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Sun Protection Practices for Children
Knowledge, Attitudes, and Parent Behaviors
Kyle Johnson, MPH;
Leigh Davy, BS;
Tim Boyett, MPH;
Laura Weathers, MD;
Richard G. Roetzheim, MD, MSPH
Arch Pediatr Adolesc Med. 2001;155:891-896.
ABSTRACT
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Objective To examine the frequency with which sun protection is used by parents
for their children.
Design and Setting Descriptive survey conducted at a university medical clinic in Florida.
Participants Parents of children aged 1 to 16 years were approached in the waiting
area, and 77 of 100 were successfully interviewed.
Main Outcome Measures Parents' self-reported use of sun protection measures for their children
and their attitudes and beliefs about sun protection.
Results Fewer than half of respondents (43%) reported regularly using sun protection
for their child. Regular use of sun protection was reported more frequently
by female caretakers and those with more favorable attitudes regarding sun
protection use. Sunscreen was the most frequently used measure, and preventing
sunburn was the primary reason for using sun protection. Respondents held
several unfavorable sun protection attitudes, including the belief that sun
exposure was healthy, that children looked better with a tan, and that it
was okay to stay out in the sun longer if the child wore sunscreen.
Conclusions Regular use of sun protection for children is infrequent and consists
primarily of applying sunscreen rather than methods that reduce sun exposure.
Parents primarily use sunscreen to prevent sunburn and may increase their
children's overall sun exposure as a result.
INTRODUCTION
SKIN CANCER is a growing public health problem. More than 1.3 million
persons will be diagnosed with some form of skin cancer in the year 2000.1 Malignant melanoma, the most fatal form of skin cancer,
is also occurring more frequently. During the period from 1973 to 1989, the
incidence of malignant melanoma increased 85%, more than any other major cancer.2, 3 Approximately 47 700 people are
expected to be diagnosed with melanoma in 2000, with an estimated 7700 deaths
owing to this malignancy.1 The lifetime risk
of acquiring melanoma is now estimated to be about 1 in 87.4
Excessive sun exposure has been associated with the subsequent development
of most types of skin cancers.5, 6
Moreover, as much as 80% of total lifetime sun exposure occurs during childhood.7, 8 Stern et al9
have calculated that routine sunscreen use by children could reduce subsequent
skin cancer development by 78%. The US Preventive Services Task Force concurred,
concluding that "avoiding sun exposure or using protective clothing is likely
to decrease the risk of malignant melanoma and nonmelanoma skin cancers."10 Thus, sun protection use for children, including
avoiding excessive sun exposure, covering exposed skin, and using appropriate
sunscreen, is one of the most important means to prevent the development of
skin cancer.
One of the objectives of Healthy People 2010 is to decrease the incidence
of skin cancer by the following methods (from objectives 3-9 and 3-9a):
Increase the proportion of adolescents in grades 9 through 12
who follow protective measures that may reduce the risk of skin cancer: avoid
the sun between 10:00 AM and 4:00 PM, wear sun protective clothing when exposed
to sunlight, use sunscreen with a sun protective factor (SPF) of 15 or higher,
and avoid artificial sources of ultraviolet light.11
Numerous health authorities, including the Centers for Disease Control
and Prevention, the American Academy of Dermatology, the American Cancer Society,
the National Cancer Institute of Canada, and the National Health and Medical
Research Council of Australia, recommend comprehensive sun safety for children.12
The types of sun protection methods used for children and the frequency
of use have not been thoroughly studied. Most studies in the United States
have addressed adults.13 In addition, most
surveys have asked only about one sun protective behavior, sunscreen use,
and the published survey results are primarily descriptive.14, 15
Few studies have framed survey questions in behavioral theory, so there is
a need to better understand the factors influencing children to practice sun
protection habits.16 This knowledge may lead
to improved designs for sun protection interventions with the goal of reducing
the lifetime risk of malignant and nonmalignant skin cancers.
One behavioral theory that may be relevant to sun protection use for
children is the social cognitive theory. Social cognitive theory asserts that
a person's surrounding social and physical environment influences his or her
behavior. Although this has served as an explanation for one's own decision-making
patterns reflecting, in particular, health behaviors, it is plausible to extend
this theory to support the claims that parents are responsible for the sun
protective behaviors of their children because of their beliefs on the subject
and their subsequent norms and practices.17
Parents are, in most cases, the primary agents for socialization with respect
to child development.18 Therefore, they are
in the right position to influence their children's sun protection habits.
