PEDIATRICS Vol. 99 No. 6 June 1997,
p. e1
Copyright ©1997 by the American Academy of Pediatrics
ELECTRONIC ARTICLE:
Solar Protection of Children at the Beach
Ardis L. Olson*, 
,
Allen J. Dietrich*,
Carol Hill Sox*,
Marguerite M. Stevens*,
Charlotte Woodruff Winchell*, and
Tim A. Ahles§
From the Departments of * Community and Family Medicine,
Pediatrics, and § Psychiatry, Dartmouth Medical School, Hanover, New
Hampshire.
ABSTRACT
- INTRODUCTION
- METHODS
- RESULTS
- DISCUSSION
- ACKNOWLEDGMENTS
- REFERENCES
ABSTRACT 
Background. Excessive sun exposure during
childhood has been associated with subsequent development of skin
cancers. Children have been advised to avoid sun exposure, use
protective clothing, and apply sunscreen lotions, but how completely
these recommendations are followed has not been studied.
Objective. To determine the extent of sun protection among
children visiting lake beaches, the methods used, and the
characteristics associated with more protection.
Design. Direct observations of children were linked with
concurrent care giver/parent interviews.
Subjects/Setting. A total of 871 children 2 to 9 years of
age and their parents/care givers at freshwater beaches in 10 small New
Hampshire towns during July and August 1995.
Outcome Measures. Protection of the head, torso, and legs
according to method used (hats, shirts, pants, sunscreen, or shade).
Results. Fifty-four percent of children were protected by
at least one method for all three body surface regions, although 17%
had no protection for any region. Sunscreen was used either alone or in
combination with clothing for at least one region in 79%. Hats were
used by 3%, shirts by 22%, and pants to the knee by 49%. Only 12%
of observed children were in the shade. The region that was protected
most often was the legs for boys (due to swim suit styles) followed by
the torso for both sexes. The region most often unprotected was the
legs for girls followed closely by the face for both boys and girls.
Girls were significantly more likely to have no protection (31.2%
female vs 7% male, 
2 83.3) due to better leg protection
from swim trunks to the knees popular with boys. Full protection of all
three regions was more common for children younger than 5 (odds ratio
[OR] = 1.8, 95% confidence interval, [CI] 1.3-2.5), for children
perceived to usually or always burn (OR = 2.0, 95% CI 1.4-2.7),
for children whose parents had more than a high school education
(OR = 1.8, 95% CI 1.3-2.5), and if the parents indicated
receiving sun protection information from a school or clinician during
the previous year (OR = 1.7, 95% CI 1.2-2.3). Approximately
51.6% of parents recalled receiving childhood solar protection advice
in the past year from either their physician, a nurse, or a school/day
care setting.
Conclusions. Sunscreen provided the most common form of
solar protection. Hats and shade were used rarely, and shirts were also
underused. Although the sun protection of these children visiting the
beach was substantial, nearly half were still not fully protected.
Clinician advice within the past year was associated with better
protection. Clinicians could increase their influence by providing more
specific counseling about how to achieve full protection. Use of
multiple methods of protection rather than just sunscreen and full
protection rather than protection for just one or two body regions
should be emphasized. It is helpful to remind families to protect the
regions most frequently omitted from protection: girls' legs and
boys' and girls' faces. Advice can be enhanced with patient education
materials such as included in the "Slip" (on a shirt), "Slop"
(on sunscreen), and "Slap" (on a hat) program developed in
Australia and available through the American Cancer Society.
solar protection, skin cancer, primary prevention, preventive
health services, counseling, primary health care.
INTRODUCTION
Excessive sun exposure during childhood has been associated with
subsequent development of skin cancers.1 The
incidence of malignant melanoma and other skin cancers is
increasing.4 Depletion of the ozone layer of the atmosphere
may accelerate these trends, especially at northern
latitudes.5
The United States Preventive Services Task Force has concluded that
"avoiding sun exposure or using protective clothing is likely to
decrease the risk of malignant melanoma and nonmelanoma skin
cancers."6 Stern and colleagues7 have also
calculated that routine sun block use by children could reduce
subsequent skin cancer development by 78%. Thus, the prime
recommendations to prevent skin cancer in children are to avoid excess
sun exposure, to cover up, and to use appropriate sun block.
