) 61 (45.9) 26.3 0.64 (0.52,
0.77)
Missing either 18 (13.5)
Missing 10 (7.5) 13 (9.8)
Outside during PE for
both pre- & post-
intervention
Yes 16 (12.0)
No or missing 117 (88.0)
When you were outside
yesterday during PE, were
you?

Mostly in the sun 5 (31.3) 7 (43.8) -12.5 1.0
Mostly in the shade/ in
sun and shade for same
amt of time
10 (6.3) 8 (50.0) -43.7 0.8 (0.44,
1.45)
Missing either 1 (6.3)
Missing 1 (6.3) 1 (6.3)
What were you wearing on
your head when you were
outdoors during PE
yesterday?

Nothing 12 (75.0) 14 (87.5) -12.5 - -
Sun visor/cap/wide-
brimmed hat
2(12.5) 0 (0.0) 12.5 - -
Missing either 2 (12.5)
Missing 2 (12.5) 1 (6.3)
What were you wearing on
your shoulders and arms
during PE yesterday?

23
(Table 2b, Continued)
No shirt/tank top/short
sleeve shirt
8(50.0) 8 (50.0) 0.0 1.0
¾ length shirt/long
sleeve shirt
7(43.8) 7 (43.8) 0.0 1.0 -
Missing either 1 (6.3)
Missing 1 (6.3) 1 (6.3)
What were you wearing on
your legs when you were
outdoors during PE
yesterday?
Short shorts or short
skirt
8(50.0) 5 (31.3) 18.7 1.0
Knee-length pants/shorts
or knee-length skirt/long
pants/jeans
7(43.8) 10 (63.5) 19.7 1.43 (0.75,
2.73)
Missing either 1 (6.3)
Missing 1 (6.3) 1 (6.3)
What were you wearing on
your skin when you were
outdoors during PE
yesterday?

No Sunscreen 11 (68.8) 14 (87.5) -18.7 1.0
Sunscreen 4 (25.0) 1 (6.3) 18.7 0.25 (0.03,
1.98)
Missing either 1 (6.3)
Missing 1 (6.3) 1 (6.3)
* Ten students did not complete the post questionnaire.
* Some students did not answer the questions.
A statistically significant increase was detected for time spent outside during
PE (d = 0.68, p < 0.0001) and a small increase was detected for mean total body
coverage score during PE (d = 0.22, p = 0.51) (Table 3b). While this suggests that
we were successful in instilling the importance of wearing sun protective clothing,
the effect size estimate is small and not statistically significant; therefore chance
remains a reasonable explanation for this finding. In addition, although there was an
increase in time spent outside during PE, this may not have been of the students’
24
choice. Students may have been required to participate in an outside activity during
PE. It may then be more useful to communicate with PE teachers the importance of
limiting sun exposure and body coverage. Furthermore, children may have been
more inclined to stay inside during PE for the pre-test days because of the mostly
rainy weather compared to the non-rainy post-test days. They may have also
increased their body coverage post-intervention because all days were overcast
during this time.

Table 3b: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for
Sun Protection Behavior Questions for Time Spent Outside During PE
Pre
2
Post
2
Effect
size
1
Pvalue
Amount of time spent outside
during PE
1.68 (1.46)
n=115
2.83 (1.94)
n=115
0.68 <.0001
Total body coverage score during
PE
8.66 (2.17)
n=19
9.1 (1.97)
n=19
0.22 0.51
*
Maximum PE total body coverage score is 15.
1
Effect sizes were considered small for d = 0.2, medium for d = 0.5, and large for d
= 0.8.
2
Mean (SD)
Time Spent Outside in General
Table 2c shows us that students were 2% less likely to report that they
applied sunscreen on all sun-exposed areas during post-intervention compared to
pre-intervention (RR = 0.98, 95% CI = 0.74 - 1.3). Although it appears that students
seem less inclined to use sunscreen after the intervention, this association was not
statistically significant and chance may be a reasonable explanation for this finding.
25
Students were 4% more likely to report that they wore clothes covering most
of their body during post-intervention compared to pre-intervention (RR = 1.04, 95%
CI = 0.93 – 1.16). However, there was no difference in staying in the shade (RR =
1.0, 95% CI = 0.93 - 1.1) before and after the intervention. Neither of these
associations was statistically significant, however chance may be a reasonable
explanation for this finding. Post-intervention, the students were 18% more likely to
report wearing a hat than in pre-intervention (RR = 1.18, 95% CI = 0.86 - 1.6).
While this suggests that the intervention was successful in teaching students about
the benefit of using hats, this association was not statistically significant and chance
may be a possible explanation for this finding.