Most studies that have examined knowledge and attitudes as determinants
of sun protection habits have focused on children's sun protection knowledge
and attitudes and not the parents'.19, 20, 21, 22, 23
Interventions that have targeted children themselves have generally shown
favorable effects on their knowledge and attitudes, but not their sun protection
behaviors.12 Few studies have examined parents'
sun protection knowledge and attitudes as a determinant of their child's sun
protection behaviors.
Several studies that have included a parental interview did not examine
parental knowledge and attitudes as a predictor of their child's sun protection
behavior.24, 25, 26, 27, 28
Other studies did not attempt to systematically examine parental knowledge
and attitudes and have often examined only a single attitude ("my child looks
healthier with a tan").15, 29, 30, 31, 32
Finally, studies that have attempted to systematically examine parent's sun
protection knowledge and attitudes were limited to selected populations. Buller
et al,33 for example, studied the parents of
children in grades 1 through 3 who were attending a summer recreational program
in Hawaii.
For these reasons, it is not yet clear how parental knowledge and attitudes
affect the sun protection behavior of children. Understanding the parental
characteristics that influence children's sun protection use is an important
area of inquiry as interventions directed at parents have generally been more
successful than interventions targeted at children themselves.12
This study, approved by our institutional review board, was performed
to examine the frequency with which sun protection is used by parents for
their children. We also sought to assess the relationship between parents'
knowledge, attitudes, and behaviors concerning sun protection and the subsequent
use of sun protection practices to benefit their children. We hypothesized
that parents having more favorable knowledge and attitudes regarding sun protection
use would report greater sun protection use for their children.
SUBJECTS, MATERIALS, AND METHODS
We systematically sampled 100 parents whose children were being seen
in the University of South Florida medical clinics during 4 arbitrarily chosen
clinic sessions in August 1999. A sample size of 100 was chosen to enable
us to estimate all proportions with maximum error of ±10%. Parents
were approached in the waiting area by a research assistant and asked to participate.
It was explained to the parents that the survey was part of a research study
examining sun protection of children and that their answers would be confidential
and not shared with their physician. It was also explained that the survey
was purely voluntary. Parents having a child between the ages of newborn to
16 years were eligible for inclusion in the study. Nonparents who were otherwise
a primary caregiver to the child (grandparent, legal guardian, etc) were also
eligible. Eligible subjects were asked to complete a 2-page self-administered
questionnaire.
The self-administered questionnaire consisted of 43 items that were
pretested for clarity and required approximately 15 minutes to complete. The
questionnaire elicited basic sociodemographic information about the respondent
and the child being seen, recorded their current methods of sun protection
for their children, and their attitudes and knowledge about sun protection.
Parents who could not complete the survey in the waiting room were offered
a self-addressed, stamped envelope to complete the survey at home. Seventy-seven
persons responded. The most common reasons for nonresponse included being
non-English speaking or having no time to complete the survey before the child's
office visit.
The main outcome of our study was self-reported use of sun protection
on a regular basis. Caretakers who reported the frequency of use of sun protection
for their child as "usually" or "always" were assigned this outcome. In bivariate
analysis we examined whether sociodemographic and clinical factors were associated
with the regular use of sun protection using the  2 test for
categorical variables, the Mantel-Haenszel 2 test for trend
for ordinal measures, and the t test for continuous
measures.
To examine whether sun protection knowledge and attitudes of caretakers
was predictive of regular sun protection use, we developed a mixed sun protection
knowledge and attitude scale based on 10 survey questions that assessed these
factors. Four items that correlated poorly (correlation coefficient, <0.3)
with the summative scale were dropped. The final scale consisted of the 6
remaining items and had a maximum potential score of 6, indicating very favorable
attitudes and beliefs regarding sun protection use. The 6 items included knowing
how quickly sunscreen becomes effective, believing that it is not okay to
stay out in the sun longer because sunscreen was applied or if the child is
in the water, that it is still necessary to apply sunscreen on cloudy days,
strongly disagreeing with the statement, "There is not much you can do to
prevent skin cancer," and believing that the sun causes most damage during
childhood.
The internal consistency of this scale was confirmed using Cronbach
coefficient  ( = .63). We also tested the construct validity
of this scale by comparing knowledge/attitude scores for 3 subgroups of parents;
(1) those who indicated that they were very knowledgeable about sun protection
(mean score, 4.8); (2) those who indicated they were somewhat knowledgeable
(mean score, 2.8); and (3) those who indicated they were not knowledgeable
about sun protection (mean score, 2.0) (Kruskal-Wallis test for differences
in mean scores, 21.7; P<.001).
