Details of Cancer Education Programs for Adolescents and Young Adults and Their Effectiveness: A Scoping Review

Abstract

The purpose of this review was to establish what cancer education programs have been carried out aimed at adolescents and young adults (AYAs) and what outcomes they achieved. The databases used were MEDLINE, CINAHL, and Web of Science, and the search period was set as 2011–2020. The extracted literature was evaluated for quality using the Joanna Briggs Institute's critical appraisal tools. The subjects of the analysis were 29 studies: 10 randomized controlled trials and 19 quasi-experimental designs. Regarding the varieties of cancers found in the data, in descending order, 10 documents looked at cervical cancer, 9 looked at cancer in general, and 4 looked at breast cancer. Most studies focused on AYAs exclusively, with just three studies involving their parents simultaneously. Many studies used lecture-based intervention, with information technology-based interventions using websites and cell phones. Topics included in the program were cancer epidemiology, cancer risk factors, cancer warning signs and symptoms, prevention methods, and screening methods. After the intervention, all studies showed statistically significant improvements in at least one outcome measure, which included knowledge and awareness of cancer, health beliefs, and intent to take preventive action, demonstrating a basis for educational intervention. Educating AYAs about cancer at a time when their ways of life are becoming more concrete can be expected to have a positive impact on cancer preventing behaviors in adulthood, increase their parents' awareness of cancer, and have a positive impact on behavior around screening.

Introduction

According to 2019 World Health Organization estimates, cancer is the leading or the second most common cause of death among up to 70-year olds in 112 of 183 countries, with an estimated 19.3 million new cases and 10 million deaths worldwide, in 2020.¹ Similarly, cancer is the leading cause of illness-related deaths among adults in Japan.² Cancer rates are also increasing yearly and it continues to be a grave health issue.³

Causes of cancer supposedly include factors such as smoking, viruses, bacteria, and diet.⁴ Moreover, knowledge about cancer is an important part of cancer prevention for the public. Furthermore, for specific types of cancer, early detection and appropriate treatment can increase chances of recovery⁵; lack of knowledge and awareness about cancer, however, prevents people from early screening.^6,7 Knowledge about cancer also significantly influences the timing when individuals consult a medical institution,⁸ lack of which results in delays in cancer diagnosis.⁹

Adolescence (ages 10–19 years) and young adult (ages 20–30 years) are critical periods for prevention and educational intervention since numerous behaviors are being established during this period such as lifestyle behaviors beneficial to health, including physical activity and healthy diet, as well as harmful behaviors, including alcohol consumption and tobacco use.¹⁰ Therefore, information given to adolescents about lifestyle factors along with cancer risk reduction messages may have a lasting impact on cancer prevention in adulthood.¹¹

Low levels of knowledge in young adults about modifiable cancer risk factors such as obesity and alcohol consumption have been previously reported.¹² Therefore, providing education about cancer to adolescents and young adults (called AYAs hereinafter) who are less familiar with cancer risk factors may be effective in reducing their risk of developing it.

Previous studies have reported that schools play an important role in educating young people about cancer.¹³ In the United Kingdom, the Teenage Cancer Trust was one of the first in the developed world to develop a cancer educational program called “Let's talk about it”¹⁴ to raise awareness about and improve knowledge of cancer among young people and provide them with advice on healthy living. The program has been introduced in many secondary schools and its effectiveness has been verified. It is implemented in 10% of schools in the United Kingdom annually.¹⁵

In contrast, in countries such as Nigeria, India, and Saudi Arabia, adolescents have few opportunities to receive education about cancer and cancer prevention in school classes, and it has been recognized that adolescents' access to information about cancer and health in school can have positive spillover effects not only on themselves but also on their families and society. Thus, several intervention studies have been conducted on school-based cancer education.^16–18

Therefore, it is important to examine what kind of cancer education is being provided to AYAs to consider how to provide effective cancer education in the future. One systematic review of school-based cancer education for adolescents was found, which was limited to cancer education programs applied in schools for teenagers.¹⁹ However, school-based interventions alone are insufficient to improve adolescent health behaviors; interventions that incorporate community and family-based approaches using local support systems have been found to be effective in reducing social barriers to adolescent behavior change.²⁰

The purpose of this review was to clarify the contents and methods of cancer education for AYAs not only in schools but also in the community and understand the results from a broad perspective.

Methods

Sources and search strategy

This review is based on the PRISMA guidelines that were followed because they provided a structured way to conduct reviews.²¹

Identification

The electronic databases, MEDLINE, CINAHL, and Web of Science, were used in the search. The PICO (population, intervention, comparison, and outcome) framework was used to determine search terms. This review was performed by combining the terms “adolescent,” “young adult,” “cancer,” “education,” “intervention,” “program,” “knowledge,” and “awareness.”

All interventional studies (such as randomized controlled trials [RCTs] and quasi-experimental designs [QEDs]) were included in the review, while observational studies were excluded. The literature focused on educational interventions for all types of cancer aimed at AYAs. The language selected for inclusion in this review was English. To combine the results of original studies, meeting proceedings and commentaries were excluded. The search period was the last 10 years, from January 1, 2011 to December 31, 2020.

Screening and inclusion

To isolate literature surrounding programs educating AYAs from the body of literature searched, results were screened using a three-step process that aligned with exclusion criteria, following the removal of duplicate literature and surveillance studies.

The exclusion criteria in the first stage were educational programs for cancer patients, pediatric cancer patients, and caregivers. The exclusion criteria in the second phase were interventions through campaigns, educational programs for adults, older adults, elementary school children, health care providers, evaluations of the content of educational programs, and protocols for programs educating about cancer. The exclusion criterion in the third stage was studies with low scores after methodological quality assessment. The first and second stages of the screening were performed by the first author (K.S.) alone. The third stage of the screening—the evaluation of the quality of each article—was carried out by two reviewers.

Critical appraisal

The methodological quality of the identified studies was evaluated using the randomized control trial or quasi-experimental research checklists from the Joanna Briggs Institute critical appraisal tools.²² A bias risk evaluation was then performed by conducting a double check by one reviewer (K.S.) against the other reviewers to address evaluation errors. All the reviewers examined the results in depth; contradictions were resolved through discussion until a consensus was reached. In the methodological quality assessment of articles, those with a total score of at least half out of the total were selected; RCTs with a score of 7 or more out of 13 and QEDs with a score of 5 or more out of 9 were selected.

Data analysis and synthesis

To organize the selected studies, a review sheet for recording the following basic information was created: author names, year of publication, title, research design, country, subjects, target type of cancer, program details, and overview of findings regarding program outcome. The program structure and method for each type of cancer were analyzed and commonalities derived. Moreover, intervention styles were categorized as follows: Interventions that primarily took the form of face-to-face lectures were classified as lecture-based intervention, interventions exclusively through the distribution of leaflets were classified as leaflet-based intervention, and interventions using the internet and cell phones were classified as information technology (IT) based intervention. Note that since this study does not involve human subjects, it is exempt from Institutional Review Board deliberation at our university.

Results

Search results

The search resulted in 3297 studies (Medline = 2016, CINAHL = 868, Web of Science = 413) (as of June 15, 2021). Subsequently, as a result of excluding duplicate literature and surveillance studies this figure dropped to 726. Furthermore, as a result of selecting literature according to the exclusion criteria of the first, second, and third stages, 622, 73, and 2 pieces of literature were excluded, respectively.

The 29 remaining studies were set as the target of analysis of this study (Fig. 1).

FIG. 1.

Search strategy diagram. As per the JBI critical appraisal checklists for systematic review.

Overview of studies

Table 1 presents an overview of the 29 studies. Ten studies had RCT design,^23–32 while 19 were QEDs. Of the QEDs, 7 were two-group pre/post-test comparative studies^16,33–38 with a control group and 12 were one-group pre/post-test comparative studies.^{17,18,39–48}

Table 1.

