Effects of a Preschool Staff Intervention on Children's Sun Protection: Outcomes of Sun Protection Is Fun!

Legislative review and recommendations for improving sun protection in schools

BACKGROUND

Sun exposure in schools can account for a large portion of childhood sun exposure before the age of 20 years, yet legislation in the United States is lacking to properly protect children. Schools serve as a foundational resource to introduce and implement sun-safe practices in the youth population.

METHODS

Federal and state legislation relating to the access of sunscreen, sun-protective apparel, and shade was reviewed via the website LegiScan.com.

RESULTS

At the time of publication, only 25 states have legislation in place that addresses and allows sunscreen to be used in school, given its classification as an over-the-counter medication. No state has implemented legislation allowing sunglasses to be worn in school, and only two states have laws explicitly allowing hats and other sun-protective apparel at schools. In addition, the provision of shade is addressed in four states.

CONCLUSIONS

With a significant portion of sun exposure occurring at schools, state and federal legislation must address sun protection for students, opening the door for expanded access and additional research related to skin cancer prevention.

A Review of the Impact of Sun Safety Interventions in Children

INTRODUCTION

In the United States, melanoma and non-melanoma skin cancers comprise the largest proportion of new cancer diagnoses every year. The prevalence of skin cancer can be largely reduced if proper preventative behaviors are adopted at an early age.

OBJECTIVES

We assessed the impact of various informational, economic, and environmental interventions on sun-protective behaviors, knowledge, attitudes, and sun exposure in the pediatric population reported in previous studies.

METHODS

A systematic search for relevant articles was conducted using three databases. Studies were included if they met the following three criteria: study subjects less than 18 years old, clear, measurable interventions and outcomes, and publication in the English language.

RESULTS

A total of 66 studies were included, of which 48 resulted in positive behavioral changes (i.e. increases in sunscreen application, use of hats and sun-protective clothing, shade-seeking, and avoidance of outdoor activities during peak UV radiation), 28 resulted in increased knowledge, 2 resulted in changes in attitudes towards tanning, and 10 resulted in decreased sun exposure effects (i.e. new sunburns, number of new nevi, and change in pigmentation of the skin).

CONCLUSIONS

It is crucial that children be educated on the importance and benefits of sun protection. Although a variety of interventions showed promise in achieving this goal, the challenges associated with adopting change were evident. This review provides direction for future interventions aimed at improving sun safety in children and illustrates the potential impact that early intervention can have on the incidence of skin cancer in future generations.

[Shaded places for skin cancer prevention in kindergartens and schools]

BACKGROUND

Excessive UV radiation from the sun may lead to skin cancer, the most common type of cancer in Germany. Therefore, among other things, the World Health Organization recommends seeking shade during the midday hours from a UV index of 3 (3 to 5 = "moderate"). However, this important preventive measure can only be taken if sufficient shaded areas are available. The aim of the study is to record shaded areas in kindergartens and schools nationwide.

METHODS

An epidemiological cross-sectional study with two samples was carried out. Management of kindergartens and schools were surveyed using online questionnaires about the provision of shading measures at their educational institution from May to August 2020 and from April to July 2021, respectively. The primary outcome was to record the presence of various structural shading measures in the outdoor area of their educational institutions. The secondary outcome was to estimate the size of the shaded exterior area.

RESULTS

From the nationwide population, 1042 kindergartens (1.9%) and 713 schools (2.3%) participated. Compared to schools, kindergartens had sun protection measures in the outdoor area significantly more often (99% vs. 82%; p < 0.001) and were able to shade a significantly larger outdoor area (43% vs. 26%; p < 0.001). Assuming a minimum required shaded outdoor area of 1 m2 per person, 45% of the schools and 10% of the kindergartens did not have sufficient shaded outdoor areas (p < 0.001).

CONCLUSION

Almost every fifth school in Germany had no shaded places in the outdoor area. Against the background of climatic changes, an urgent high need for improvements seems obvious.