To determine if more favorable parental knowledge and attitudes was
associated with sun protection use, we compared the mean scores for the sun
protection knowledge/attitude scale among caretakers who reported regular
use of sun protection and those who did not using the t test. We also performed multivariate analysis on the outcome of regular
sun protection use using multiple logistic regression and a stepwise variable
selection algorithm. All variables were eligible for selection into the logistic
model, with specified levels for initial entry into the model and remaining
in the final model both set at 0.01. Logistic models determined which characteristics
were independently associated with the odds of regular sun protection use.
The statistical significance of predictors was assessed using the 2 likelihood ratio test.34
RESULTS
Table 1 gives the demographic
characteristics of the caretakers and their children. Most respondents were
women, had received more than a high school education, and were ethnically
and racially diverse. The average age of the children was 5.8 years, and boys
outnumbered girls.
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Table 1. Demographic Characteristics of 77 Caretakers and Their Children*
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The forms of sun protection that parents used to protect their children
are reported in Table 2. Sunscreen
was the most frequently reported form of sun protection used. Staying indoors
during peak sun hours or staying in the shade and using hats and/or sunglasses
were other frequently reported sun protection methods. Thirty-three respondents
(42.9%) reported using some form of sun protection for their children either
usually or always. Among respondents who indicated that they used some form
of sun protection for their child, the most common reasons cited for doing
so included preventing sunburn (n = 55), skin cancer (n = 41), or premature
aging of skin (n = 22); because of information from the media (n = 12); because
their doctor recommended it (n = 11); and because of information from the
child's school (n = 1).
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Table 2. Sun Protection Behaviors Reported for 77 Children*
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Not surprisingly, the amount of time that children were reported to
be outside was substantial. Among the 77 respondents, 29 indicated that their
child was outside between 1 to 2 hours each day, 15 indicated their child
was outside 3 to 4 hours each day, and 5 indicated their child was outside
5 or more hours each day. In addition, 24 respondents indicated that their
child had developed sunburn at some time during the past year.
Respondents held several unfavorable attitudes or beliefs regarding
sun protection use. Fewer than half of respondents indicated sun exposure
was healthy and that children looked better with a tan. Almost half of respondents
indicated it was okay to stay out in the sun longer if the child wore sunscreen.
When asked at what age does the sun cause the most damage, only 27 respondents
(35%) indicated in childhood.
Table 3 gives characteristics
associated with the regular use of sun protection for the respondent's child.
Parents were more likely to report use of sun protection if they were white,
lived in an urban area, reported being knowledgeable about sun protection,
used sun protection regularly themselves, and reported teaching their children
about sun protection. Parents who regularly used sun protection for their
children tended to be older than those who did not (mean age, 38.1 vs 32.0
years; t test, 2.4; P =
.02). The average age of children who regularly received sun protection did
not differ from those who did not use sun protection regularly (mean age,
5.7 vs 5.9 years, respectively; t test, 0.12; P = .90). Parents who reported using sun protection regularly
for their child had higher scores on the knowledge/attitude scale than those
who did not (mean score, 4.4 vs 3.0; t test, 3.2; P = .002).
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Table 3. Predictors of Sun Protection Measures Being Used Usually or
Always
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In multivariate analysis, 2 factors were statistically significant predictors
of regular sun protection use. Female caretakers had almost 10 times greater
odds of reporting regular use of sun protection for their children compared
with male caretakers (adjusted odds ratio [OR], 9.8; 95% confidence interval
[CI], 1.1-89.6; P = .04). The odds of regularly using
sun protection also increased 63% with each unit increase in the knowledge
and attitudes scale (adjusted OR, 1.63; 95% CI, 1.1-2.5; P = .02). There were nonstatistically significant trends for greater
use of sun protection among parents who used sun protection themselves (adjusted
OR, 3.8; 95% CI, 0.9-15.3; P = .06) and with increasing
caretaker age (adjusted OR, 1.06; 95% CI, 1.0-1.1; P
= .07).
COMMENT
Even in a state with a high intensity of sun exposure and a high incidence
of skin cancer, regular use of sun protection for children was infrequently
reported by parents. Fewer than half of parents reported regularly using sun
protection for their children. Among parents who did use sun protection for
their children, sunscreen was the most frequently used method. Avoiding the
sun (by staying indoors or in the shade) or using hats or protective clothing
were less frequently used methods of sun protection.
Our results are similar to those of previous studies reporting infrequent
use of sun protection for children.16, 20, 22, 28, 31, 35
These studies similarly reported that sunscreen was the most common method
of sun protection used by parents. Sun avoidance or the use of protective
hats and/or clothing were not commonly reported.