Study Overview

First author	Country	Study design	Sample size/age of participants	Type of cancer	Intervention type, contents and methods of intervention, outcome measures timeline	Measurement tools	Main findings	Quality assessment
Suryadevara⁴⁰	United States	QEDs (single-group and pre-posttest design)	Adolescents and their parents N = 6 large general pediatric practices (from 1900 to 6000/practice) Ave age: — Range of age: 11–18	Cervical cancer	Intervention style: Leaflet-based intervention Intervention contents and methods: Booklets were distributed to all adolescent and their parents during office visits over a 12-month period. The booklet was designed by the study team by combining resources available from both the U.S. Centers for Disease Control and Prevention and the American Cancer Society with the goal of bundling HPV vaccine information with other generally well-accepted anticipatory guidance for cancer prevention. Outcome measures timeline: Baseline (T0), 6 months after distributing booklets (T1), 12 months after distributing booklets (T2)	HPV vaccine series initiation rates, HPV vaccine series completion rates, percent change in vaccine series completion rates	Percent changes in vaccine series initiation and completion rates for each practice over the 12-month study period are following. Three practices improved vaccine initiation rates by at least 10% and 5 improved by greater than 5% in both age groups. Similarly, 2 and 3 practices had at least a 10% change in vaccine completion rates in 11- to 12-year olds and 13- to 18-year olds, respectively, and 4 of the practices had at least a 5% change in vaccine completion rates in both age groups.	5/9
Lyson⁴¹	United States	QEDs (single-group and pre-posttest design)	Undergraduate female students N = 569 Ave age: — Range of age: 18–26	Cervical cancer	Intervention style: IT-based intervention Intervention contents and methods: The intervention was the delivery of online messages. Throughout the enrollment period, participants were consecutively assigned to nine-person groups on the Health Connect platform. The 900 tweets were then randomly distributed to the 9 women in each online group over 5 days. Each participant was shown a unique random set of 20 tweets per day in a personalized message feed. Participants could select and share her messages to her online group and everyone could then comment on the shared messages. Outcome measures timeline: Baseline (T0), After intervention (T1)	Questionnaire included HPV awareness, knowledge on HPV, HPV vaccine awareness, vaccine interest, vaccination behaviors, and Pap test behavior.	While no statistically significant changes in any knowledge or behaviors related to HPV or cervical cancer prevention were fund from T0 to T1, a statistically significant change in HPV awareness increasing from 90% to 94% (p = 0.003) from the T0 to the T1 was observed.	5/9
Egawa²⁴	Japan	RCT	20-Year-old females who had not yet received a cervical cancer screening and who lived with their mother N = 2548 IG1 = 1274 IG2 = 1274	Cervical cancer	Intervention style: Leaflet-based intervention IG1: IG1 was sent a leaflet to daughter only. The leaflet for the daughter consisted of an informational section, which discussed cervical cancer and the importance of getting screening for cervical cancer, along with a cartoon strip of a conversation between a daughter and her mother. IG2: IG2 was sent a leaflet to daughter and their mother. The leaflet for daughter was same one with IG1. The leaflet for the mother consisted of suggestions for simple words which she could use to talk to her daughter about cervical cancer and cervical cancer screening and had more detailed explanations of cervical cancer and cervical cancer screening. Outcome measurement timeline: Baseline (T0), 3 months following the distribution of the leaflets (T1)	Cervical cancer screening rate	In the IG1 a leaflet for the daughter was sent, the number of females who received cervical cancer screening was 9%, whereas it was significantly higher at 11% (p = 0.0049), in the IG2 for which the intervention actively involved the mothers.	10/13
Staples⁴²	United States	QEDs (single-group and pre-posttest design)	Undergraduate female students N = 54 Ave age: — Range of age: 17–21	Cervical cancer	Intervention style: Lecture-based intervention Intervention contents and methods: The program was packaged as a 1-hour lecture which included a Power Point presentation, female body diagrams, and topic-specific medical instruments, including plastic speculums and Pap brushes. Topics of the intervention included (a) basic female anatomy, (b) normal cervical function, (c) common cervical pathologies, (d) cervical dysplasia, (e) cervical cancer, (f) HPV, (g) disparities in cervical cancer, (h) pap smear, and (i) HPV vaccination. The intervention method used a PowerPoint presentation and interactive questions. The program was delivered by a senior OB/GYN resident who is African American. Outcome measures timeline: prelecture surveys (T0), postlecture surveys (T1)	Questionnaire included knowledge about HPV and cervical cancer and a change in attitude about Pap smears and the HPV vaccine.	Of the 16 knowledge-based questions, correct response rates significantly increased (p = 0.005) with the intervention. At what age should women start getting Pap tests, had the most significant increase in correct response rates (21% vs. 91%). 94% of participants affirmed plans to get regular Pap smears. 87% of unvaccinated participants affirmed plans to get the HPV vaccine.	5/9
Sadoh¹⁷	Nigeria	QEDs (single-group and pre-posttest design)	Female students of junior and senior secondary schools N = 1201 Ave age: 13.36 (±1.64) Range of age: 9–17	Cervical cancer	Intervention style: Lecture-based intervention IG: The trained students delivered messages on cervical cancer and HPV using fliers containing key information (peer training) to their school mates in formal delivery in a class setting. Students from the different classes were selected to attend the training seminar which was given by one of the authors. Key information on cervical cancer was emphasized while each student was given a flier containing the key information. Within 2 weeks of the training, each student delivered a mini lecture on the subject to her classmates using the flier as a guide and to emphasize key points. Outcome measures timeline: Baseline (T0), Within a week of the students delivering their lectures (T1)	The questionnaire consisted of questions which sought information on awareness about cervical cancer and various knowledge domains such as causative organism, risk factors, treatment and prevention.	Awareness of cervical cancer, knowledge of risk factors, and cause of cervical cancer was low before the peer training at T0. There was statistically significant improvement in awareness about cervical cancer and in the knowledge domains following peer training at T1 (p < 0.001). Mean knowledge score at T0 was 12.07 ± 9.74 and this increased significantly to 53.74 ± 10.69 following T1 (p < 0.0001).	5/9
Al-Shaikh¹⁸	Saudi Arabia	QEDs (single-group and pre-posttest design)	Female medical students N = 535 Ave age: 20.3 (±1.3) Range of age: —	Cervical cancer	Intervention style: Lecture-based intervention Intervention contents and methods: Program activities were introduced in 2 weeks and were conducted in five stations, each situated in a participating college (pharmacy, nursing, health and rehabilitation, medicine, and dental). Each lecture lasted for 1 hour and was followed by 15 minutes of active discussion. The health education topics covered the following items: risk factors of cervical cancer, clinical presentation, oncogenic strains of HPV, and detailed information about HPV vaccines and Pap smear. Unified interactive series of lectures using audiovisual aids such as Microsoft PowerPoint, video films, charts, and posters led by experienced faculty were conducted in each college. Outcome measures timeline: Baseline (T0), 6 months after intervention (T1)	Questionnaire included about knowledge and beliefs about cervical cancer and cervical cancer screening and assessed their intent post-test to undergo screening and if they received a Pap test after the intervention.	Overall, the effectiveness of the intervention program on most of the items was positive. After the program, 76.6% students identified cervical cancer as a preventable disease compared to 50.3% before the intervention (p < 0.01). Besides, 92.5% students recognized vaccination, avoidance of sexually transmitted diseases, screening, and early detection as effective preventive measures from cervical cancer after the intervention compared to 88.2% before the intervention (p = 0.02).	5/9
Lai³⁴	Taiwan	QEDs (two group pretest and posttest design)	Senior high school female students N = 200 IG = 100 CG = 100 Ave age: 15.35 (±5.35) Range of age: 15–17	Cervical cancer	Intervention style: Lecture-based intervention Intervention contents and methods: CCPE was developed by Ministry of Health and Welfare to assist teens in understanding cervical cancer, Pap smear screening, HPV vaccination, and cervical cancer prevention and is based on the Health Belief Model. During the 2 weeks following the classroom CCPE lecture, participants entered optional discussion sessions (either Facebook-assisted or face-to-face). IG: The lecturer initiated the discussion with the question; this was followed by a brief introduction of the HPV vaccine and the CCPE lecture conducted. The lecture was conducted for 50 minutes, once. Then 6-hour Facebook-assisted discussion sessions were offered. During the 2 weeks following the classroom CCPE lecture, participants held Facebook-assisted discussion sessions. The provider of the program was a nursing teacher. CG: The CG participants attended CCPE lectures on the same topics as the IG and then participated in face-to-face discussions over the course of 2 weeks. Outcome measures timeline: Baseline (T0), 2 weeks after intervention (T1), 8 weeks after intervention (T2)	Cervical Cancer Prevention Questionnaire included knowledge of cervical cancer and attitude of cervical cancer.	A comparison of change from T0 to T1 across groups indicated that scores of the knowledge (p < 0.001) and attitude (p = 0.01) of cervical cancer improvement IG than CG. A comparison of change from T1 to T2 across groups indicated that scores of the knowledge (p = 0.047) and attitude (p = 0.097) of cervical cancer improvement IG than CG. Under the condition of the vaccine being an out-of-pocket expense, IG's improvement scores from T0 to T1 were 2.284 times greater those scores CG (p < 0.001). Under the condition of receiving the vaccine free of charge, scores improvement scores from T0 to T1 were 1.958 times greater IG than CG (p = 0.033).	8/9
Lee⁴⁷	United States	QEDs (single-group and pre-posttest design)	Korean American women N = 30 Ave age: — Range of age: 21–29	Cervical cancer	Intervention style: IT-based intervention Intervention contents and methods: A mobile phone text message-based cervical cancer screening (mScreening) intervention was developed based on Fogg's Behavior Model. The educational content of the mScreening covered the following topics: (a) introductory information on the cervix and cervical cancer, including statistical facts of cervical cancer incidence and mortality, and screening rates of cervical cancer among Korean American women compared to other racial/ethnic groups in the United States, (b) introduction of the Pap test as a preventive mode for cervical cancer, (c) information on health care accessibility, (d) introduction of cultural barriers, (e) availability of local clinics and cost of Pap test, (f) testimony of a Korean American woman who had gone through the Pap test experience, and (g) testimony of a Korean American cervical cancer survivor who found cervical cancer at later stage and had no previous receipt of a Pap test. The mScreening intervention was delivered to each participant over 20–30 minutes each day for a 7-day period at each participant's preferred time. Outcome measures timeline: Baseline (T0), 1 week after the completion of mScreening (T1), 3 months after the completion of mScreening (T2)	Questionnaire included the knowledge and beliefs about cervical cancer and cervical cancer screening and assessed their intent to undergo screening at T1 and if they received a Pap test at T2.	Changes in measures of knowledge, attitudes, and beliefs about the cervical cancer and intention of Pap test were compared T0 to T1. Significant improvements were observed for general knowledge about cervical cancer (p < 0.001), knowledge about the Pap test (p < 0.001), knowledge about risk factors of cervical cancer and its screening (p < 0.001), beliefs and attitudes toward the Pap test (p = 0.006).	5/9
