A Community-based Randomized Trial Encouraging Sun Protection for Children

Abstract

Objective. We evaluated the impact of an intervention promoting sun protection behavior among children 2 to 11 years of age through schools and day care centers, primary care practices, and recreation areas. Methods. Ten towns in New Hampshire were paired, then assigned randomly to intervention or control status. The multicomponent SunSafe intervention was provided to children and caregivers through primary care practices, day care centers, schools, and beach recreation areas. Training support and materials were provided by the SunSafe project, but project staff had no direct contact with children or parents in providing the intervention. All intervention components promoted the same message: avoid the sun between 11 AM and 3 PM, cover up using hats and protective clothing, use sun block with a sun protection factor ≥15, and encourage sun protection among family and friends. The impact of the intervention was determined by observing children's sun protection behavior at the beach during baseline compared with 1 year later. The primary outcomes of interest were changes in the proportion of children per town using at least some sun protection and changes in the proportion of children fully protected. Children were clustered by town, with the town thus being the unit of analysis. The primary care practice component included one practice meeting for clinicians and staff at which project staff presented background on skin cancer and how to promote its prevention; a sun protection office system manual based on our previous work, which provided specific direction on how to share responsibility among office staff and clinicians in carrying out routines that promote sun protection; and educational posters, pamphlets, and self-adhesive reminder notes designed to enhance sun protection counseling. SunSafe removable tattoos and stickers were offered to children at well-child and illness visits during the summer months. Schools each received three project staff visits: a brief visit with the principal to describe the intervention and to answer questions; an in-service program to educate teachers about skin cancer and to introduce curricular materials; and help with one parent outreach program. Larger day care centers each received one project staff visit. An additional six smaller day care centers received curricular materials through the mail but no visits. Two similar sets of curricular materials were used, one for grade schools and the other for preschools and day care centers. Both emphasized the importance of sun protection rather than the danger of skin cancer. Materials emphasized dynamic activities modeled after the “Slip, Slop, Slap” and “SunSmart” programs and included new material developed to suit regional needs. Both manuals offered structured plans but also provided a variety of activities from which teachers could choose. Teachers agreed to devote a minimum of two class periods to these materials. For recreation areas, lifeguards in each of the intervention communities attended an in-service meeting, during which background about skin cancer prevention was presented by project staff. The project also provided displays about the ultraviolet (UV) light index and about sun protection to be posted at each beach. Subsequently, project staff called beach staff in each community each morning with the predicted UV index for the day to post on the display. Educational pamphlets about the UV index and free sun-block samples were available to beachgoers through the lifeguards. One brief follow-up visit by project staff was made to each beach area to provide reinforcement. Results. We observed 1930 children. Use of some sunscreen on at least one body area increased in all 5 intervention towns compared with paired control towns. In intervention towns, this mean proportion increased from 0.56 of those observed at baseline to 0.76 of those observed postintervention, with a minimal increase among control town children. Among intervention town children perceived by their caregiver not to burn easily but having fair or medium white skin, the proportion using sunscreen increased from 0.44 to 0.69 with little change among similar children in control towns. Use of protective clothing and shade did not increase. Postintervention, the proportion of children who lacked any protection was 0.13 in intervention towns compared with 0.20 who lacked protection in control towns. For full protection from clothing, sunscreen, and/or shade, the proportion of children increased from a mean of 0.53 to 0.74 in the intervention town group compared with a smaller increase in the control town group from 0.66 to 0.72. There was substantial town-by-town variation in full protection. Conclusion. Sun protection behavior of children can be improved with the SunSafe intervention provided through schools, day care centers, primary care offices, and beach recreation areas. This intervention should be tested in other areas and expanded to preteens and adolescents. If shown to be efficacious elsewhere, the intervention could be disseminated more widely through schools, departments of health, professional organizations of clinicians and educators, and advocacy organizations such as the American Cancer Society. Some pediatricians may want to promote its application now in their offices and communities. Materials are available from the authors.