Knowledge Levels of Kindergarten Teachers About Skin Cancer, Sun Protection Behaviors, and Affecting Factors

The aim of this study was to determine the knowledge level of kindergarten teachers regarding skin cancer, the sun protection behaviors they exhibit for themselves/their students, and the affecting factors. This descriptive study was carried out in the Mediterranean region in a province located by the sea. The universe of the study consisted of 181 teachers working in kindergartens, and data were collected from the 81% who agreed to participate in the study. The mean Skin Cancer and Sun Knowledge Scale of the teachers was 12.50 ± 3.27 (range 0-25) and the mean Sun Protection Behavior Scale score was 24.78 ± 6.26 (range 8-40). When the Sun Protection Behavior Scale sub-dimensions were analyzed, the teachers' mean score of refraining from the sun was 13.02 ± 2.02, sunscreen use was 9.88 ± 4.46, and hat use was 5.13 ± 2.52. Significant positive correlations were found between the teachers' knowledge scores and refraining from the sun (r = 0.222; p = 0.007) and sunscreen use (r = 0.243; p = 0.003). The least used sun protection practice of the teachers regarding the students was wearing sunglasses (64.8%) and the most used practice was remaining in the shade (75.9%). The level of teachers' knowledge about skin cancer and sun protection and their behavior regarding sun protection for themselves were moderate, but the sun protection behaviors they use for their students were inadequate. Thus, educational programs about sun exposure are needed in schools and non-formal education institutions.

Cluster Randomized Trial: Sun Protection Intervention 'Clever in Sun and Shade for Preschools'-Effectiveness and Dissemination

Skin cancer is one of the most common types of cancer and UV radiation is one of the main risk factors. Therefore, sun protection, especially in childhood, is strongly recommended. We examined the effectiveness of the ‘Clever in Sun and Shade for Preschools’ program (CLEVER) in promoting sun protection behavior among preschool staff (trial registration: DRKS00023468) and describe its dissemination. Within a cluster randomized trial with 24 preschools (n = 273 staff members) stating a high need for sun protection measures, an educational workshop for preschool staff and a project kit with materials applicable in preschool groups was provided. Staff members of preschools taking part in CLEVER report significantly stronger sun protection behavior to avoid the sun (effect size [ES] 0.70, 95% confidence interval [CI] 0.04 0.71, p < 0.05) and less perceived impediments to avoid the sun (ES −0.56, CI −0.82 −0.17, p < 0.01) after 12 months as well as higher self-efficacy to avoid the sun (ES 1.09, CI 0.39 1.07, p < 0.001) and to use sunscreen (ES 0.71, CI 0.03 0.88, p < 0.05) after 1 month. Compared to the control group, there was no significant effect on sunscreen use and further psychosocial outcomes. The effectiveness of CLEVER may be underrated due to a high drop-out rate. Within three years, an enhanced free-of-charge program kit, including a media-based workshop and materials, had reached over 4000 preschools, i.e., 7.1% of all daycare centers in Germany. The results show that CLEVER can strengthen sun protection, offer high-quality information at low cost, and is easily disseminable.

The effect of 'I am Protecting my Child from the Sun' programme on parental sun protection behaviours: Randomized controlled trial

AIMS

This study aims to examine the effect of the 'I am Protecting my Child from the Sun' program based on the social cognitive theory, on parental use of sun protection products and sun avoidance behaviours.

DESIGN

Cluster randomized controlled trial.

METHODS

The study was conducted with three groups using a pre-test, post-test, and follow-up design. The study included 185 parents, of which 63 were in the education group, 62 were in the education + SMS group, and 60 were in the control group. The parents in the intervention group were engaged in the 'I am Protecting my Child from the Sun' program for a period of 6 weeks, while the education + SMS group, in addition to the program, also received. Primary outcomes include sunscreen use and sun avoidance behaviour and secondary outcomes were self-protection and protection of their children's behaviour. A repeated-measures ANOVA and marginal homogeneity were the main statistical tests.