Marek³⁸	Hungary	QEDs (two-group and pre-posttest design)	Male and female adolescents N = 394 IG = 191 CG = 203 Ave age: 15–16 Range of age: 14–19	Cervical cancer	Intervention style: Lecture-based intervention IG: The educational program was of 45 minutes duration, consisting of a didactic presentation with information on the viral life cycle and HPV, the female reproductive system focusing on the cervix, gynecological screening (a cytobrush and cusco-speculum were demonstrated), and risk factors of cervical cancer with emphasis on sexual behavior and methods of prevention. The presentation was followed by a question-and-answer session, and the students were provided with handouts containing key messages. This intervention was delivered by a trained health educator. CG: No education Outcome measures timeline: Baseline (T0), 3 months after intervention (T1)	The questionnaire consisted of items on past and present sexual behavior, knowledge of cervical cancer and HPV, and beliefs and attitudes toward screening and vaccination.	IG had significantly increased knowledge of the causes of cervical cancer (p < 0.001) and early symptoms (p < 0.001) at T1 than at T0 compared to CG. There was also a significant increase in the belief that the HPV vaccine prevents cervical cancer (p < 0.001) and a significant decrease in those willing to be vaccinated if free screening was available in the CG (p < 0.05).	7/9
Kwan⁴⁸	Hong Kong	QEDs (single-group and pre-posttest design)	Adolescent girls from local secondary schools N = 953 Ave age: 14.74 (±1.79) Range of age: —	Cervical cancer	Intervention style: Lecture-based intervention Intervention contents and methods: The educational program consisted of a didactic slide presentation followed by an interactive question-and-answer session to enhance understanding of the contents. To motivate attendance and enhance understanding, the program was designed as follows: (a) personal relevance is the most important factor affecting motivation. We used explicit statements to highlight the relevance of cervical cancer to the adolescent audience and elaborated on issues directly related to their current life stage. (b) Adolescents are less capable of abstract thinking. Thus, special attention was paid to achieve maximum content simplicity and clarity. (c) Adolescents are less prone to anticipate future feelings and consequences. Thus, practices that could be immediately applied, such as HPV vaccination and refraining from smoking, were promoted along with their benefits. The presentations were conducted by an experienced gynecological oncologist during regular school days, each lasting about 1 hour. Outcome measures timeline: Baseline (T0), After intervention (T1)	Questionnaire included knowledge about cervical cancer and HPV, attitude toward HPV vaccination and participants' perceived social norms in terms of whether family and peers thought she should be vaccinated.	After the program, a significant increase in knowledge of HPV and cervical cancer (p < 0.001) and more positive attitude of HPV vaccination (p < 0.001) were noted. It's significant increase in perceived social norms of family (p < 0.001) or peer (p < 0.001) after the program. There was an 11.3% increase in the proportion of participants who indicated a positive intention to be HPV vaccinated after the program.	5/9
Hwang³³	Taiwan	QEDs (two group pretest and posttest design)	University students (medical and nursing students were excluded) N = 325 IG1 = 104 IG2 = 78 CG = 143 Ave age: 20.42 (±1.54) Range of age: 18–26	General cancer	Intervention style: Lecture-based intervention Intervention contents and methods: The cancer education program was part of the course. The course comprised a 2-hour session every week for 18 weeks; weeks 9 and 18 were examination weeks, and no classes were conducted. The instructor designed identical topics for all three groups. The six learning objectives of the cancer topic were the pathophysiology of cancer, established cancer risk factors, prevention strategies, warning signs, free cancer screening programs offered by the government, and cancer treatments. The cancer topic was offered during week 8 for the PBLG1 and the LBLG, whereas it was offered during week 17 (after the posttest) for the PBLG2. PBLG1 and PBLG2 were instructed using problem based learning, while LBLG was instructed using lecture based learning. The cancer program for PBLG1 comprised the aforementioned PBL activities and a 30-minute cancer-related lecture that addressed the learning objectives that were not presented clearly by the students. The cancer program for LBLG comprised a 100-minute lecture, examples, and questioning. The provider was a nurse and was the same person in all three groups. Outcome measurement timeline: Baseline (T0), Post lecture at week 8 (T1)	Cancer awareness Measure included awareness of cancer risk factors, prevention strategies, and warning signs.	After controlling for confounding variables, cancer awareness significantly improved between the pretest and post-test in LBLG (p < 0.001). No significant difference in cancer awareness improvement was observed between PBLG1 and LBLG (p = 0.934). Cancer awareness improvement in PBLG2 was significantly less than in the control group (p = 0.01). Therefore, both PBLG and LBLG with the cancer topic had a significant effect on improving cancer awareness in undergraduates, and no significant difference in cancer awareness improvement was observed between PBLG and LBLG.	7/9
Hubbard²⁶	United Kingdom	RCT (a cluster RCT)	Adolescents N = 2173 IG = 1129 CG = 1044 Ave age: 12.4 (±0.55) Range of age: 12–13	General cancer	Intervention style: Lecture-based intervention Intervention contents and methods: The study was conducted in 20 schools, with 10 schools in the IG and 10 schools in the CG. IG: The psychoeducational interventions in this program were structured using social cognitive theory and the common sense model of self-regulation of health and illness. The intervention method used was a 50-minute lecture style using a PowerPoint presentation, role play, and homework. Topics included: what is cancer, teen and young adult cancer statistics, common teen and young adult cancers, early warning signs of cancer, importance of knowing your body, cancer stories, cancer treatment, smoking, sun safety, alcohol, physical activity, diet, and information about Teenage Cancer Trust. Information about the program was included. Homework assignments were handed out at the end of the intervention and were exercises to be completed with a parent or guardian. The provider was a paid educator with three and a half years of experience employed by Teenage Cancer Trust. CG: No education Outcome measures timeline: Baseline (T0), After 2 weeks (T1), 6 months later (T2)	Cancer Awareness Measure included awareness of cancer risk factors, prevention strategies, and warning signs.	Regression models showed significant differences in the number of cancer warning signs (p < 0.001) and risk factors (p < 0.001) recognized between IG and CG. In IG, the greatest increases in recognition of cancer warning signs at T2 were for unexplained weight loss (from 44.2% to 62.0%) and change in the appearance of a mole (from 46.3% to 70.7%), up by 17.8% and 24.4%, respectively. Greatest increases in recognition of cancer risk factors were for getting sunburnt more than once as a child (from 41.0% to 57.6%) and being overweight (from 42.7% to 55.5%), up by 16.6% and 12.8%, respectively. Regression models showed that adolescents in IG were 2.7 times more likely to discuss cancer at T1 compared with the CG.	10/13
Khalil²⁷	United States	RCT	Young adults N = 101 HCG = 43 LCG = 43 CG = 15 Ave age: — Range of age: 18–35	General cancer	Intervention style: IT-based intervention Game Intervention Format and Key Features: This Re-Misson game was developed according to the protection motivation theory. The story in Re-Mission revolves around a nanorobot designed by a doctor and injected into the body of virtual cancer patients to help them fight cancer cells. Re-Mission involves a first-hand experience of cancer threat that ultimately allows players to perceive cancer risk. A highly challenging environment with cancer cells may facilitate perceived severity of cancer and intentions to seek cancer-related information. HCG: Young adults who play Re-Mission at HC. HC was conceptualized as a condition that arises from a set of obstacles (e.g., invasion by and multiplication of cancer cells) that prevent the players from attaining their goals in the game (e.g., killing cancer cells and helping the patient recover from cancer). Three characteristics of challenge were manipulated in the game-mechanics to form an HC environment: difficulty level, vulnerability to cancer cells, and limited ammunition. LCG: Young adults who play Re-Mission at LC CG: Young adults who do not play Re-Mission. Outcome measures timeline: Baseline (T0), Immediate after game (T1), 10-day follow-up (T2), 20-day follow-up (T3)	The primary outcome was cancer-related information seeking behavior; the secondary outcomes were perceived severity of cancer and perceived susceptibility to cancer.	Participants in the HCG and LCG were more likely to increase in perceived susceptibility to cancer (p = 0.03), perceived severity of cancer (p = 0.02), and cancer-related information seeking behavior (p = 0.01) than participants in the CG. The LCG took until T2 to show increase in perceived susceptibility (p = 0.005). The HCG showed an immediate increase in perceived susceptibility at T1 (p = 0.002). The LCG exhibited no changes in perceived severity (p = 0.24). Conversely, the HCG showed a significant increase from T0 to T1 (p = 0.005), maintaining this increase until T3 (p = 0.98). Further analyses indicated that perceived threat from virtual cancer cells in the game is related to the increase in perceived severity (p = 0.001), and perceived susceptibility is related to changes in ISB at T2 (p = 0.008).	10/13
Anbazhagan¹⁶	India	QEDs (two group pretest and posttest design)	Adolescent male and female N = 120 Kugur School = 96 Lakkur School = 104 Ave age: 14.2 (±0.7–0.8) Range of age: 13–16	General cancer	Intervention style: Lecture-based intervention Kugur School: Outline of health education contained definition of cancer, epidemiology, prevention, and control and some common cancers. Using lecture method, namely, board and chalk with show cards, interactive session was conducted. Lakkur School: 24 students volunteered for the session and divided them into three groups with 8 in each. Group 1 did—general knowledge—skit in Kannada, Group 2 on—warning signs—song and skit, and Group 3—risk factors—skit and show cards. Groups then practiced for 30 minutes. Health education was given for all the students by volunteered students. Outcome measures timeline: Baseline (T0), Immediately after intervention (T1), 2 weeks later intervention (T2)	Cancer Awareness Measurement scale, including general knowledge of cancer, knowledge on warning signs of cancer, and knowledge on risk factors of cancer.	The knowledge of students in both schools increased significantly in all the three domains of general knowledge of cancer (p < 0.001), risk factors (p < 0.001), and warning signs of cancer (p < 0.001) in T1 than in T0. Knowledge scores of Lakkur schools were significantly more persistent than Kugur schools in all the three domains of general knowledge (p < 0.008), risk factors (p < 0.001), and warning signs of cancer (p < 0.001) in T2.	8/9
