Kaiser Kids Sun Care Program

Skin cancer incidence is rising more rapidly than the incidence of any other cancer. The cumulative lifetime risk of melanoma is estimated to have risen to at least 1 in 87 individuals, an increase of more than 1800% since the 1930s. The increased incidence of skin cancer has been attributed largely to changes in lifestyle and clothing habits, resulting in greater sun exposure. It is estimated that 65-90% of melanomas are caused by sun exposure. Furthermore, few programs have focused specifically on very young children. Pediatric care during early childhood well-child visits tends to be oriented towards education of parents for optimum child development and health ("anticipatory guidance") rather than towards treatment of illnesses. This environment provides a unique opportunity to integrate cancer prevention into pediatric care. It is particularly important to focus skin cancer prevention efforts on children because a single severe sunburn in childhood may increase the risk of malignant melanoma two-fold. Furthermore, establishing childhood routines of sun protection is likely to promote lifelong sun protection habits.

Kaiser Kids Sun Care Program was designed to be delivered over a 3-year period at all well-child visits between 2 and 36 months. Pediatricians are trained to give recommended anticipatory guidance messages to parents. These messages are linked to "Sun Protection Tips" provided in parent packets and designed for each well-child visit. Anticipatory guidance alerts are placed in medical records, and lists of recommended messages are placed in medical records and examination rooms. Parents receive their first packet at their child's 2-month well-child visit. This packet contains a tote bag and sun hat, brochures produced by the Skin Cancer Foundation, a "Sun Protection Tips" sheet specific to the age of the child, and an activity sheet for parents and children. Each additional packet includes a new "Sun Protection Tips" sheet specific to the age of the child. Starting with the 6-month packet, two small sunscreen samples are included in all packets. The 12-month packet includes UV-protective sunglasses for the child. The 36-month packet includes recommendations for parent-child activities to teach the importance of sun protection.

The intervention is designed to be delivered in several minutes at each well-child visit, which is recommended at 2, 4, 6, 9, 12, 18, 24, and 36 months of age.

The intended audience for this intervention is parents of young children, aged 2 months through 36 months, and the healthcare staff who deliver anticipatory guidance at each well-child visit. 

This intervention is suitable for implementation by pediatric care providers (e.g., pediatricians, family practitioners, nurse practitioners, physician assistants) during routine well-child visits. 

Required resources include:

• Clinician orientation/training PowerPoint presentation
• Anticipatory guidance recommendations sheet
• Protection Tip Sheets
• Activity sheet for parents and children

The Kaiser Kids Sun Care Program was evaluated using a randomized clinical trial to assess changes in provider delivery of sun protection advice and parents' practice of sun protection for their children. The intervention was delivered during well-child visits by healthcare providers from 14 primary care practices of Kaiser Permanente of Colorado. The 14 offices were matched into pairs according to patient volume, number and type of providers, and socio-demographic profiles of the populations served, and then randomly assigned to intervention and control groups. Offices in the control condition provided usual care: the use of prompt sheets for anticipatory guidance that included a prompt under the safety section to discuss the use of sunscreen for children age 6 months and older. Parents of children aged 1 to 6 months were identified using hospital birth records and contacted by telephone for recruitment. 

The sample was composed of 728 parent-child pairs. Children were between the ages of 1 and 6 months at the start of the study, with 49.7% female and 50.3% male. Child's race/ethnicity was reported as White (61.7%), Black (0.8%), Hispanic (8.4%), other (4.4%), and missing (24.7%). The majority (78.6%) of the parents were between the ages of 25 and 39 years. 

Parents' sun protection behaviors and parent-reported provider delivery of sun protection advice were gathered via telephone interviews with parents. Consenting parents completed a baseline interview at recruitment and at follow-up telephone interviews at 1-, 2-, and 3-year follow-ups. Parents were asked whether they "always, frequently, seldom, or never" use each of the following seven sun protection strategies for their child between 11 a.m. and 3 p.m.: stay inside, stay in the shade, use clothing that covers most of the arms and legs, use sunscreen with SPF>15, use a hat, limit time in the sun, and use sunglasses. Responses were combined into an additive scale that measured overall number and frequency of practices. Scale scores ranged from 7 (no strategies used ever) to 28 (all strategies used always). The researchers also examined the proportions of parents who reported frequently or always using each individual sun protection strategy. Parents were also asked whether they received any sun protection materials from their healthcare provider, whether their provider had discussed sun protection with them, and if so, what advice was given.

Health care providers completed written surveys prior to the implementation of the intervention and at 1-, 2-, and 3-year follow-ups. The questionnaire asked how often providers included eight anticipatory guidance topics in well-child care and how often they included seven specific sun protection topics when they discussed sun protection with parents.

Effects of the Kaiser Kids Sun Care Program on Parents' Sun Protection Behaviors

• At both the 2- and 3-year follow-up interviews, parents in the intervention group reported using significantly more sun protection strategies at higher frequencies (Year 2 M=18.52; Year 3 M=18.18) compared with parents in the control group (Year 2 M=18.05; Year 3 M=17.71; p<.05).

• At the 2-year follow-up, 79.2% of parents in the intervention group reported always or frequently using shade, compared to 71.9% of parents in the control group (p<.05). At the 3-year follow-up, parents in the intervention group reported always or frequently using hats (57.3%) and sunglasses (39.4%) significantly more often than parents in the control group (hats: 47.4%, p<.05; sunglasses: 29.9%, p<.05). 

Effects of the Kaiser Kids Sun Care Program on Provider Delivery of Sun Protection Advice

• At the 3-year follow-up, parents in the intervention group reported discussing sun protection with their child's healthcare provider (75%) and receiving written or other materials about sun protection (72.5%) at significantly higher rates across all three follow-up interviews (p<.001) compared to parents in the control group (advice: 52.6%; materials: 40.2%), Furthermore, the advice delivered in the intervention group was considerably more in-depth, covering more topics about sun protection (e.g., limiting time in the sun; using sunscreen; avoiding midday sun; using shade, clothing, hats). 

• Provider responses to the written questionnaires indicated that, at baseline, sun protection advice was the least common anticipatory guidance topic and was reported to be delivered more often by control group providers than intervention group providers (40% vs. 18% always or almost always discuss it, p=.03). At 1-, 2-, and 3-year follow-ups, higher proportions of providers in the intervention group compared to the control group reported routinely providing sun protection advice, although this difference was significant only at Year 1 follow-up (Year 1: 71% vs. 53%, p=.05; Year 2: 70% vs. 57%, p=.20; Year 3: 73% vs. 58%, p=.13).