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, χ2 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.
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.
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.
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 3pm.
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.
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 χ2 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.
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.
The extent of solar protection for children is summarized in Fig1. 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.
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 Fig2. 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, χ2 = 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.
Girls were more likely than boys to have no protection (31.2% female vs 7% male, χ2 = 83.3, P = .001) but full solar protection by clothing or sunscreen was similar between groups (44.4% girls and 51.5% boys, χ2 = 4.4,P = .037). Fewer 5- to 9-year-old children had full solar protection (42% vs 59%, χ2 25.0,P = .001). Logistic regression analysis (Table2) 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.
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 (χ2 = 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, χ2 19.9,P = .001).
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.
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.
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.
This study was supported by grants CA63029 and CA 23108 of the National Cancer Institute.
- Received December 23, 1996.
- Accepted February 7, 1997.
Reprint requests to (A.L.O.) Department of Pediatrics, Dartmouth Hitchcock Medical Center, HB 7450,1 Medical Center Dr, Lebanon, NH 03756.
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- ↵US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996:145
- ↵American Cancer Society. Public education materials. Atlanta, GA: American Cancer Society; 1996
- Copyright © 1997 American Academy of Pediatrics