Table 2c: Sun Awareness Behavior Before and After a Sun Awareness Program
for Time Spent Outside in General in 4
th
-8
th
Grade Students at St. Vincent’s
School, Spring 2006
Pre Post % Diff
(pre-
post)
RR 95% CI
I apply a sunscreen on all
my sun-exposed areas when
I go outside.

Rarely/never 76 (57.1) 77 (57.9) -0.8 1.0
Always/often/sometimes 55 (41.4) 54 (40.6) 0.8 0.98 (0.74,
1.3)
Missing either 2 (1.5)
Missing 1 (0.8) 1 (0.8)
I wear clothes covering most
of my body, including my
arms and legs.

Rarely/never 23 (17.3) 19 (14.3) 3.0 1.0
Always/often/sometimes 104
(78.2)
108
(81.2)
-3.0 1.04 (0.93,
1.16)
Missing either 6 (4.5)
Missing 3 (2.3) 4 (3.0)
26
(Table 2c, Continued)
I wear a hat.
Rarely/never 82 (61.7) 74 (55.6) 6.1 1.0
Always/often/sometimes 45 (33.8) 53 (39.9) -6.1 1.18 (0.86,
1.6)
Missing either 6 (4.5)
Missing 4 (3.0) 2 (1.5)
I stay in the shade.
Rarely/never 12 (9.0) 11 (8.3) 0.7 1.0
Always/often/sometimes 107
(80.5)
108 (81.2)-0.7 1.0 (0.93,
1.1)
Missing either 14 (10.5)
Missing 11 (8.3) 3 (2.3)
* Ten students did not complete the post questionnaire.
* Some students did not answer the questions.
Small increases were detected for unfavorable responses in application of
sunscreen and wearing clothes that covered most of the body (d = 0.04 and d = 0.01,
respectively). In contrast, there was a decrease in unfavorable responses for mean
use of hats and time spent in the shade after the intervention (d = -0.22 and d = -0.03,
respectively). There was a statistically significant increase in wearing hats (p =
0.006). There were no statistically significant differences in applying sunscreen,
wearing clothes that covered most of the body, or staying in the shade (p = 0.67, p =
0.92, p = 0.75, respectively). However, these findings may be due to chance.
Because some of these sun protective measures increased and others decreased after
intervention, some sun protective measures may have been taught better than others
or perhaps other barriers exist to increasing sun protection. For these questions
regarding sun protection outside in general, no specific time period was specified.
Therefore it is unclear what weather conditions students had in mind when
answering these questions.
27
Table 3c: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for
Sun Protection Behavior Questions for Time Spent Outside in General
Pre
2
Post
2
Effect
size
1
Pvalue
I apply sunscreen when I go
outside.
3.66 (1.09)
n=131
3.70 (0.95)
n=131
0.04 0.67
I wear clothes covering most of my
body.
2.66 (0.97)
n=127
2.67 (0.85)
n=127
0.01 0.92
I wear a hat. 3.9 (0.96)
n=127
3.68 (1.08)
n=127
-0.22 0.005
I stay in the shade. 2.57 (0.79)
n=119
2.54 (0.84)
n=119
-0.03 0.75
*All ratings are on a (1-5) scale.
1
Effect sizes were considered small for d = 0.2, medium for d = 0.5, and large for d
= 0.8.
2
Mean (SD)
2. Examination of Sun Awareness Attitudes Before and After a Sun Awareness
Program in 4
th
to 8
th
Grade Students at St. Vincent’s School
Post-intervention, the students were 12% more likely to believe that it is not
important to have a suntan than in pre-intervention. (RR = 1.12, 95% CI = 0.9 -1.39)
(Table 2d). While this is a considerable increase in sun protective attitudes, this
result is not statistically significant and therefore it may be due to chance. In
contrast, when the importance variable was not dichotomized there was a slight
increase in mean ratings of importance of having a suntan after the intervention (d =
0.082, p = 0.36) (Table 3d). Although this appears to be a slight increase, this
association is not statistically significant and therefore this finding may be due to
chance.