Adamowicz³⁵	Poland	QEDs (five group pretest and posttest design)	High school students N = 307 The number of people in each group is unknown. Ave age: — Range of age: —	General cancer	Intervention style: Lecture-based intervention Intervention contents: The lecture contents were covered general knowledge about cancer, lifestyle impact on the development of cancer, and knowledge about the possibilities of early detection of cancer. IG1: IG1 was assimilation of knowledge using simple methods and involved conducting two 45-minute lectures within 1 week and ending in a 15-minute discussion. IG2: IG2 was assimilation of knowledge using complex methods and involved conducting two 45-minute lectures within a week, supported by audiovisual means of communication. IG3: IG3 was independent inquiry, learning by discovery, and given a task in which students were asked to write a short note on cancer prevention, which was evaluated by a clinical oncologist and discussed in the entire group. IG4: IG4 was valorization learning by experiencing and students conducted an interview with a patient suffering from a cancer that could have been prevented by lifestyle modification (lung cancer; early breast cancer; 45-minute interview week after week). CG: No intervention Outcome measures timeline: Baseline (T0), 2 months after intervention (T1), 1 year after intervention (T2)	Two questionnaires used the first evaluated knowledge about cancer; the second was a questionnaire, HBI.	Cancer knowledge scores increased significantly for IG1 and IG2 (p < 0.001) and IG3 (p < 0.05) at T1 compared to T0, but not for IG4 and CG. In the T2, the knowledge score was maintained significantly in IG1 and IG2 (p < 0.001). HBI scores increased significantly in IG1, IG2, IG3, and IG4 (p < 0.001) at T1 compared to pre-evaluation, however only CG showed no significant difference. HBI scores were significantly maintained in IG1 and IG2 (p < 0.001) at T2. The group that showed the greatest educational effect was IG2, which used a complex method.	7/9
Stölzel³⁰	Germany	RCT	Seventh-grade students N = 235 IG = 152 CG = 83 Ave age: 13 (±0.7) Range of age: 12–15	General cancer	Intervention style: Lecture-based intervention IG: The BSAC program was taught in 1 week and covers cancer and lifestyle factors associated with cancer risk reduction. The four modules are “What is cancer?” “Nonsmoking,” “Sun protection,” and “Physical activity, healthy nutrition, and limited alcohol consumption.” Each module required one school day. A fifth day was used for recapitulating the project. Handouts were provided, including the most important facts for the students. A variety of didactic methods were used, including information, class discussion, role-play, quiz, pantomime, group work, and video clips. Provider was trained by a teaching-experienced member of the UCC-Cancer Awareness Group. CG: No intervention Outcome measures timeline: Baseline (T0), In the IG the post-test was given at the last day of the project (T1), and in the CG 4 to 5 days after the baseline (T1)	BSAC questionnaire contained risk behavior, knowledge and intention of six areas: engaging in physical activity; applying sun lotion in the summer; smoking cigarettes; eating fruits and vegetables; eating sweets and drinking soft drinks; drinking alcohol.	BSAC program was effective in increasing knowledge about cancer and risk factors for cancer (p < 0.001), as well as in increasing intentions to engage in health-promoting behavior (p < 0.001).	9/13
Lana³²	Spain	RCT	Adolescents N = 737 IG1 = 177 IG2 = 244 CG = 316 Ave age: — Range of age: 12–16	General cancer	Intervention style: IT-based intervention Intervention contents and methods: The website intervention included several sections to learn how to prevent and treat main cancer risk behaviors using the theoretical framework of the A.S.E (acronym of Attitude, Social influence and self-Efficacy) model, that is: (a) emphasizing advantages of following the recommendations and disadvantages of risk behaviors, (b) creating a healthy online social environment, and (c) strengthening the skills to avoid risk behaviors. The section with the highest educational capacity contained problems or challenges that students had to solve. The educational intervention lasted an entire academic year (9 months) IG1: Website intervention only IG2: Website intervention plus text messages. Adolescents received weekly text messages to encourage compliance with healthy behaviors. The text message focused on a healthy diet. CG: No intervention Outcome measures timeline: Baseline (T0), After intervention (9 months from baseline) (T1)	Questionnaire, including about the presence of six cancer risk behaviors: smoking, unhealthy diet, alcohol consumption, obesity, sedentary lifestyle, and sun exposure.	At T1, the prevalence of students who did not eat fruit was reduced significantly in all groups: IG1 (−62.6%), IG2 (−71.5%), and even the CG (−66.8%). Being overweight was only reduced in the IG2 (−19.6%). The total cancer behavioral risk score, which ranged from 0 to 100 points (highest risk), was significantly reduced in the IG1 (−3.5 points) and in the IG2 (−5.3 points). The text-supplemented online intervention (IG2) increased the probability of improving the T1 total cancer behavioral risk (OR = 1.62).	9/13
Kyle³⁶	United Kingdom	QEDs (two group and pre-posttest design)	Adolescents N = 422 IG = 290 CG = 132 Ave age: 13.8 (±1.26) Range of age: 11–17	General cancer	Intervention style: Lecture-based intervention IG: The intervention was an educational program called “Let's talk about it” delivered by Teenage Cancer Trust in ∼10% of U.K. schools each year. “Let's talk about it” was a 1 hour presentation delivered verbally by a single Teenage Cancer Trust educator to groups of adolescents in a classroom or assembly setting. Topics covered in the presentation include an introduction to cancer; identifying the warning signs of cancer; the physical, emotional, and social effects of cancer; cancer diagnosis and treatment; and the importance of taking responsibility for one's own health and well-being. CG: No education Outcome measures timeline: Baseline (T0), 2 weeks after intervention (T1), 6 months after intervention (T2)	Cancer awareness was assessed using the Cancer Awareness Measure.	Recognition of common cancer warning signs significantly increased T1 (p < 0.001) and was maintained at T2 (p < 0.001). However CG significantly increased only three of recognition common cancer warning signs (p < 0.001) at T1. Endorsement of emotional barriers to help-seeking “not confident to talk about symptoms” (p = 0.021) and “worried about what the doctor might find” (p = 0.021) significantly decreased at T1 but changes were not maintained at T2. On the other hand, CG was not significantly improved at all.	8/9
Hwang³⁷	Taiwan	QEDs (two group pretest and posttest design)	Undergraduate students N = 256 IG = 145 CG = 111 Ave age: 20.8 (±1.3) Range of age: 18–26	General cancer	Intervention style: Lecture-based intervention Intervention contents and methods: The four IGs participated in a cancer educational program separately, and the two CGs participated in a stroke educational program. IG: The intervention consisted of a 1-hour lecture and a 30-minute video viewing. The lecture consisted of five sections: Section 1 covered the pathophysiology of cancer, Section 2 covered 11 cancer risk factors, Section 3 listed 10 cancer prevention strategies, and Section 4 listed 10 established on the 10 warning signs of cancer, and Section 5 on the four free cancer screening programs offered by the government (cervical cancer screening, breast cancer screening, oral cancer screening, and bowel cancer screening). After the lecture, participants watched a video describing the causes of cancer and cancer treatment by four patients. CG: Educational program on stroke. Outcome measures timeline: Baseline (T0), 6 weeks after the intervention (T1), 15 weeks after the intervention (T2)	The researchers developed a questionnaire that included items related to awareness of risk factors, prevention strategies, and warning signs of cancer.	The mean scores for awareness of cancer risk factors, preventive measures, and warning signs were significantly higher for the four IGs (all p < 0.001) and two CGs (both p ≤ 0.018) than for T0 for both T1 and T2 as a result of the paired t-test. However, the results of the ANOVA showed that the mean score of T2 for the IG (except for class D) was significantly higher compared with the two CGs (p ≤ 0.001). After the educational intervention, the analysis of variance of changes from T0 for all four IGs were all significantly higher than those of the two CGs (p ≤ 0.001), except for the change of the retention test score from the T0 score for IG.	8/9
Soto-Perez-de-Celis⁴⁴	Mexico	QEDs (single-group and pre-posttest design)	Adolescent females N = 114 Ave age: 13.5 Range of age: 12–16 Female relatives N = 182	Breast cancer	Intervention style: Lecture-based intervention Intervention contents and methods: The educational program consisted of five 40-minute sessions. The sessions were the following: (a) breast cancer information, facts, and misconceptions; (b) a breast cancer survivor's story; (c) BSE; (d) critical thinking collage; and (e) role-playing activity. These programs were tailored by a pedagogue and a psychologist to be culturally sensitive and age appropriate. Students were assigned to four groups of 25–30 students per group. The program provider was a team consisting of students from the school of education, a breast cancer survivor who coauthored a children's book, a medical student, and an oncologist. Outcome measures timeline: Baseline (T0), Immediately after intervention (T1), 4 months after intervention (T2)	Questionnaire included the knowledge of breast cancer, their satisfaction with the program, open-ended questionnaires rating its appropriateness.	The students' T0 mean proportion of correct answers was 63%. At T1, mean proportion of correct answers increased to 89%, showing a relative increase in knowledge of 41% (p < 0.001). At T2, the students' mean proportion of correct answers was 82%, showing a relative increase in knowledge of 30% compared with basal knowledge at T0 (p < 0.001). The relatives' T0 mean proportion of correct answers was 55.5%. At T2, the relatives' mean proportion of correct answers increased to 60.7%, showing a relative increase in knowledge of 9.3% compared with basal knowledge at T0 (p < 0.001). Of note, the proportion of students who reported feeling comfortable talking about breast cancer at home increased from 71% at T0 to 90% at T2 (p < 0.001).	5/9
Akhtari-Zavare²⁹	Malaysia	RCT (a single-blind RCT)	Female undergraduate students N = 370 IG = 186 CG = 184 Ave age: 21.79 (±1.24) Range of age: —	Breast cancer	Intervention style: Lecture-based intervention IG: The educational module on breast health awareness was developed based on the Clinical Guidelines of Malaysia for breast cancer screening and American Cancer Society. The content of the education module includes the normal breast, breast health awareness, breast cancer, and other screening methods. The IG participated in an 1-hour lecture which covered all contents of the “educational module on breast health awareness” in the form of slide presentation. In addition, the IG received another 1-hour training on breast silicon model to learn how to do the BSE practice. After the training, each participant was asked to duplicate the BSE practice on the breast silicon model to ensure that they can do it correctly. The interventions were implemented to make small group of 12–13 students. CG: No intervention Outcome measures timeline: Baseline (T0), 6 months after intervention (T1), 12 months after intervention (T2)	Questionnaire, including the BSE practice and frequency, the knowledge of breast cancer and self-examination and Champion's Health Belief Model Scale.	Mean scores of knowledge on breast cancer (p < 0.003), knowledge on BSE (p < 0.001), benefits of BSE (p < 0.001), barrier of BSE (p < 0.01), and confidence of BSE practice (p < 0.001) in the IG had significant differences in comparison with those of the CG at T1 and T2. In addition, among those who never practiced BSE at T0, frequency of BSE practice increased at T1 and T2 (p < 0.05).	11/13
Masso-Calderón⁴⁵	Colombia	QEDs (single-group and pre-posttest design)	Adolescents female N = 155 Ave age: 13.72 (±1.9) Range of age: 10–20	Breast cancer	Intervention style: Lecture-based intervention Intervention contents and methods: Two 90-minute educational sessions were conducted according to the Colombian guidelines on educational communication within the framework of cancer control. The methods were presentation and open discussion. Intervention topics included the normal breast, BSE, breast cancer risk factors and symptoms, the role of healthy lifestyles on breast cancer prevention, and methods for screening and early detection. Education providers were researchers and school teachers. Outcome measures timeline: Baseline (T0), Immediately after intervention (T1), 1 month after intervention (T2), 3 months after intervention (T3), 6 months after intervention (T4)	Cancer Awareness Measure of breast section included awareness of cancer risk factors, prevention strategies, and warning signs.	T0 scores showed poor levels for these outcomes. Knowledge of the BSE technique showed a significant exponential increase across all measurements (p < 0.0001) after the intervention. Eighty percent of the participants scholars had never examined their breasts, and this rate showed a significant decrease of 67.8% (from 12.9% to 80.7%) at T4 (p < 0.0001). Similar increases were also found for the frequency of BSE in all the categories evaluated.	5/9
Schwartz³¹	Canada	RCT (a cluster RCT)	Adolescent girls N = 618 IG = 242 CG = 376 Ave age: 14 Range of age: 13–15	Breast cancer	Intervention style: IT-based intervention IG: A tailored intervention message was designed to be sensitive to gender and Aboriginal status. The resulting message included images of four different girls playfully holding bras, with the statement “Smoking affects more than your lungs” followed by “Cigarette smoke, even secondhand smoke, puts girls at risk for breast cancer at an early age.” The message also included the following suggestions for action: “Avoid places where you and your friends are exposed to secondhand smoke. If you smoke, think about quitting. Do it for yourself and all the girls you know.” CG: CG was presented with a standard message that cigarette smoke contains carcinogenic agents. The message was sourced from Health Canada's online library of health labels and warnings for cigarette tobacco. Outcome measures timeline: Baseline (T0), Approximately 6 months after the baseline (T1)	Questionnaire, including knowledge and risk perceptions regarding cigarette, smoking behavior and intention, and stage of change related to avoidance of smoking and SHS.	Compared with the CG, girls in the IG were significantly more likely to report that breast cancer is an illness caused by cigarette smoke (ARR 1.33, 95% CI 1.05–1.68) and to agree that exposure to SHS increases their risk of breast cancer (ARR 1.10, 95% CI 1.02–1.20). No significant effects were observed for a change in smoking status, intention to try smoking, or stage of change related to avoidance of SHS.	9/13
Brinker²³	Brazil	RCT (a cluster RCT)	Adolescents N = 1573 IG = 734 CG = 839 Ave age: 15.9 (±1.3) Range of age: —	Skin cancer	Intervention style: IT-based intervention IG: This intervention consisted of a 45-minute educational module in the classroom setting using the free face aging mobile app Sun face and the mirroring approach. In the mirroring approach students' altered three-dimensional selfies using the app were projected in front of their entire class. The intervention classes received the app-based intervention by centrally trained, local volunteer medical students. CG: No Intervention Outcome measurement timeline: Baseline (T0), 3 months after baseline (T1), Follow-up survey at 6 months after baseline (T2)	Sun Exposure and Protection Index questionnaire, including Fitzpatrick skin type, ancestry of the students, and frequency of sunscreen use in the past 30 days, and other skin protection behaviors, and SSE.	Daily sunscreen use increased from 15.0% to 22.9% (p < 0.001) at T2 in the IG. The proportion of pupils performing at least 1 SSE in the IG rose from 25.1% to 49.4% (p < 0.001). Use of tanning decreased from 18.8% to 15.2% (p = 0.04). No significant changes were observed in the CG. The intervention was more effective for female students than male students.	9/13
Erkin³⁹	Turkey	QEDs (single-group and pre-posttest design)	Nursing students of a university N = 136 Ave age: — Range of age: 18–23	Skin cancer	Intervention style: Lecture-based intervention Intervention contents and methods: 6-week intervention, aimed to raise awareness about skin cancer risks and SSE. 1 Week: Posters/pictures were hung in the restroom, the cafeteria, and the classrooms and remained in place for 6 weeks. 2 Week: PowerPoint presentation (30-minute) containing information about the effect of the sun on health, the skin problems related to sun exposure, and how to practice SSE. 3 Week: PowerPoint presentation (30-minute) containing information about how to practice SSE. 4 Week: The handouts/brochures were given to students which explained how SSE should be performed, at what frequency and by whom, and provided information about the ABCDE rule. 5–6 Week: 5-minute David Cornfield Melanoma Fund video entitled “Dear 16-Year-Old Me” was sent as a short message by mobile phone to the students. Outcome measures timeline: Baseline (T0), 6 weeks after intervention (T1) Educational materials were removed before administering the T1 assessment.	Questionnaire included knowledge of skin cancer risk and knowledge and practice of SSE.	The mean score of knowledge of skin cancer risks among the participants with complete program participation was 5.75 ± 1.20 in the T0 and 6.84 ± 1.17 in the T1. In the covariance analysis, T1 scores increased significantly compared with T0 with complete program participation (p = 0.011). Significant difference was found between the mean T0 and T1 score for knowledge of the ABCDE rule (p < 0.05).	5/9
Heckman²⁸	United States	RCT	Young adults N = 963 IG = 287 CWG = 338 AG = 340 Ave age: 21.8 (±2.2) Range of age: 18–25	Skin cancer	Intervention style: IT-based intervention IG: IG (UV4.me) was targeted to young adults, personally tailored, and included interactive, multimedia, and goal-setting components. Major topics include skin cancer information, prevention, true stories, healthy lifestyle, news, and getting involved, among others. The intervention was based on the Integrative Model of Behavioral Prediction and intended to be interactive, tailored, utilize multiple media formats, and maximize participant engagement. Twelve modules were created, with topics determined to be important in terms of risk or protective behaviors. CWG: The control website was the SCF website (www.skincancer.org). According to the SCF website, the SCF “is the only international organization devoted solely to education, prevention, early detection, and prompt treatment of” skin cancer. AG: No intervention Outcome measures timeline: Baseline (T0), 3 weeks after baseline (T1), 12 weeks after baseline (T2)	Primary outcome was overall UV exposure and skin protection and secondary outcomes were intentional and incidental UV exposure, sunburns, sunscreen use, and skin cancer screening.	For the IG, there were significant decreases in UV exposure and increases in skin protection at both follow-up time points compared with the AG (p < 0.001). The effect sizes (Cohen's d) comparing the IG and AG for exposure behaviors were 0.41 at 3-week follow-up and 0.43 at 12-week follow-up. The effect sizes for protection behaviors were 0.41 at 3-week follow-up and 0.53 at 12-week follow-up. The CWG was not significantly different from the AG. All three groups exhibited decreased exposure and increased protection at both follow-ups (p < 0.01), but the effect was much stronger in the IG.	9/13
Nayak²⁵	India	RCT (a cluster RCT)	Students of the first and second year Bachelor of commerce N = 150 IG = 72 CG = 78 Ave age: IG = 20.2 (±1.3) CG = 20.7 (±1.5) Range of age: 17–22	Oral cancer	Intervention style: IT-based intervention Intervention contents and methods: The IG received health education through WhatsApp messages, a smartphone application. Messages were sent everyday along with pictures and videos. Participants were asked to meet once a week in a WhatsApp chat room for a group discussion. Participants shared information, photos, and videos about the effects of tobacco and oral cancer in the chat room. The health education topics included (a) tobacco types and effects, (b) risk factors for oral cancers, (c) epidemiology of oral cancer, (d) clinical signs of oral cancers and precancerous conditions, and (e) primary prevention procedures, including screening. CG: The CG received health education about oral cancer using the PowerPoint presentation in a university classroom twice a week for 4 weeks. The topics of the health education were the same as in the IG. The providers of health education were dental experts in both groups. Outcome measures timeline: Baseline (T0), 4 weeks after intervention (T1)	The questionnaire consisted of pertaining to knowledge on tobacco use and oral cancer and smoking history of participants and the their willingness to quit et al.	In both groups, knowledge scores on the effects of tobacco and the etiology, signs, epidemiology, and treatment of oral cancer increased significantly after the intervention compared to T0. In between-group comparisons, there was no significant difference in T0 knowledge scores for both groups, however IG had significantly higher T1 knowledge scores than CG (p < 0.001). When asked on their willingness to quit before the start of study, three males among IG and six males among CG said that they are willing to quit. T1 results showed statistically significant increase in the number of subjects willing to quit in both IG (six men) (p = 0.008) and CG (eight males) (p = 0.037).	9/13
Quadri⁴⁶	Saudi Arabia	QEDs (single-group and pre-posttest design)	Students of higher secondary schools and the universities N = 1051 Ave age: 20.3 (±1.98) Range of age: 15–25	Oral cancer	Intervention style: Lecture-based intervention Intervention contents and methods: This intervention comprised distribution of brochures, educational session, and finally a question-answer period. To avoid the dropping-out of the participants and to minimize any extraneous interfering event to happen, the second set of similar questions was distributed to the exact same respondents immediately after the intervention program. Providers of program were dental graduates from the College of Dentistry trained as field staff. Outcome measures timeline: Baseline (T0), Immediately after the intervention (T1)	Questionnaire included the knowledge of oral cancer, involvement of various risk factors, early appearance of the lesions, self-examination and the role of health care provider.	At T0 participants showed a lack of knowledge with regards to the signs, symptoms, risk factors, and prevention of oral cancer among the participants. A significant change with more number of correct answers was observed in T1. The questions pertaining to the causal habits such as the use of smoking, sheesha and shamma had an increase in their mean values. A drastic change in the value was observed in the questions pertaining to the use of ill-fitting dentures, self-examination of lesions, and metastases. By comparing the means of both “before and after values” using a two-tailed t-test, a p-value of 0.001 was obtained.	5/9
Meneses-Echávez⁴³	Colombia	QEDs (single-group and pre-posttest design)	Adolescents female N = 243 Ave age: 14 (±1.5) Range of age: 10–17	Lung cancer	Intervention style: Lecture-based intervention Intervention contents and methods: Two 90-minute educational sessions were conducted according to the Colombian guidelines on educational communication within the framework of cancer control. The methods were presentation and open discussion. Intervention topics included the normal lungs, warning signs and risk factors for lung cancer, smoking, and the role of healthy lifestyle habits in lung cancer prevention. Education providers were researchers and school teachers. Outcome measures timeline: Baseline (T0), Immediately after intervention (T1), 1 month after intervention (T2), 3 months after intervention (T3), 6 months after intervention (T4)	Cancer Awareness Measure included awareness of cancer risk factors, prevention strategies, and warning signs.	T0 measurements revealed low awareness of the warning signs for lung cancer. Awareness of all warning signs for lung cancer showed exponential increases across all measurements (p < 0.0001). More than half of the students identified smoking as the main risk factor for lung cancer, and this outcome increased by 12.3% at T4 (p < 0.0001). The educational intervention increased the recommendation by students of physical exercise for both prevention and treatment of lung cancers up to T4. The educational intervention decreased weekly self-report of smoking at T4 (p < 0.05). Improvements were also observed on the practice of physical activity and the intake of high-fat food, vegetables, and fruits.	5/9