The current sun protection methods and their frequency of use in
children have not been thoroughly studied. Most studies in the United
States have addressed adults.8 In a small beach survey of
82 parents in Galveston, Texas, about half of their children were using
sunscreen and only about 18% recalled receiving sun protection
information from the children's primary care physician.9 A
parent survey of family sun protection behavior was obtained during
summer pediatric emergency room visits in Nova Scotia. Any sunscreen
use in children in the previous 2 months was found to be related to
parental use, higher parental education, assessment of child's skin
color as fair, an estimate of safe exposure time of <30 minutes, and
parental knowledge of sun block sun protection factor.10
This report addresses sun protection among 2- to 9-year-old children at
lakeside beaches in the state of New Hampshire based on direct
observations of children and concurrent interviews with parents or
other care givers. The results of this report can assist clinicians in
providing focused realistic sun prevention advice to families.
METHODS
The New Hampshire Sun Protection Project is providing selected
communities with a multicomponent intervention directed at increasing
the sun protective behaviors of children. The intervention involves
schools, day care settings, primary care practices, and town beaches.
This report describes the behavior of children while at freshwater
beach areas during the summer months before any intervention activity
was initiated.
Study Population and Setting
Children, ages 2 to 9, living in 10 New Hampshire study towns or
adjacent areas provided the subjects for this study. Towns were
selected with populations between 4000 and 20 000 whose rate of
families with poverty level incomes exceeded the state mean. In
addition each town was required to have at least one primary care
practice serving children in the town or nearby and have a freshwater
lake beach used by that community. Care givers of these children
included parents, relatives, friends, and child care providers.
Measurement
Data were gathered through direct structured observations of
children while at the beach, and linked with simultaneous interviews with the child's care giver. Sun protection behaviors were observed directly regarding: (1) use of shade; (2) coverage of body surface regions with clothing or hat; and (3) coverage of regions with sunscreen. The criteria for coverage of a region with clothing or hat
were as follows: wearing a hat with at least 2 inches of forward brim;
wearing a shirt covering the torso, shoulder, and at least 50% of the
upper arm; and wearing pants to just above the knee or more.
The care giver interview addressed 40 items including demographics,
child's sunscreen use that day on face, arms, legs and back, typical
solar protection methods used for the child, care giver knowledge and
attitudes about sun protection and skin cancer, and information
received about sun protection during the past year. Certain demographic
characteristics such as parent educational level and information
sources about sun protection were only ascertained if the parent rather
than a nonparent care giver was with the child. Current sunscreen use
was verified by asking to see the container.
Interview and Observation Procedure
Data were collected in July and August 1995. Water and air
temperature, wind, and cloud cover were recorded periodically during each observation period. Interviewers had received extensive training and demonstrated high interrater reliability before entering the field
and at periodic quality checks. Data were collected at various intervals 7 days/week between 10 AM and 3 PM.
Interviewers systematically approached all adults on the beach,
described the study, and requested consent to participate. Camp groups
were excluded from the study. If consent was granted, eligibility was
determined and the children under care were identified by the care
giver. Observations were made on specific children under care during
the interview regarding their clothing and hat coverage. Children in
water above the knee were considered "not visible" as were children
participating in organized swimming classes.
Analysis
Observed children provide the unit of analysis. Sun protection
for each child by specific body surface region and by type of
protection was determined for each child. These were then collapsed in
the analysis into three body surface regions: head, torso, and legs.
This was based on a pilot test of 102 individuals, where we found that
sunscreen application was highly correlated (Pearson) within
regions: for face and neck (0.83 to 0.90); for torso front and back
(0.93); and for legs front and back (0.80). Correlation in this study
population between arms and back was also high (0.93) so only back was
used to represent torso coverage.
Sun protection was then categorized as none, partial, or full. No
coverage was defined as no sun screen, hat or clothing other than a
typical bathing suit (no back coverage for girls). Partial solar
protection was defined as one or two regions covered by sunscreen or
clothing. Full solar protection had the all three regions covered with
either sunscreen, clothing/hat, or a combination of both.
In the analysis, the proportion of subjects using shade for protection
was first determined. Because shade was rarely used as the only
protection, was used temporarily, or was usually accompanied by either
clothing or sunscreen, subsequent analyses focused on solar protection
due to the use of clothing and sunscreen regardless of shade
protection.