RESULTS

The interventions made as part of the 'I am Protecting my Child from the Sun' program increased the following behavioural components of parents in the education group and the education + SMS group, compared with the control group: sun protection product use behaviours, sun avoidance behaviours, and behaviours related to protecting themselves and their children from the sun. There was an even higher increase in these behavioural components for those parents who also received short reminder text messages.

CONCLUSION

The 'I am Protecting my Child from the Sun' program and the receiving of short reminder messages had positive effects on the parents' behaviours related to protecting themselves and their children from the sun.

IMPACT

The 'I am Protecting my Child from the Sun' developed parents' sunscreen use self-efficacy, norms/attitudes about sunscreen use and sunscreen use expectancy behaviour, and reduced their impediments to sunscreen use behaviour. In addition, the program developed parents' sun avoidance self-efficacy, norms/attitudes about sun avoidance and sun avoidance expectancy behaviours, and reduced tanning expectancy behaviour. Receiving SMS messages following the training was effective in parental behaviours for use of sunscreen, sun avoidance, and protecting themselves and their children from the sun. Registration number: Study is registered at ClinicalTrials.gov NCT04251598.

A decade of sun protection in Australian early-childhood services: analysis of cross-sectional and repeated-measures data

Limiting ultraviolet radiation exposure during early childhood can significantly reduce the risk of developing skin cancer, making early childhood a critical time for sun protection strategies. This study aimed to measure sun protection practices utilized in Australian early-childhood services over the past decade and evaluate the impact of Cancer Council Australia's SunSmart Early-Childhood Program. Results are presented from cross-sectional and repeated-measures survey data, completed by directors or other staff at randomly sampled early-childhood services in 2008, 2013 and 2018 (N�=�3243). Most sun protection practices were used by a significantly greater proportion of services in 2018 relative to earlier years, such as requiring the use of sunscreen (98.4%), and sun-protective hats (99.7%) and clothing (88.8%). However, only a small and declining proportion of services (16.3%-22.4%) required the use of specific items of sun-protective clothing. SunSmart program members reported enacting significantly more sun protection practices compared to non-members, while new members showed an increase in the use of those practices relative to services whose status did not change (d�=�0.48). The results demonstrate improvements in sun protection in Australian early-childhood settings, and highlight the benefits and limitations of the SunSmart program.

Sun-Protective Behaviors: An Educational Intervention With Hospital Staff Aimed at Skin Cancer Prevention in Children

BACKGROUND

Melanoma incidence and mortality rates are predicted to steadily increase. Sun protection is important during early development because of the potential for overexposure to ultraviolet radiation while outdoors.

OBJECTIVES

The purpose of this project was to design, implement, and evaluate an educational intervention provided to healthcare professionals (HCPs) with the intention of influencing the behaviors of child populations served.

METHODS

The project evaluated HCPs' baseline knowledge about sun-protective behaviors, their level of knowledge regarding sun-protective behaviors postintervention, their intent to change behavior, and the feasibility of implementing behavior change within the organization.

FINDINGS

Pre- to post-test knowledge significantly increased. All participants reported that they would encourage children's sunscreen usage, and 98% reported that they would support the behavior change; however, 35% indicated likeliness that they would personally use sunscreen or sun-protection methods.