AG, Assessment only group; ARR, adjusted relative risk; BSAC, Be smart against cancer; BSE, breast self-examination; CCPE, cervical cancer prevention education; CG, control group; CI, confidence interval; CWG, control website group; HBI, Health Behavior Inventory; HC, high challenge; HCG, high challenge group; HPV, human papillomavirus; IG, intervention group; ISB, information seeking behavior; IT, information technology; LBLG, lecture based learning group; LC, low challenge; LCG, low challenge group; OR, odds ratio; PBL, problem-based learning; PBLG, problem based learning group; QEDs, quasi-experimental designs; RCTs, randomized controlled trials; SCF, Skin Cancer Foundation; SHS, secondhand smoke; SSE, self-skin examination.

Regarding the target country, six studies were from the United States (the largest group),^{27,28,40,41,42,47} followed by the Taiwan, which had three studies,^33,34,37 United Kingdom,^26,36 Colombia,^43,45 India,^16,25 and Saudi Arabia^18,46 with two studies each, and other countries with one study each.

Looking at the cancer types examined in this study 10 pieces of literature looked at cervical cancer, the largest single grouping,^{17,18,24,34,38,40,41,42,47,48} followed by 9 which looked at cancer generally,^{16,26,27,30,32,33,35,36,37} and 4 looking at breast cancer,^29,31,44,45 3 looking at skin cancer,^23,28,39 et al.

Structure and outcomes of cancer education programs

Cervical cancer

One study design involved RCTs,²⁴ two that leveraged two groups of before-and-after comparison experiments,^34,38 and seven designs with a single-group before-after comparative experiment.^{17,18,40–42,47,48} Five studies looked at adolescents,^{17,34,38,40,48} five looked at young adults,^{18,24,41,42,47} with two of these studies also involving guardians.^24,40

There were six pieces of literature that used lecture based interventions,^{17,18,34,38,42,48} with two using leaflet based interventions^24,40 and two using IT based interventions.^41,47 The content of the lecture based intervention consisted of a combination of (1) presentations on uterine cancer and HPV,^{18,34,38,42,48} (2) interactive question-and-answer sessions,^18,38,42,48 and (3) group discussions.³⁴

Common topics in the presentations included: (a) the normal female body and the reproductive system, (b) cervical cancer (including epidemiology, risk factors, pathology, including signs, and symptoms and preventative measures involving sexual behavior and refraining from smoking), (c) methods of carrying out pap smears, and (d) information on HPV (risks of HPV infection, symptoms, and HPV vaccination). Many presentations were given only once, with the time of each between 45 and 60 minutes.

As an outcome of the intervention, knowledge of cervical cancer (p < 0.001),^17,48 (p = 0.005),⁴² (p < 0.01),¹⁸ knowledge of cervical cancer prevention (p = 0.02),¹⁸ and attitudes toward vaccination (p < 0.001)⁴⁸ were statistically significantly improved before and after the intervention (in pre/post-tests). In QEDs, the intervention group also showed statistically significant improvements in knowledge of cervical cancer (p < 0.001),³⁴ (p < 0.001),³⁸ attitudes toward cervical cancer (p < 0.001),³⁴ belief in vaccination (p < 0.001),³⁸ and intention to vaccinate against HPV (p < 0.001)³⁴ compared with the control group, demonstrating the effectiveness of the educational program.

As an example of a leaflet-based intervention, Suryadevara et al. intervened and distributed leaflets about cancer prevention, including HPV-vaccine information to adolescents and their parents when attending pediatric practices.⁴⁰ After the intervention, the commencement rate for the HPV vaccine series increased by 10% at 3 facilities and 5% at 5 facilities, with the completion rate increasing by >10% at 3 facilities.

Egawa et al. also used an RCT design to distribute leaflets containing cervical cancer information and the importance of receiving screening to a group of women aged 20 years and a separate intervention to distribute leaflets to women aged 20, as well as their mothers.²⁴ As a result, the rate of screening for cervical cancer (p = 0.0049) increased by a statistically significant amount and the effect of the intervention was demonstrated when the mothers were included in the intervention compared to when it was targeted at 20-year-old women alone.²⁴

Turning to IT-based interventions, Lyson et al. made use of an online social media platform.⁴¹ The intervention was involved creating online groups of nine people with information regarding HPV and cervical cancer, as well as how to prevent it distributed using personal messages to participants over 5 days.⁴¹ When comparing the period before and after the intervention, a significant improvement was only found in awareness of HPV (p = 0.003).⁴¹ In addition, Lee et al. conducted an intervention to deliver text messages for 7 days at the desired time of participants that included information about cervical cancer, pap smear referrals, health-care access information, and cancer survivor stories.⁴⁷ Before and after the intervention, a statistically significant improvement was shown in knowledge of cervical cancer, risk factors, and pap testing (p < 0.001) and belief in pap testing (p = 0.006).⁴⁷

General cancer

Study designs in this group included four RCT studies^26,27,30,32 and five two-group before and after comparative experiments.^{16,33,35–37} Six studies targeted adolescents^{16,26,30,32,35,36} with three targeting young adults.^27,33,37

There were seven^{16,26,30,33,35–37} lecture-based interventions and two^27,32 IT-based interventions. Lecture-based interventions were composed of a combination of the following: (1) presentations about cancer,^{16,26,30,33,35–37} (2) group discussions,^30,35 (3) role-playing to enhance self-efficacy in communicating about cancer,^26,30 (4) homework involving communicating with families about cancer,²⁶ (5) tasks involving independent exploratory learning,³⁵ (6) quizzes,³⁰ (7) skits made by students,¹⁶ (8) interviews with cancer survivors to learn values through experience,³⁵ and (9) listening to the experience of cancer survivors.^26,37 A wide variety of methods were used in these studies.

The topics common to the presentation on cancer included (a) cancers that affect AYAs and the number of people affected; (b) cancer risk factors (tobacco, alcohol, and ultraviolet rays); (c) pathophysiology (warning signs and symptoms); (d) prevention measures (physical activity, diet); (e) cancer screening program; (f) cancer treatments; (g) physical, psychological, and social effects of cancer; and (h) the importance of taking responsibility for one's health. Lectures were often given once or twice that lasted between 45 and 60 minutes. Furthermore, problem-based learning (PBL) was used in cancer education for university students.³³ The results of the intervention showed that when comparing the control and intervention groups before and after the intervention, the effectiveness of the intervention was shown through statistically significant increases in knowledge of general cancer (p < 0.001),^16,30,35 the warning signs of cancer (p < 0.001),^16,26,36,37 the risk factors for cancer (p < 0.001),^16,26,30,37 awareness of cancer prevention strategies (p < 0.001),³⁷ intent to engage in healthy behaviors (p < 0.001),³⁰ and healthy behaviors (p < 0.001)³⁵ compared to the control group, as well as significantly lower emotional barriers to help seeking (p = 0.021).³⁶

In addition, when comparing the awareness of cancer risk factors, warning signs, and prevention strategies between PBL group 1, which included topics concerning cancer, PBL group 2, which did not include topics concerning cancer, and a group that received lectures about cancer as part of lecture based learning (LBL), it was shown that cancer awareness (p = 0.010) was higher to a statistically significant extent in the PBL1 and LBL groups before and after the intervention, with no significant differences between the two groups.³³ This indicates that both the PBL methods and lectures were effective.

Turning to IT-based interventions, Khalil et al. used gaming-based interventions to increase cancer awareness among young adults.²⁷ It was shown that the intervention group had statistically significantly higher sensitivity toward cancer (p = 0.03), awareness of its severity (p = 0.02), and cancer-related information seeking behavior (p = 0.01) after the intervention compared with the control group.²⁷ Moreover, Lana et al. conducted a website based intervention, including sections for visitors to learn about risky behavior related to cancer, as well as treatment in adolescents.³² The intervention group had a statistically significant reduction in cancer risk behavior compared with the control group, and in addition, an increased probability of improving risk behaviors surrounding cancer was reported in an intervention group in which text messages were used to supplement the website (OR = 1.62).³²

Breast cancer

Regarding research designs, two studies^29,31 featured RCTs, with two studies^44,45 featuring one group of before and after comparative experiments. Three studies^31,44,45 targeted adolescents, with one²⁹ featuring young adults. Among all of these studies one included relatives at the same time.⁴⁴

Regarding intervention methods, three studies featured lecture-based intervention^29,44,45 and one featured IT-based intervention.³¹

The contents of the lecture-based intervention comprised (1) presentation on breast cancer, breast self-examination (BSE), and screening^29,44,45; (2) stories from cancer survivors⁴⁴; (3) group discussion⁴⁵; (4) role-playing with scenarios⁴⁴; and (5) BSE training with breast silicone model.²⁹

The topics common to the presentation on breast cancer, BSE, and screening included (a) the normal breasts, (b) breast cancer (epidemiology, risks, pathophysiology, including symptoms and warning signs, prevention methods, including diet and exercise), (c) BSE methods, and (d) types of breast cancer screening. The number of sessions in the program varied from 1 to 4. A single session lasted between 45 and 60 minutes. The group discussion included open conversations⁴⁴ with friends and relatives about breast health.

As an outcome of the intervention, there was a statistically significant improvement in breast cancer knowledge (p < 0.001),^44,45 knowledge of BSE (p < 0.001),⁴⁵ and BSE implementation rate (p < 0.001)⁴⁵ before and after the intervention. In addition, Soto-Perez-de-Celis et al. also performed the same educational intervention on the relatives of the participants.⁴⁴ In a 4-month follow-up investigation, a statistically significant increase was reported in relative's knowledge of breast cancer, (p < 0.001) as well as a significant increase in the number of students who did not feel reluctant to talk about breast cancer at home (p < 0.001).⁴⁴

Regarding RCT studies, comparing intervention and control groups, those in the intervention group were statistically significantly more likely than those in the control group to have knowledge of breast cancer (p = 0.003), knowledge of BSE (p < 0.001), benefits from BSE (p < 0.001), barriers to BSE (p < 0.01), and confidence in BSE implementation (p < 0.001),²⁹ demonstrating the effectiveness of the educational program.

Regarding IT based interventions, Schwartz et al. took cigarettes as a risk factor for breast cancer, conducting an intervention using a website which included messages that stressed the importance of behaviors to avoid damage from tobacco.³¹ Results showed that the intervention group showed a statistically significant higher perception after the intervention that smoking and secondhand smoke were associated with a higher risk of breast cancer compared to the control group.³¹

Skin cancer

Looking at research design, two studies involved RCTs^23,28; one study involved a one-group before and after comparative examination.³⁹ One study targeted adolescents²³ and two targeted young adults.^28,39

Regarding intervention method, there was one study combining a lecture-based intervention and IT-based intervention³⁹; two used IT-based interventions.^23,28 In the study that combined lecture-based intervention and IT-based intervention, there was an educational intervention aimed at nursing students that focused on skin cancer and self-examination, with presentations, including six topics, related to risk factors for skin cancer and methods of self-skin examination (SSE) combined with the sending of a cell phone message titled “Dear 16-Year-Old Me.”³⁹ Regarding outcome, the participants' knowledge of skin cancer risk (p = 0.011) and SSE (p < 0.05) significantly improved after the intervention.³⁹

Turning to IT-based interventions, Brinker et al. conducted a 45-minute educational intervention for adolescents using a face-aging mobile app and a mirroring approach, led by trained medical students.²³ The intervention group showed a significant increase in the proportion of students who underwent SSE (p < 0.001) and a significant decrease in tanning (p = 0.04), however no significant change was reported in the control group.²³ See Table 1 for details of Heckman et al.'s study.²⁸

See Table 1 for details of oral^25,46 and lung cancers.⁴³

Discussion

This review highlights 29 pieces of literature to identify evidence of the content, methods, and outcomes of AYA cancer education programs worldwide and presents the effects of cancer education on AYAs, as well as new directions for future research.

The most common type of cancer looked at was cervical cancer,^{17,18,24,34,38,40–42,47,48} with breast cancer^29,31,44,45 being the third most common, both cancers often found in women. Males and females in their teens have similar cancer rates, however cancer rates for women in their 20s and 30s are about twice as high as men, with breast cancer being the most common. Although cervical cancer is highly preventable, it is the second leading cause of cancer death among women ages 20–39 years.⁴⁹ Consequently, it may be considered that there were many educational interventions for cervical and breast cancers targeted at women expecting to prevent them.

Programs targeting general cancer were the second most common and consisted of content related to cancer risk factors such as smoking, alcohol, specific viruses and bacteria, tanning, and obesity.^{16,26,27,30,32,33,35–37} Given that cancer is correlated with exposure to lifestyle risk factors and impacts the risk of cancer in a number of different areas,⁵⁰ it may be desirable for education targeting AYAs to focus more on common cancers than on a single cancer. In addition, smoking^51,52 is a risk factor for oral and lung cancers with exposure to ultraviolet light⁵³ being a risk factor for skin cancer, and these factors can also be prevented, which may have made these cancers a target for cancer education.

Educating youth can be used to improve the awareness and behaviors of family members, including parents.⁵⁴ Therefore, most of the studies targeted exclusively AYAs themselves.

However, there were three interventional studies involving AYAs and their parents, including those looking at cervical cancer and breast cancer.^24,40,44 In Kim et al.'s study,⁵⁵ most South Korean adolescent girls indicated that cervical cancer prevention education should be provided in the household; about half of them consulted their mothers about cervical cancer. Researchers should motivate mothers to provide cervical cancer prevention education for their daughters.⁵⁵ In addition, Abraham et al.⁵⁶ reported that 93% of 233 adolescents are likely to share knowledge about cancer prevention with their parents.

Therefore, a family-based approach⁵⁷ that targets both parents and children, as well as encourages communication between family members, may be effective in cancer education. In fact, research has shown that a family-based approach to health promotion can have beneficial effects on both children and parents.^58,59 Therefore, using a family-based approach as a method of intervention for AYAs and their parents together will promote communication about cancer between parents and children and raise awareness of cancer more easily than individual education.

In addition to the traditional lecture-based intervention, the use of active learning methods such as group discussions to create opportunities for parents and children to discuss cancer together will help them to share a common understanding of cancer; this will have a synergistic effect on cancer prevention behavior and cancer screening behavior and contribute to improving the cancer screening uptake rate. Therefore, it is necessary to develop not only school-based but also family-based cancer education programs that offer interventions for both parents and children in the future. It is believed that widespread cancer education, both in accessible schools and communities, will make it easier for adolescents to participate repeatedly and maintain cancer prevention behaviors.

Many studies contained lecture-based interventions, however IT-based intervention^{23,25,27,28,31,32,41,47} was also uncovered. Zeinomar et al. cite interactive and dynamic methods such as social media (Snapchat, Instagram) and videos (YouTube) as effective ways to communicate cancer health-related information to AYAs.⁵⁰ Abraham et al.⁵⁶ also emphasized the need for the development of technology-based cancer prevention education programs, considering that adolescents cited websites like Google as the most common source of information about cancer, and online videos and educational video games as the most useful sources of information for learning about cancer and cancer prevention. This emphasizes the need for the development of technology-based cancer prevention education programs.⁵⁶

In addition, they stated that the repetitive nature of online videos and video games makes them ideal educational tools for positive health impacts.⁵⁶ Therefore, future cancer education will be more effective if interventions are based on AYA preferences and make good use of IT. IT-based interventions will be beneficial in establishing knowledge of cancer and maintaining preventive behaviors among AYAs. Furthermore, if an IT-based cancer prevention education tool that is not limited by time or place can be developed, and its effectiveness verified, then it can be used to educate young people in various countries about cancer awareness and contribute to improving the knowledge and awareness of cancer among many young people.

Topics in educational interventions for cancer commonly included “cancer epidemiology,” “cancer risk factors,” “cancer warning signs,” “cancer prevention methods,” and “screening methods.” The U.S. Department of Health emphasizes the importance of raising public awareness of cancer alert signs and risk factors,⁶⁰ and in collaboration with the United Kingdom Institute of Cancer Research, it conducted public awareness surveys of 3700 people in two countries in 2008. They found that smoking was the most recognized risk factor for cancer, while recognition of alcohol, dietary factors, cervical infection, and lack of exercise was poor. Unprompted recollection of cancer symptoms was poor, and awareness of cancer warning signs was lower in men, younger people, ethnic minorities, and those from lower socioeconomic groups.⁶¹

Therefore, it will be possible to enhance AYA awareness of cancer and cancer prevention by covering topics commonly addressed in this review and arranging the content of the intervention.

All educational interventions provided evidence of statistically significant gains in one or more of the outcome measures of cancer and risk factors, cancer warning signs and symptoms, preventive behaviors, knowledge and awareness of screening, awareness of barriers to seeking help, the health beliefs of vaccination and preventive behaviors, intention to engage in preventative behaviors, and rates of self-examination.

However, it is said that healthy behaviors do not become embedded unless they persist for >6 months,⁶² and there were nine studies that included long-term follow-up of 6 months or longer.^{18,23,26,29,31,36,40,43,45} Six months later, there was a significant increase in awareness of cancer risk factors,^26,43 the health beliefs of breast cancer self-examination,²⁹ and in the rate of preventative behaviors.^23,43 Few studies have examined the extent to which this knowledge and awareness has influenced preventative behaviors, and this finding was consistent with the results of other reviews.¹⁹ Moving forward, it is necessary to test how well awareness of cancer warning signs, risk factors, and other factors will help maintain preventative behaviors in the future.

Limitations

This review included cancer awareness programs geared toward not only adolescents but also young adults and, therefore, covered a wide range of literature. However, because it has been limited to the last decade and the databases were limited, relevant articles published in other time periods and databases may be excluded. The inclusion of one group of front and back comparative experiments may have had some impact on the methodological quality assessment, but the outcomes of the intervention were objectively assessed.

Conclusions

In this review, 29 studies featuring analyses of AYA cancer awareness education were examined, with different target cancer types, program composition, intervention methods, outcomes, and program rationales. Although many educational interventions targeted specific single cancers, AYAs is an important time to initiate or modify lifestyle habits that are cancer risk factors, with wide ranging program of education being implemented that include common cancer risk factors, cancer warning signs, and symptoms.

In addition, there was little cancer education for parents and children, however it is effective to include parents of AYAs, the age group often affected by cancer. Particularly, interventions using the family-based approach may facilitate communication between parents and children regarding cancer, which may increase cancer awareness and improve and promote behaviors that prevent cancer, with synergistic effects between the two. It is also crucial to consider effective cancer education while actively incorporating the preferred methods of AYAs, such as IT intervention.

Footnotes

Authors' Contributions

K.S. contributed to the entire research process, including preparation of the research protocol, data collection, data analysis, and preparation of the article. M.Y., Y.M., N.H., E.Y., A.F., Y.T., Y.F., T.D., I.S., and Y.T. contributed to the preparation of the research protocol, data collection, and data analysis. All authors read and approved the final article.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was supported by JSPS KAKENHI Grant No.JP20H03989.

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