28
Table2d: Sun Awareness Attitudes Before and After a Sun Awareness Program
in 4
th
-8
th
Grade Students at St. Vincent’s School, Spring 2006
Pre Post

% Diff
(pre-
post)
RR 95%
CI
How important do you think it
is to have a suntan?

Kind of important
/important/very important
64 (48.1) 56
(42.1)
6.0 1.0
Not important 69 (51.9) 77
(57.9)
-6.0 1.12 (0.9,
1.39)
Missing either 0 (0.0)
Missing 0 (0.0) 0 (0.0)
* Ten students did not complete the post questionnaire.
* Some students did not answer the questions.
Table 3d: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for
Sun Protection Attitude Questions
Pre
2
Post
2
Effect
size
1
Pvalue
Importance of having a sun
tan
1.74 (0.92)
n=133
1.83 (1.11)
n=133
0.089 0.32
* Ratings are on a (1-4) Likert scale.
1
Effect sizes were considered small for d = 0.2, medium for d = 0.5, and large for d
= 0.8.
2
Mean (SD)
Some students reported that they had spoken with their parents (38.5%),
friends (33.6%), or siblings (23.1%) about sun protection after the intervention.
Therefore it is possible that their attitudes towards sun protection had changed since
they had communicated with someone else about the topic. However these questions
were not asked during the pre-test so a comparison cannot be made.

29
Table 4a: Frequencies and Percentages of Questions Regarding Communication
with Others About Sun Protection
In the last 2 weeks, have you spoken with a parent,
guardian, or other adult in your household about sun
protection?

Yes 55 (38.5)
No 77 (53.9)
Missing 11 (7.8)
In the last 2 weeks, have you spoken with a sibling
about sun protection?

Yes 33 (23.1)
No 100 (70.0)
Missing 10 (7.0)
In the last 2 weeks, have you spoken with a friend about
sun protection?

Yes 48 (33.6)
No 83 (58.3)
Missing 12 (8.4)
* These questions were asked only during the post-test.
3. Examination of Sun Awareness Knowledge Before and After a Sun
Awareness Program in 4
th
to 8
th
Grade Students at St. Vincent’s School
It appears that the greatest changes from the intervention program lie in sun
protection knowledge. Students were 26% more likely to correctly answer the
question “It is most harmful to your skin to be in the sun between 10:00 am and 3:00
pm”, during post-intervention rather than pre-intervention (RR = 1.26, 95% CI =
1.02 - 1.56) (Table 2e). Post-intervention, the students were also 4.19 times as likely
to correctly answer the question, “You can get a sunburn on a cloudy day” than
during pre-intervention (RR = 4.19, 95% CI = 2.58 - 6.81). These two associations
were statistically significant. Therefore, it appears that our intervention program was
effective in communicating these aspects of sun awareness.
30
Post-intervention, the students were 4% more likely to correctly answer the
question “A sunscreen with a SPF of 2 is better than a sunscreen with an SPF of 15”
than during pre-intervention (RR = 1.04, 95% CI = 0.95, 1.12). Students were 6%
more likely to correctly answer the question “I should put sunscreen on once in a day
and then not bother to reapply it” during post-intervention compared to pre-
intervention (RR = 1.06, 95% CI = 0.96, 1.17). The students were also 12% more
likely to correctly answer the question, “Getting a lot of sunburns increases your
chances of getting skin cancer” during post-intervention than during pre-
intervention. (RR = 1.12, 95% CI = 0.98 - 1.28). These results suggest that the sun
awareness program was successful in teaching students about these aspects of
sunscreen and sunburns. However, none of these associations are statistically
significant, so chance is a possible explanation for these findings.
One drawback lay in the question; “People with light-colored skin are less
likely to get skin cancer than people with darker-colored skin”. Post-intervention,
the students were 5% less likely to correctly answer this question than during pre-
intervention. (RR = 0.95, 95% CI = 0.86 - 1.0). Although this appears to be a setback
in the intervention, this estimate is not statistically significant and may be due to
chance.