The most common reason that parents gave for using sun protection was
to prevent sunburn, and almost half of respondents indicated that it was okay
for children to stay in the sun longer if they used sunscreen. Previous studies
have similarly found that the primary reason parents use sunscreen is to prevent
sunburn.15, 24, 32
Unfortunately, the use of sunscreen, although preventing sunburn, may lead
to increased overall sun exposure for children. Studies by Autier et al36, 37 have found that the use of sunscreen
by children was associated with overall greater sun exposure and the subsequent
development of a greater number of nevi. Wearing protective clothing on the
other hand was associated with a reduced number of subsequent nevi. Educational
campaigns may be placing too much emphasis on the use of sunscreen rather
than on measures that would better protect the skin from damage, such as avoiding
the sun, using shade, or wearing protective clothing.
Predictors of regular sun protection use in bivariate analysis included
subjects who were white, parents using sun protection themselves, increasing
caretaker age, more favorable attitudes and beliefs for sun protection use,
and residing in a nonurban area. In multivariate analysis female caretakers
and caretakers having more favorable knowledge and attitudes remained independent
predictors of regular sun protection use. These findings are similar to previous
studies showing that children's use of sun protection correlated with their
parent's use15, 16, 19, 21, 29, 33, 38, 39
and with more favorable parental attitudes.15, 16
These findings have implications for sun protection interventions and
education campaigns that are targeted at children. One method of increasing
sun protection use of children may be to target the sun protection behaviors
of the parents themselves. Campaigns that target both the parent's and child's
sun protection use may have additive effects. In addition, health education
campaigns should not emphasize solely sunscreen as a method of sun protection,
but should include other sun avoidance behaviors such as staying indoors or
in the shade and wearing hats and other protective clothing. Finally, it should
be stressed to parents that sunscreens are important not only for preventing
sunburn but also to protect their child's skin from the damaging effects of
the sun. Relying solely on sunscreen to prevent sunburns may paradoxically
increase children's overall sun exposure and subsequent risk of melanoma and
nonmelanoma skin cancers.
This study has some important limitations. First our study population
consisted primarily of younger children (average age, roughly 6 years) who
have generally been found to have higher rates of sun protection use.28 Rates for use of sun protection for older children
are probably lower than what we found. In addition we relied solely on patient
self-reports of sun protection use; there was no attempt to independently
verify their responses. As preventive health behaviors are generally overreported
in surveys, one might expect actual rates of sun protection use to be lower
than what we have found. For multivariate findings, our limited sample size
produced CIs that were quite wide and limited our ability to exclude chance
as an explanation for these findings. Our sampling method was primarily one
of convenience and the resultant sample may not be representative of all children
who are seen in the university medical clinics. Finally, our study was conducted
among parents attending a medical clinic in Florida, and findings may be different
in other settings or in other states.
In conclusion, parents of young children often hold unfavorable beliefs
and attitudes about sun protection, and these factors were associated with
less frequent use of sun protection for their children. Regular use of sun
protection for children was infrequent in our sample and consisted primarily
of applying sunscreen rather than methods that reduce sun exposure (staying
indoors or in the shade, wearing hats and/or protective clothing). Parents
primarily use sunscreen to prevent sunburn and may increase their children's
overall sun exposure as a result. These findings have relevance for those
preparing interventions or educational campaigns that promote the use of sun
protection for children.
AUTHOR INFORMATION
What This Study Adds
Few studies have examined parents' sun protection knowledge and attitudes
as a determinant of their child's sun protection behaviors. Determining parental
characteristics that influence children's sun protection use is an important
area of inquiry as interventions directed at parents have generally been more
successful than interventions targeted toward children themselves. In our
study, the regular use of sun protection for children was infrequent and consisted
primarily of applying sunscreen rather than methods that reduce sun exposure
(staying indoors or in the shade, wearing hats and/or protective clothing).
Parents of young children often held unfavorable beliefs and attitudes about
sun protection, and these factors were associated with less frequent sun protection
use for their children.
Accepted for publication April 23, 2001.
From the Departments of Family Medicine (Mr Johnson and Dr Roetzheim),
Pediatrics (Dr Weathers), and Family Medicine (Ms Davy and Mr Boyett), University
of South Florida, and the Division of Cancer Control, H. Lee Moffitt Cancer
Center & Research Institute (Dr Roetzheim), Tampa.
Reprints: Richard Roetzheim, MD, MSPH, Department of Family Medicine,
University of South Florida, 12901 Bruce B. Downs Blvd, MDC 13, Tampa, FL
33612 (e-mail: rroetzhe{at}hsc.usf.edu).
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