The use of sun protection was then examined in two ways: (1) full
protection by any combination of clothing or sunscreen vs partial/no
coverage, and (2) no protection versus partial/full coverage by any
combination of clothing or sunscreen. For both full and no protection
groups step-down logistic regression explored the role of the following
factors: whether the parent recalled receiving information about solar
protection from a source in the community, gender, age (2 to 4 and 5 to
9 years), skin type, ease of burning, number of siblings, parent vs
other care giver interviewed, amount of sunshine and wind, warm air
temperature, and parental education. This analysis was restricted to
the children accompanied by a parent rather than a nonparent care
giver. From this initial analysis, any item with a
2 P > .05 was removed to create the final
model. Weighting observations by the number of children/family observed
did not change results and was not used in subsequent analyses.
RESULTS
Of 2303 adults approached for an interview, 84 declined. Of those
found to be ineligible, 641 had no children age 2 to 9 years with them
or no visible children, 551 did not reside locally, 351 had been
interviewed previously on an earlier visit to that beach, and 19 were
camp counselors. Sixteen interviews yielded incomplete data. If we
assume that all who declined an interview were eligible, then complete
interview data were obtained on 541 of 641 eligible adults (84.4%).
Observations were made on 871 children with matched care giver
interviews available on all these children. Some adults were caring for
more than one child. For 670 of these children, the care giver was
their parent. Characteristics of the children observed and the care
givers interviewed are provided in Table 1. The mean air
temperature at 1 PM on days during interviews and
observations was 84°F with a range of 67 to 96°F.
|
Table 1.
Characteristics of Children Observed and Care Givers Interviewed
[View Table]
|
The extent of solar protection for children is summarized in Fig
1. Overall, 54% of children observed were fully protected by either shade, sunscreen, clothing, or a combination of methods. Seventeen percent of children had no protection by any method although
29% had partial protection. Overall, 105 children (12%) of the fully
protected children were observed in the shade with nearly half of these
(n = 47) also fully protected by clothing, sunscreen, or both.
Fig. 1.
Proportion of observed children (n = 871) according to extent of
protection by any method (full = 3 body surface areas,
partial = 1 or 2 areas, none = 0 of the areas-face, torso,
legs).
[View Larger Version of this Image (40K GIF file)]
Sunscreen was the most common form of protection, used either alone or
in combination with clothing or a hat, by 688 children (79%). However,
only 344 (50% of the children using sunscreen and 39.5% of children
observed overall) had full protection. Of the 479 observed children who
easily or always burned, 47% had full protection and 12% had no
protection.
The type of sun protection by age and gender is shown in Fig
2. Each of the three body surface regions are better covered in younger children. More boys than girls have protection of the legs
in each age group and overall (85% boys and 10% girls,
2 = 458, P = .001). Most of the leg
coverage was attributable to clothing alone or in combination with
sunscreen. The predominant swimsuit style for boys reached the knees.
Sole reliance on sunscreen for protection was highest for the face with
minimal use of hats observed in either sex or age group (3% female and
6% males). Sunscreen use, either alone or in combination with
clothing, was lower in older children.
Fig. 2.
Percent of children by method used to protect body surface region (166 boys and 160 girls 2 to 4 years; 287 boys and 253 girls 5 to 9 years;
age or sex was not recorded for 5 children). 
Indicates a
P < 0.05 when comparing the protection of boys to
girls within age group. Comparisons of protection of each body surface
region of all children between age groups had P < .05.
[View Larger Version of this Image (62K GIF file)]
Girls were more likely than boys to have no protection (31.2% female
vs 7% male, 2 = 83.3, P = .001) but
full solar protection by clothing or sunscreen was similar between
groups (44.4% girls and 51.5% boys, 2 = 4.4, P = .037). Fewer 5- to 9-year-old children had full
solar protection (42% vs 59%, 2 25.0, P = .001). Logistic regression analysis (Table
2) further explores which factors are associated with no
solar protection and full solar protection. Full solar protection was
1.8 times more likely if parents had more than high school education
and 1.8 times more likely for children younger than 5. Children who always or usually burned were 2.0 times more likely to be fully protected.
|
Table 2.
Logistic Regression Analysis of Risk Factors for Full Protection and No
Protection*
[View Table]
|
Among parents interviewed, 51.6% recalled receiving childhood sun
protection information from one or more community sources in the past
year with about one-fourth identifying each of the following sources:
talking with a physician or nurse; receiving information from school or
day care teachers; and receiving written information from a health care
settings. Overall, 36.1% indicated receiving information from only one
source, 12.3% from two sources, and 3.1% from all three.