31
Table 2e: Sun Awareness Knowledge Before and After a Sun Awareness
Program in 4
th
-8
th
Grade Students at St. Vincent’s School, Spring 2006
Pre Post
a
% Diff
(pre-
post)
RR 95%
CI
A sunscreen with a SPF of 2 is
better than a sunscreen with a
SPF of 15.

True 15 (11.3) 11 (8.3) 3.0 1.0
False/ not sure 114
(85.7)
118
(88.7)
-3.0 1.04 (0.95,
1.12)
Missing either 4 (3.0)
Missing 3 (2.3) 1 (0.8)
I should put sunscreen on once
in a day and then not bother to
reapply it.

True 21 (15.8) 15 (11.3) 4.5 1.0
False/not sure 106
(79.7)
112
(84.2)
-4.5 1.06 (0.96,
1.17)
Missing either 6 (4.5)
Missing 5 (3.8) 1 (0.8)
It is most harmful to your skin
to be in the sun between 10am
and 3pm.

False/not sure 59 (44.4) 42 (31.6) 12.8 1.0
True 65 (48.9) 82 (61.7) -12.8 1.26 (1.02,
1.56)
Missing either 9 (6.8)
Missing 8 (6.0) 1 (0.8)
You can get a sunburn on a
cloudy day.

False 109
(82.0)
58 (43.6) 38.4 1.0
True 16 (12.0) 67 (50.4) -38.4 4.19 (2.58,
6.81)
Missing either 8 (6.0)
Missing 5 (3.8) 3 (2.3)
People with light-colored skin
are less likely to get skin cancer
than people with darker-
colored skin.

True 13 (9.8) 19 (14.3) -4.5 1.0
False/not sure 116
(87.2)
110
(82.7)
4.5 0.95 (0.86,
1.04)
32
(Table 2e, Continued)
Missing either 4 (3.0)
Missing 4 (3.0) 0 (0.0)
Getting a lot of sunburns
increases your chances of
getting skin cancer.

False/ not sure 36 (27.1) 25 (18.8) 8.3 1.0
True 94 (70.7) 105
(79.0)
-8.3 1.12 (0.98,
1.28)
Missing either 3 (2.3)
Missing 3 (2.3) 0 (0.0)
* Ten students did not complete the post questionnaire.
* Some students did not answer the questions.

There was a statistically significant increase in the total number of correct
sun protection knowledge questions in post-intervention compared to pre- (p <
0.0001) (Table 3e). This gives further evidence that overall our intervention
program was effective in improving knowledge of sun safety.