Shedding Light on the Shade: How Nurseries Protect Their Children from Ultraviolet Radiation

Minimizing exposure to ultraviolet radiation (UVR) is strongly recommended as the most important primary prevention measure regarding skin cancer. The responsibility for adequate sun protection of young children lies with their parents and external caregivers. Since a high proportion of 3- to 6-year-old children in Germany attend nurseries, the practice of sun protection in this setting was assessed. A survey was conducted in 246 nurseries in southern Germany during spring and summer of 2014 and 2015. Shade coverage in the outdoor area of the nursery was assessed by study team members and UVR protective behavior of staff was assessed by an interview with the directors. On average, 52% of the entire outdoor area and 65% of the children’s outdoor play area were covered by shade, with a significant difference between nurseries of different sizes, pointing to a better shade coverage in larger nurseries. The daily outdoor stay was not regularly scheduled before or after peak sun intensity hours around noon to avoid intense UVR exposure. General sun protection rules were present in the majority of the nurseries and addressed predominantly wearing sunhats and applying sunscreen. Our findings show that current sun protection recommendations for children are only partially met in nurseries and indicate a lower level of sun protection in small institutions. Especially, avoidance of excessive exposure to UVR around noon and the importance of shade provision over play structures needs to be emphasized in future information campaigns.

An online skin cancer risk-reduction intervention for young adults: Mechanisms of effects

OBJECTIVE

The study's purpose was to investigate moderator, implementation, and mediator variables related to the efficacy of UV4.me, an Internet intervention that decreased ultraviolet radiation (UV) exposure and increased skin protection behaviors among young adults.

METHOD

A total of 965 18-25 year olds at risk for skin cancer were recruited nationally online. Participants were randomized to an experimental website (UV4.me), a control website, or assessment only. Participant characteristics (moderators), engagement with and perceptions of interventions (implementation measures), and exposure and protection attitudinal variables (mediators) were assessed. Linear regression and mediation analyses were conducted.

RESULTS

Intervention effects on skin protection were greater for participants with a family history of skin cancer (p = .01). Intervention effects on UV exposure were greater among recent indoor tanners (p = .04). Improvements in skin protection (but not UV exposure) were associated with perceiving the interventions as satisfying or helpful (ps < .01). The experimental group had better outcomes if they completed more modules (ps < .01) or set more behavioral goals (ps < .01). Knowledge and exposure decisional balance mediated intervention effects for UV exposure (ps < .05), and protection decisional balance, self-efficacy, and intentions mediated intervention effects for protection (ps < .05).

CONCLUSIONS

The experimental intervention was more efficacious for certain high risk groups. The more individuals liked and engaged with the interventions (e.g., by setting goals), the better their outcomes. Mediation results inform theory about change mechanisms and differed by behavioral outcome. (PsycINFO Database Record

Efficacy of an Intervention to Alter Skin Cancer Risk Behaviors in Young Adults

INTRODUCTION

Skin cancer is the most common cancer, and its incidence is increasing. Young adults expose themselves to large amounts of ultraviolet radiation (UV) and engage in minimal skin protection, which increases their risk. Internet interventions are effective in modifying health behaviors and are highly disseminable. The current study's purpose was to test an Internet intervention to decrease UV exposure and increase skin protection behavior among young adults.

STUDY DESIGN

RCT conducted in 2014, with data analyzed in 2015.

SETTING/PARTICIPANTS

A national sample of adults aged 18-25 years at moderate to high risk of developing skin cancer by a self-report measure was recruited online.

INTERVENTION

Participants were randomized to one of three intervention conditions: assessment only, the website of a skin cancer organization, or a tailored interactive multimedia Internet intervention program (UV4.me) based on the Integrative Model of Behavioral Prediction.

MAIN OUTCOME MEASURES

Self-reported overall UV exposure and skin protection assessed at 3 and 12 weeks after baseline. Secondary outcomes were self-reported intentional and incidental UV exposure, sunburns, sunscreen use, and skin cancer screening.

RESULTS

For the intervention arm, there were significant decreases in UV exposure and increases in skin protection at both follow-up time points compared with the assessment-only condition (p<0.001). The effect sizes (Cohen's d) comparing the experimental and assessment-only arm 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 control condition was not significantly different from the assessment only condition. All three conditions exhibited decreased exposure and increased protection at both follow-ups (p<0.01), but the effect was much stronger in the intervention group. Secondary outcomes were generally also significantly improved in the intervention condition compared with the other conditions.

