Sun Protection for Early Childhood

In the United States, the most common type of cancer is skin cancer, causing more than 9,000 deaths each year. More than five million people are treated for skin cancer annually, with a treatment cost of $8.1 billion, and rates of skin cancer incidence are increasing. People of all skin tones are at risk for skin cancer; although skin cancer is more common among people with a light complexion, people with darker skin are still at risk, even if their skin does not tend to get sunburned. Most cases of skin cancer are preventable by practicing sun protective behaviors that minimize the skin's UV exposure (e.g., avoiding the sun during peak sunlight; seeking shade; using sunscreen; and wearing protective clothing, including a hat and sunglasses) and by avoiding intentional tanning. Protecting children from the sun is important, because a few serious sunburns can increase a child's risk of developing skin cancer later in life. Interventions are needed to educate parents on how to protect their children from the sun.

Sun Protection for Early Childhood is a multi-component educational intervention that aims to increase sun protection behaviors among children aged 2-6 years. Based on past research and recommendations from the American Academy of Pediatrics, the intervention comprises three components- a read-along book, a sun-protective swim shirt, and four weekly reminders sent electronically to encourage sun protection behaviors and ultimately reduce the risk of developing skin cancer.

Parents and other relatives (hereafter called caregivers) receive the swim shirt and 13-page read-along book during an appointment with a pediatric provider. Caregivers read the book at home with their children. The read-along book teaches children and caregivers about the sun and the importance of protecting skin from harmful UV rays through the adoption of various sun protection behaviors on sunny and cloudy days, such as wearing protective clothing, applying sunscreen, and staying in the shade. The book is culturally appropriate for all ethnic/racial groups to reinforce the notion that all children need to adopt sun safety behaviors, regardless of their ethnicity or skin tone. It also contains activities for children to complete to demonstrate their understanding of the material (e.g., labeling the areas of the body that need sunscreen). A shopping list is included to remind caregivers to purchase sunglasses, a hat with a brim, a shirt, and sunscreen (with an SPF of 30 or more). Providers can also give caregivers optional age-specific handouts that convey information on caring for a young child and cover topics such as safety, communication, and family routines.

Following the pediatric appointment, caregivers receive four messages by telephone text over a 4-week period. The texts ask four questions (i.e., whether caregivers read the book with their child and whether the child wore sun protection clothing, a hat, and sunscreen) that caregivers answer with a 'yes' or 'no'. Messages are sent the first workday after a weekend or holiday and are re-sent the next day if the caregiver does not respond.

The intervention is typically implemented at the beginning of the summer. However, the time of year will vary, depending on the climate where implementation takes place. Implementation can occur any time of year when the conditions present potentially harsh sun exposure.
 

-- Approximately 2 minutes for staff to distribute the handout and read-along book to each caregiver
-- 15 minutes to 1-2 hours to set up the automatic text messages, depending on whether the clinic already uses a text messaging service
 

The intervention is intended for caregivers of children aged 2-6 years.

The intervention is suitable for implementation in urban clinical, preschool, and home settings.

Required resources to implement the program include the following:
-- Protocol for Sun Protection
-- Read-Along Book (English version)
-- Read-Along Book (Spanish version)
-- Bright Futures 2.5 Year Handout (optional)
-- Bright Futures 5-6 Year Handout (optional)

For costs associated with this program, please contact the developer, June Robinson. (See products page on the EBCCP website for developer contact information.)

A randomized controlled trial was conducted to compare sun protection behaviors and sun exposure among intervention and wait-list control participants. The study included caregivers and their children who received care at two urban pediatric clinics and saw one of the 15 participating pediatricians. Caregivers were included in the study if they were at least 18 years old, could read English or Spanish, brought a child 2- to 6-years old to the pediatric appointment, were able to receive text messages, and were able to return for a follow-up visit between 4 and 6 weeks after the appointment.

Of the 347 eligible caregivers-child pairs, 300 were enrolled. Caregivers were randomized to the intervention group (n=153) or wait-list control group (n=147) through block randomization by day. The average age of caregivers was 36.0 years; caregivers were mothers (90.7%), fathers (7.0%), and other relatives (2.3%). College graduates constituted 63.0% of the mothers and 48.0% of the fathers. The ethnicities of the caregivers were as follows: 70.7% were White, 12.7% were Black, 9.7% were Asian or Pacific Islander, 2.3% were of mixed race, less than 1% were 'other', and 4.3% did not respond. Further, 27.0% were Hispanic. The children's ages ranged from 2 to 6 years; 34.7% were 2 and up to 3 years old, 16.3% were greater than 3 and up to 4 years old, 18.3% were older than 4 and up to 5 years old, and 30.7% were older than 5 and up to 6 years old. The groups differed significantly in the caregiver relationship to the child (i.e., mother, father, other relative) and in the level of education of the mothers and fathers.

The study's primary outcomes were sunny day sun protection behaviors, cloudy day sun protection behaviors, sunscreen use, and biologic measures of skin pigmentation (melanin index), which were assessed during the summer months at baseline and 4- to 6-week follow-up. A self-administered caregiver survey with 10 items was used to measure sunny and cloudy day sun protection behaviors. Each of the five items asked about the frequency of a behavior (using sunscreen, wearing a shirt with sleeves, wearing a hat with a brim, wearing sunglasses, and staying in the shade), with response options on a 5-point Likert scale ranging from 1 (never) to 5 (always). These five behaviors were assessed separately for sunny days and cloudy days, so that a sunny day composite score and a cloudy day composite score, each ranging from 5 to 25, could be calculated. Sunscreen use was measured by combining the responses about sunscreen use from the sunny day and cloudy day questions, for a total ranging from 5 to 10. Biologic measures were assessed by trained research coordinators; at baseline and follow-up they measured the sun-exposed right dorsal forearm and the sun-protected (wearing a short-sleeved shirt) right upper outer arm near the shoulder. A spectrophotometer was used to take the measurements of the melanin indices.

At baseline, caregivers categorized their children's skin type as type 1, type 2, type 3, type 4, type 5, or type 6 by comparing their child's skin tone with color bars that depicted skin tones from lighter (1) to darker (6) and selecting the type that matched their child's skin the best. Skin types 4-6 were grouped together, since darker skin tones (higher melanin) are less likely than lighter ones to develop sunburn or skin irritation due to the sun.
 

• From baseline to follow-up, the intervention group had improvement in composite scores of sunny day sun protection behavior compared with the control group (p=.002).

• From baseline to follow-up, the intervention group had improvement in composite scores of cloudy day sun protection behavior compared with the control group (p=.01).

• From baseline to follow-up, the intervention group had improvement in sunscreen use scores compared with the control group (p<.01).

• From baseline to follow-up, intervention group children with skin type 1 (p=.001), skin type 2 (p=.01), and skin types 4-6 (p=.001) had a smaller increase in skin pigmentation compared with their counterparts in the control group.