Full protection was 1.7 times more likely if the parent recalled
receiving information about childhood solar protection (Table 2). Of
parents who recalled receiving information, 54% had fully protected
children compared with 38% of parents who recalled receiving no
information (2 = 14.1, P = .003). The
children of these parents also had more complete sunscreen protection
(52% full protection by sunscreen if parent recalled information and
37% full protection if no information, 2 19.9, P = .001).
DISCUSSION
The sun protection message has begun to reach families. The
majority of children were observed to have full protection, and only
17% had no protection. In New Hampshire the Scotch/Irish/English heritage may have contributed to a higher proportion of children who
were perceived to always or easily burn (54%). Boys swim suit styles
contributed substantially to leg protection. However, these findings
remain encouraging. The majority of parents recalled receiving
information from community sources about sun protection of children and
their children were better protected.
Sunscreen has been nationally promoted as an adjunct to covering up and
using shade.11 Despite the inconvenience, mess, and
cost, sunscreen provided most children with their primary means of
protection at the beach and not shade, hats, or clothing. The lower
rate of full coverage in older children may reflect this reliance on
sunscreen. With less use of sunscreen in older children, rates of full
coverage decreased. In the school age group the only increase in use of
clothing was due to boys swimwear that extended to the knees. Although
fashion has helped the leg protection of boys, hats seem to remain
firmly out of fashion for boys and girls.
This study has certain strengths and limitations. To our knowledge, it
is the first United States large scale observation/interview study of
children and sun protection that considers a variety of protection
methods, not just sunscreen. However, because actual sun protection was
determined at only one point, this may not be representative of typical
behavior. As a northern state, New Hampshire may not represent
patterns elsewhere, and patterns on playing fields or at the ocean may
be different. This study also does not address adolescent sun
protection. From previous published surveys12,13 their use
of sun protection may be worse than in younger children. The focus on
younger children was intended to determine behavior during a time with
stronger parental influence on solar protection behaviors.
Clinical Implications
How can clinicians use this information to improve sun protection
in the children in their practices? Although most children have some
sun protection, some are less well protected than others and methods
other than sunscreen are not used often. Sun protection advice needs to
be more specific than the suggestion to use sunscreen. Because only
half the children using sunscreen are fully protected, more emphasis on
complete coverage as well as use of different methods of protection is
needed. Hats are used rarely and, even if used, most American styles
provide poor neck coverage. Increasing shirt use of more than the 20%
and hat use of more than the 3% we observed should be possible because
the Australian experience14 in popularizing the use of
protective hats and ultraviolet radiation protection shirts shows that
fashion can change.
Shade was seldom used for sun protection, and most fresh water beaches
observed had little shade. Promotion of portable shade, such as beach
umbrellas, and encouragement of community recreation areas to
provide a shaded areas through natural or man-made means can encourage
its use.
Children perceived by their families as burning easily are certainly at
increased risk for sunburns and already better protected by their
families, although there is room for improvement. Clinicians should
inquire how easily the child burns and emphasize how to provide full
protection with more than sunscreen. Higher rates of full solar
protection among children whose parents discussed solar protection with
clinicians or received educational materials support the value of
pediatrician's advice to families on these issues.
Parents were more vigilant about solar protection in preschoolers, yet
the grade school years remain important as a time to help children
develop their own solar protection habits. The message of the
Australian Cancer Council to "Slip" (on a shirt), "Slop" (on sunscreen), and "Slap" (on a hat) is being promoted in this country by the American Cancer Society15 and should be used by clinicians and parents to help children think in terms of using multiple methods to protect themselves. It will require consistent, definite messages from parents and community to instill strong sun
protection habits before adolescence.
Conclusions
Solar protection has become part of routine beach behaviors for
most families at lakes in this region. Reliance on sunscreen and
limited use of clothing and hats were observed. The easily burned
population and younger age groups demonstrated better rates of full
protection, but should do more. Clinicians should emphasize full
protection and multiple approaches to protection, not just sunscreen.
FOOTNOTES
Received for publication Dec 23, 1996; accepted Feb 7, 1997.
Reprint requests to (A.L.O.) Department of Pediatrics,
Dartmouth Hitchcock Medical Center, HB 7450,1 Medical Center Dr,
Lebanon, NH 03756.
ACKNOWLEDGMENTS
This study was supported by grants CA63029 and CA 23108 of the
National Cancer Institute.
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