CONCLUSIONS

This is the first published report describing the results of an RCT of an Internet intervention to modify skin cancer risk behaviors among young adults. The UV4.me intervention significantly improved self-reported skin cancer prevention behaviors. Future research will investigate mechanisms of change and approaches for dissemination.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02147080.

A randomized controlled trial of an educational programme with telephone reinforcement to improve perceived health status of Brazilian burn victims at 6-month post discharge

AIM

The aim of this study was to compare health status, self-efficacy, symptoms of depression and anxiety and post-traumatic stress between two groups of burn victims receiving information on self-care through routine care or an educational programme with telephone reinforcement.

BACKGROUND

Self-care post discharge is an important factor on quality of life of burn victims. Reinforcement of self-care programme via telephone follow-up might improve self-efficacy and general health perception in burn victims.

DESIGN

Randomized, controlled clinical trial.

METHOD

From 2011-2012, we randomized 108 burn victims either to an educational programme on self-care tailored for burn victims according to the cognitive social theory and reinforcement by telephone every 4-6 weeks for 6 months post discharge, or to the routine instructions given at discharge from the hospital. During hospitalization, at discharge, at 6 and 12 months post discharge, we collected data on socio-demographic characteristics, Burns Specific Health Scale Revised (BSHS-R), Perceived Self-Efficacy Scale (PSE), Hospital Anxiety and Depression Scales (HADS) and Impact of the Event Scale (IES). We analysed data using t-test, Chi-square test and linear regression models.

RESULTS

Groups were similar regarding clinical and demographic characteristics, except for age. At 6-month follow-up, there were no differences between the groups on BSHS-R, PSE and HADS Depression, while the intervention group showed fewer symptoms of anxiety (HADS Anxiety) and lower IES scores than the control group.

CONCLUSION

The educational programme, when compared with usual care, reduced anxiety symptoms and post-traumatic stress. Educational programmes with telephone follow-up might be a viable intervention to improve self-care for burn victims.

Randomized controlled trial of a sun protection intervention for children of melanoma survivors

BACKGROUND

We studied whether a melanoma survivor-centered intervention was more effective than materials available to the general public in increasing children's sun protection.

METHODS

In a randomized controlled trial, melanoma survivors (n = 340) who had a child ≤ 12 years received a targeted sun protection intervention (DVD and booklets) or standard education. Primary outcomes were children's sunburns, children's sun protection, and survivors' psychosocial factors at baseline and postintervention (1 and 4 months).

RESULTS

The intervention increased children's sunscreen reapplication at 1 month (P = 0.002) and use of wide-brimmed hats at 4 months (P = 0.045). There were no effects on other behaviors or sunburns. The intervention improved survivors' hats/clothing self-efficacy at both follow-up assessments (P = 0.026, 0.009). At 4 months, the intervention improved survivors' clothing intentions (P = 0.029), knowledge (P = 0.010), and outcome expectations for hats (P = 0.002) and clothing (P = 0.037). Children's sun protection increased with survivors' intervention use. The intervention was less effective in survivors who were female or who had a family history, older children, or children with higher baseline sun protection scores.

CONCLUSIONS

A melanoma survivor-centered sun protection intervention can improve some child and survivor outcomes. The intervention may be more effective in survivors who have younger children or less experience with sun protection. Intervention delivery must be enhanced to maximize use.

IMPACT

This is the first study to examine a sun protection intervention for children of melanoma survivors. Findings will guide interventions for this important population at increased melanoma risk.

Sun protection training based on a theater play for preschoolers: an effective method for imparting knowledge on sun protection?

Sun protection in childhood is important to reduce the risk of developing skin cancer later in life. The "Periods-of-Life-Program" for primary prevention of skin cancer introduces a combination of individual and environmental interventions for the preschool period. Within this pilot study, an intervention group received cognitive-behavioral and environmental interventions. A control group had solely received the environmental intervention, and a wait-control group received no intervention. Nursery school children (n = 80, 3 to 6 years of age) of four nursery schools were randomly assigned to these groups on school level. The ability of the cognitive-behavioral intervention (a theater play) to enhance sun protection knowledge was examined. The theater play improved knowledge over all age groups (p < .05 η(2) = .06). Age-specific analyses showed better results for children aged 5 to 6 (p < .05 η(2) = .20) compared to children aged 3 to 4 years (p = .17 η(2) = .04). In combining cognitive-behavioral and environmental interventions, the "Periods-of-Life-Program" is a promising strategy for primary prevention of skin cancer.

Skin Protection for (SPF) Kids Program

Skin cancer is increasing faster than any other cancer in the United States. Individuals who have had excessive sun exposure during childhood and adolescence set the stage for the development of skin cancers later in life. In 2009, there were more than 1 million newly diagnosed cases of skin cancer in the United States. This primary prevention program combined the guidelines in the literature resulting in a unique evidence-based program for teachers and informational guidelines for parents. These guidelines were used in classrooms and at home, supporting intervention among school-age children, specifically those in kindergarten through fifth grade.

Is the Global Solar UV Index an effective instrument for promoting sun protection? A systematic review

Exposure to ultraviolet radiation is an important risk factor for skin cancer. The Global Solar Ultraviolet Index (UVI) was developed as a tool to visualize the amount of harmful radiation and to encourage people to use sun protection. We conducted a systematic review of the effectiveness of the UVI. We employed a comprehensive search strategy to explore the impact of the UVI on five outcome categories. Twenty-seven of a total of 260 studies met our inclusion criteria; data extraction and quality appraisal were undertaken for 25 studies, comprising 3 randomized controlled trials, 2 non-randomized intervention studies and 20 cross-sectional studies. Nearly half of these studies were from Australia and New Zealand. We found low to intermediate levels of UVI awareness and low levels of UVI understanding. Studies rated moderate or strong suggest that the UVI does not influence knowledge, attitudes, sun protection behavior or sun exposure. Overall, the findings imply that the UVI, as currently implemented, has not been successful at improving sun protection practices and reducing sun exposure among the population at large. Drawing on experience with theory-based sun protection programs, we advocate for more realistic expectations of what the UVI can and cannot achieve.

Effects of video-based, online education on behavioral and knowledge outcomes in sunscreen use: a randomized controlled trial

OBJECTIVES

To compare online video and pamphlet education at improving patient comprehension and adherence to sunscreen use, and to assess patient satisfaction with the two educational approaches.

METHODS

In a randomized controlled trial, 94 participants received either online, video-based education or pamphlet-based education that described the importance and proper use of sunscreen. Sun protective knowledge and sunscreen application behaviors were assessed at baseline and 12 weeks after group-specific intervention.

RESULTS

Participants in both groups had similar levels of baseline sunscreen knowledge. Post-study analysis revealed significantly greater improvement in the knowledge scores from video group members compared to the pamphlet group (p=0.003). More importantly, video group participants reported greater sunscreen adherence (p<0.001). Finally, the video group rated their education vehicle more useful and appealing than the pamphlet group (p<0.001), and video group participants referred to the video more frequently (p=0.018).

CONCLUSION

Video-based learning is a more effective educational tool for teaching sun protective knowledge and encouraging sunscreen use than written materials.

PRACTICE IMPLICATIONS

More effective patient educational methods to encourage sun protection activities, such as regular sunscreen use, have the potential to increase awareness and foster positive, preventative health behaviors against skin cancers.

Improving short-term sun safety practices among adolescent survivors of childhood cancer: a randomized controlled efficacy trial

INTRODUCTION

Skin cancer is one of the most common secondary neoplasms among childhood cancer survivors. However, little evidence exists for effective interventions to promote sun safety behaviors within this population.

METHODS

This small-scale randomized controlled trial examined the efficacy of the Survivor Health and Resilience Education (SHARE) Program intervention, a multiple health behavior change intervention designed to increase sun safety practices among adolescent survivors of childhood cancer. Adolescent survivors of childhood cancer (11-21 years) were randomly allocated to a group-based behavioral intervention (n  =  38) or wait-list control (n  =  37). Self-reported sun safety behaviors were assessed using a valid, 8-item scale at baseline and 1-month post-intervention.

RESULTS

Controlling for baseline sun safety, gender, and seasonal influences, intervention participants reported significantly more sun safety practices (e.g., using sunscreen, reapplying sunscreen regularly) at 1-month post-intervention than control participants (B  =  2.64, 95% CI  =  1.02, 4.27, p  =  0.002).

CONCLUSIONS

The results suggest that SHARE was efficacious in producing improvements in short-term self-reported sun safety practices among adolescent survivors of childhood cancer. Future research is needed to build upon this work by incorporating objective measures of sun safety behaviors and examining intervention durability.

IMPLICATIONS FOR CANCER SURVIVORS

Behavioral interventions addressing lifestyle factors, including sun safety behaviors, among adolescent survivors of childhood cancer should be integrated into long-term care to reduce the risk for secondary malignancies and diseases.

Differential effects of self-efficacy and perceived control on intention to perform skin cancer-related health behaviours

Previous research using the Theory of Planned Behaviour (TPB) for predicting skin cancer-related health behaviours has not adequately incorporated empirical advances in the conceptualization of the perceived behavioural control (PBC) component of the theory. This study examined the role of self-efficacy and controllability for predicting sunscreen and sunbed use intentions. Five hundred and ninety young adults completed a questionnaire on beliefs and intentions regarding sunscreen and sunbed use. Analysis using confirmatory factor analysis and multiple regression supported a conceptual distinction between two PBC subcomponents: controllability and self-efficacy. While self-efficacy--but not controllability--emerged as a significant predictor of intentions to use sunscreen, the opposite pattern was observed for the prediction of intentions to use sunbeds, whereby lower controllability beliefs were associated with higher intentions. Campaigns aimed at influencing health behaviours should consider the differential effects of the components of perceived control.

Sun protection at elementary schools: a cluster randomized trial

BACKGROUND

Elementary schools represent both a source of childhood sun exposure and a setting for educational interventions.

METHODS

Sun Protection of Florida's Children was a cluster randomized trial promoting hat use at (primary outcome) and outside of schools among fourth-grade students during August 8, 2006, through May 22, 2007. Twenty-two schools were randomly assigned to the intervention (1115 students) or control group (1376 students). Intervention schools received classroom sessions targeting sun protection attitudes and social norms. Each student attending an intervention school received two free wide-brimmed hats. Hat use at school was measured by direct observation and hat use outside of school was measured by self-report. A subgroup of 378 students (178 in the intervention group and 200 in the control group) underwent serial measurements of skin pigmentation to explore potential physiological effects of the intervention. Generalized linear mixed models were used to evaluate the intervention effect by accounting for the cluster randomized trial design. All P values were two-sided and were claimed as statistically significant at a level of .05.

RESULTS

The percentage of students observed wearing hats at control schools remained essentially unchanged during the school year (baseline = 2%, fall = 0%, and spring = 1%) but increased statistically significantly at intervention schools (baseline = 2%, fall = 30%, and spring = 41%) (P < .001 for intervention effect comparing the change in rate of hat use over time at intervention vs control schools). Self-reported use of hats outside of school did not change statistically significantly during the study (control: baseline = 14%, fall = 14%, and spring = 11%; intervention: baseline = 24%, fall = 24%, and spring = 23%) nor did measures of skin pigmentation.

CONCLUSIONS

The intervention increased use of hats among fourth-grade students at school but had no effect on self-reported wide-brimmed hat use outside of school or on measures of skin pigmentation.

Certification of sun protection practices in a German child day-care centre improves children's sun protection--the 'SunPass' pilot study

BACKGROUND

Nonmelanoma skin cancer (NMSC) and malignant melanoma (CMM) are among the most common malignancies in the white population. The major risk factor for those malignancies is ultraviolet radiation (UV) causing directly DNA damage and promoting the development of skin cancer. It is suggested that the exposure to UV during childhood elevates an individual's lifetime risk of developing skin cancer more than exposure in adulthood. Since an increasing number of children spend the time of the most intense UV in a day-care centre, it seems an excellent place for establishing primary skin cancer prevention. Important targets are staff members and parents of the day-care centre, since sun protection of children depends directly on their knowledge and their attitude towards sun protection practices.

OBJECTIVES

To establish a feasible certification program for sun protection in a German child day-care centre, for a better sun protection of the children and the reduction of skin cancer incidence in the long term.

METHODS

Initially sun protection practices of the centre at baseline were assessed. A written sun protection policy was developed in consultation with all members of the day-care centre as basis for certification. It was followed by training sessions for staff members (n=12) and parents (n=46). After a fixed period of time the final assessment of the child day-care centre was conducted and the centre then was certified for improved sun protection practices and better protection of the children. The primary assessed outcomes were the gain in knowledge of staff members and parents after the training sessions, the number of children wearing a hat when playing outside, the use of sunscreen and the percentage of shaded areas on the playground.

RESULTS

Sun protection was an issue more discussed during the time of intervention than before. Staff members (n=12) and parents (n=27) had a significant gain in knowledge (staff members: P=0.002; parents: P=0.001) concerning sun related issues. The number of children wearing a hat increased from 13.2% to 73%. The sunscreen use increased, 58.8% of staff members reported a more regular application of sunscreen to the children. There was a higher percentage of shaded area on the playground (70-80% before intervention, 90% after intervention). The intervention failed in keeping the children inside during the most intense UV and in educating the staff members to be a convincing example of sun protection by wearing appropriate clothes.

CONCLUSIONS

The intervention showed that the introduction of a simple certification program including a written sun protection policy and training sessions for staff members and parents helps to improve children's sun protection. We suggest that a certificate for adequate sun protection acts as a motivating factor. It seems important to refresh sun protection practices each year by repeating training sessions and reviewing the sun protection policy.

An intervention for parents to promote preschool children's sun protection: effects of Sun Protection is Fun!

BACKGROUND

Young children are an important focus of sun-protection efforts, but there has been relatively little study of sun-protection interventions developed for preschool-aged children and their parents. This paper reports on the evaluation of Sun Protection is Fun! (S.P.F.), designed to improve parents' practices and psychosocial outcomes related to protecting preschool children from sun exposure.

METHODS

A group-randomized trial was conducted in 20 preschools to evaluate the S.P.F. parent intervention that included a video, newsletters, and handbooks. A separate, on-site intervention for preschool staff aimed to create a preschool climate that encouraged parents' sun protection for their children. Cross-sectional samples of parents completed surveys at baseline (n = 384), 12 months (n = 640), and 24 months (n = 694).

RESULTS

S.P.F. demonstrated significant effects on parents' sun-avoidance strategies at 12 months (P < .05) and sunscreen use at 24 months (P < .05). There were significant intervention effects on parents' sun-protection knowledge (P < .001), perceived norms of teachers' sunscreen use (P < .001), sunscreen impediments (P < .05), and sunscreen expectancies (P < .05) at 12 months. Parents' perceived norms of teacher sunscreen use were significantly improved at 24 months (P < .001).

CONCLUSIONS

More intense intervention strategies may need to complement take-home materials to result in greater effects on parents' sun protection for their children.