Table 3e: Mean Ratings, Standard Errors, Sample Sizes, and Effect Sizes for
Number of Correct Sun Protection Knowledge Questions.
Pre
2
Post
2
Effect
size
1
Pvalue
Number correct out of six items 2.57 (1.53)
n=237
3.94 (1.59)
n=237
-0.87 <0.0001
*
Maximum number of correct items is 6.
1
Effect sizes were considered small for d = 0.2, medium for d = 0.5, and large for d
= 0.8.
2
Mean (SD)
33
CONCLUSION
Even though sun awareness behaviors did not improve significantly, we
found that sun awareness knowledge did improve after the intervention program.
Favorable sun awareness attitudes increased after the intervention; however we only
had one question in our survey relating to this topic.
Our findings are supported by other studies that have also found an increase
in sun awareness knowledge, but we found smaller increases in behavior and
attitudes. This indicates that our intervention was successful in increasing children’s
awareness of prevention strategies and risk factors of skin cancer. However, it did
not appear to impact their behavior, and therefore may not reduce their skin cancer
risk.
One limitation of our study is that we had a much smaller sample size for
time spent outside during lunch and PE. In addition, sun protection behavior for
time spent outside in general may have been more informative if we had specified a
time period or weather conditions for these questions. Furthermore, our JEP teachers
did not have extensive training, which could have resulted in an ineffective
curriculum and teaching strategies. If we had more effective teaching strategies
perhaps sun protection attitudes and behaviors would have also improved after the
intervention.
Our results indicate that perhaps our intervention curriculum was not as
successful in enforcing sun protection strategies compared to Girgis’ study and the
SDHW prevention program implemented in the Colorado, New Mexico, and Arizona
34
schools (Girgis et al., 1993; Buller et al., 2006). More research is needed on
methods to instill sun protection practices in young children.
Future intervention programs should also be based on the CDC materials, but
should be further adapted so that they are age-appropriate and consist of current
prevention intervention strategies. Objectives of the curriculum should be to
increase perceived personal risk for skin damage and skin cancer, positive outcome
expectations about sun protection, and positive self-abilities to use sun protection
strategies in a variety of situations. Children should be taught the following
prevention methods: selection and application of sunscreen, wearing protective
clothing, using hats and sunglasses, and limiting time in sun. The curriculum should
also include activities to help children set goals for sun protection, monitor progress
towards achieving these goals, and overcoming barriers to sun protection. Ideally, a
more formal training program should be taught to the JEP teachers with instruction
of the curriculum and teaching strategies.
In designing future intervention programs, it would be beneficial to examine
possible barriers to sun protection practices and ways to avoid them. Since it is
much easier to change sun protection knowledge, the focus should now be on finding
effective ways to change sun protection attitudes and behavior.
35
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Abstract (if available)

Abstract Sun exposure is a potential risk factor for skin cancer and melanoma. Since most sun exposure during one's lifetime occurs during childhood, sun protection at a young age may be an effective method of primary prevention. It remains unclear how to effectively instill sun protective behaviors in children. -- In this study, a sun awareness intervention program was conducted to see if there were significant changes in sun awareness before and after the intervention. Based on a study of 143 subjects, this thesis examines sun awareness behavior, knowledge, and attitudes before and after the sun awareness program. -- Results show that sun awareness knowledge increased after the intervention, but smaller changes were observed for attitudes towards sun protection and sun protective behaviors. This indicates that our intervention program increased children's awareness of skin cancer, but it didn't appear to impact their behavior, and therefore may not reduce their risk of skin cancer.

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Asset Metadata

Creator Tavares, Venessa (author)

Core Title Examination of sun awareness behavior, knowledge, and attitudes before and after a sun awareness program in 4th to 8th grade students

School Keck School of Medicine

Degree Master of Science

Degree Program Biostatistics

Publication Date 05/31/2007

Defense Date 05/31/2007

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag intervention,Melanoma,OAI-PMH Harvest

Language English

Advisor Myles Cockburn (committee chair), [illegible] (committee member), Reynolds, Kim D. (committee member), Richardson, Jean L. (committee member)

Creator Email vtavares@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m501

Unique identifier UC1448225

Identifier etd-Tavares-20070531 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-492018 (legacy record id),usctheses-m501 (legacy record id)

Legacy Identifier etd-Tavares-20070531.pdf

Dmrecord 492018

Document Type Thesis

Rights Tavares, Venessa

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu