Public education projects in skin cancer prevention: child care, school, and college-based

Public Education Projects in Skin Cancer Prevention: Child Care, School, and College-Based DAVID B. BULLER, PhD RON BORLAND, PhD

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xposure to ultraviolet radiation (UVR) during childhood may elevate an individual’s lifetime risk of developing skin cancers more than exposure in adulthood. Consequently, medical and public health experts have identified the adoption of sun safety practices by children and their families as a priority.1– 6 It has been estimated that if sunscreen were used on the face, ears, neck, and upper extremities of children from birth to age 20, their lifetime risk of nonmelanoma skin cancer would be reduced by 85 percent. Use of sunscreen just from birth to age four, would reduce risk of nonmelanoma skin cancer by almost half. Risk reduction should be greater if UVR exposure in childhood exceeds exposure in adulthood.7 Eliminating severe overexposure (i.e., blistering sunburns) prior to age 20 also may reduce risk for melanoma by half.8 Even if those estimates prove optimistic, there is still likely to be considerable benefit from reducing UVR exposure in children. Programs to reduce UVR exposure of children and adolescents can occur as part of society-wide efforts to reduce exposure and/or as a targeted intervention in smaller locales. As yet, only Australia has implemented society-wide sun safety campaigns. Skin cancer prevention programs for children in North America and Europe primarily address local populations, although several medical organizations (e.g., the United States Centers for Disease Control and Prevention, American Academy of Dermatology) are supporting efforts that may yield society-wide programs in the near future. In this paper, we will review the results of solar protection programs designed to improve the sun safety of infant and preschool (under age 5 years), preadolescent (ages 5–11), adolescent (ages 12–18), and college-aged children (ages 18 –22). Programs implemented for children in Australia, North America, and Europe are reported and compared to derive recommendations for success-

ful sun safety programs. Programs are also described that communicate with adults who care for younger children (e.g., parents, day care staff, pediatricians). Most of the programs were conducted in day care centers, preschools, and primary, secondary, and tertiary educational institutions, because these organizations provide easy, regular access to a large proportion of children. Prevailing levels of sun protection in the community and trends in these activities provide a context for any programs aimed at children. At one extreme, a sun safety activity for children may demonstrate limited effectiveness because it occurs in a broader social context antagonistic to change (i.e., in populations that see no urgency to take precautions). At the other extreme, programs for children may not be able to add anything detectable in a society with a strong shared value of keeping UVR exposure at safe levels (i.e., in populations with high levels of protective behaviors and a supportive [shady] environment). This review begins with a description of current skin cancer prevention habits by children, as health promotion theories emphasize the importance of the total context in understanding the effectiveness of sun safety programs for children.

From the AMC Cancer Research Center, Denver, Colorado, and the Anti-Cancer Council of Victoria, Carlton South, Victoria, Australia. Address correspondence to Dr. David B. Buller, AMC Cancer Research Center, 1600 Pierce Street, Denver, CO 80214.

Representative samples of secondary school children suggest that about two-thirds of adolescents report painful sunburn during the previous summer.10,11 As

© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

Sun Safety Habits of Children in Australia In Australia, there have been community-wide efforts to reduce excessive sun exposure to reduce the risks of skin cancer since the early 1980s.9 The evidence on population attitudes and behavior and the bulk of the community-wide interventions are state-based. In Victoria, for example, the population aged 14 to 70 has been monitored regularly since the summer of 1987– 1988 (December through February).

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would be expected, those with sun sensitive skin were most likely to have been burnt. Increased reported use of sun protection was associated with reduced burning in the last year, except for sunscreen use where the converse was the case.11 This suggests that adolescents’ skill at using sunscreen may be insufficient to guard against sunburn. Part of the reason for this is that it is difficult to know if all areas are covered and if the coverage is sufficient to afford adequate protection. Further, use of sunscreen may encourage increased exposure both in terms of the proportion of the body exposed and of the amount of time spent in the sun.

Children’s Sun Protection Young people in Victoria in 1987–1988 typically had lower levels of unprotected exposure and less positive attitudes toward tanning than older residents.12 A survey of beachgoers shortly afterward found that children (aged 7 to 12) were better protected than their parents.13 Since then, all groups have improved their sun protection behavior, at least up until 1993.14,15 However, unpublished research in Victoria16 has shown that adolescents increasingly reject advice to avoid going outside. The studies of Victoria youth reveal an age differential in sun protection practices. Broadstock et al.10 found that secondary (middle and high) school student reports of sun protection declined from age 11 to age 15, when it either stabilized or began to rise, suggesting that late adolescence is the period of worst sun protection by Australian youth. Dixon et al.17 recently extended this work into primary (elementary) schools in Victoria and reported that the decline in sun protection practices begins at around age 7 or 8. Foot et al.18 reported that children under age 10 were better protected than 11- to 14-year-old children. In primary school, there is little evidence of gender differences,17,19 but by secondary school, boys have a relative preference for wearing hats (although typically baseball caps) and girls for using sunscreen for sun protection.17 Girls in a Queensland survey were both more likely to want to get a suntan and more likely to protect themselves when out in the sun compared to boys; however, boys were more likely than girls to be concerned about not having a suntan.19 These genderbased preferences continue into adulthood in Australia. In the studies of Victorian youth and adults, women were more interested than men, went outside more often than men with the expressed intention of getting a suntan, but were more careful than men as to how they go about it. By contrast, men tended to have more of an outdoor lifestyle than women and to go out in the sun for reasons other than specifically to get a suntan, but they saw getting a tan as an important side-effect to outdoor activities.10,12 Thus, gender-based norms related to sun exposure emerge in adolescence: girls are

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more likely to sunbathe than boys, and boys spend a lot more time outside than girls. Finally, there have been recent initiatives to increase sun safety policies and the provision of shade structures in child care centers and schools in Australia. A survey of child care centers in one region of New South Wales prior to 1993 found that these centers had only moderate sun safety policies and there was no relationship between the existence of these policies and the sun protection of children at the centers.20 Since then, a national accreditation scheme requiring sun protection policies has been implemented in Australia, and it is likely that the situation has improved. A survey of local governments in the summer of 1993–1994 revealed that over three-quarters of prep programs (kindergartens) had sun protection policies in place.21 This was an increase from a similar survey in 1990. Day care programs and holiday child care programs also had increased sun protection in that survey. Primary schools appeared to be more advanced in their sun safety policies than secondary schools22 and were leading the way in educating a generation of sun smart children. Secondary schools are taking the issue more seriously as a result of parental demand and the increased likelihood of getting some degree of compliance from these children.

Children’s Sun Safety Knowledge and Attitudes By 1987–1988, young people in Victoria had virtually universal awareness of the Slip (on a shirt), Slop (on sunscreen), Slap (on a hat) message.23 Likewise, a study of secondary school students in Queensland, the northern-most Australian state and the one where sun exposure is the biggest problem, found that students had high knowledge of the risks associated with unprotected UVR exposure but also significant barriers to good sun protection practices.19 Adolescents’ desire for a suntan and interest in sunbaking were obstacles to their sun protection on beaches in Victoria. Social factors also were important barriers, but their influence was indirect.24

Summary The data from Australia is very encouraging because it shows that sustained society-wide efforts can improve sun safety for children. Many children in Australia are aware of the dangers of UVR exposure and of the recommended protection practices. Australian children are better protected today than they were 15 years ago. Sun safety policies and sun protection structures have become common in Australian childcare centers and schools. Specific programs for children evaluated in this very supportive context may show less success, because protection practices have already been elevated by the society-wide sun safety campaigns. It is also difficult to distinguish between gains in child sun protection that

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accrued from campaigns aimed at the general population and from features of these campaigns that were delivered specifically to children. Despite the successes in Australia, children there take fewer precautions as they approach puberty, and late adolescence continues to be a period of frequent high risk exposure. Additionally, gender differences continue to emerge early in secondary school years. It is plausible that there are precursors to these genderbased norms that if identified at an early age could be intervened upon to forestall their emergence. Research on this is urgently needed.

Sun Safety Habits of Children in North America and Europe There have been almost no national assessments of sun exposure and protection by and for children in North America, although national surveys of adults have been reported.25 Assessments of European populations also are rare. Trends for children can be derived from surveys of individual populations; however, one must be cautious when applying these results to the national child populations. The following review is limited to data collected since 1985, to document current sunrelated behaviors.

Children’s Sun Exposure Surveys of parents, adult caregivers, pediatricians, and children in North America suggest that many infants, preschool, and preadolescent children have a great deal of unprotected sun exposure, and adolescent and college-aged children have even higher unprotected exposure. This occurs despite adults’ and older children’s knowledge of the harmful effects of sun on children’s skin. For instance, one North American study of parents with children aged six months to six years found that children were outside every day for an average of almost three hours.26 A survey of day care centers showed that children in nearly all of the sampled centers (96 percent) were outdoors during daily peak periods of UVR (i.e., between 10 a.m. and 2 p.m.), and for two to three hours each day at over half of the centers.27 Parents of children under age 13 in a third study reported that their children spent an average of 2.5 hours outside during the previous day.28 Studies of adolescents also showed a great deal of time outdoors.29 One study of sixth graders estimated that they spent over 6 hours outdoors on weekends and 21 hours over the entire week.30 Estimates from a sample of parents with three-year-olds in Marseille, France, showed similar sun exposure for three-year-olds and children aged 13–14 years—35 to 45% were reported to spend more than 15 hours per week outside in swimsuits.31 Several demographic and social characteristics were associated with children’s sun exposure in the North

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American studies. Weekend sun exposure was higher among children using sunscreen, having parents who suntan, and finding suntans attractive; weekly sun exposure was highest among those finding suntans attractive, with less sun sensitive skin, and believing that they cannot avoid the sun.30 Adolescent boys spent more time outside than adolescent girls,30,32 but women college students spent more time in intentional suntanning than their male counterparts,33 a patterns similar to Australian youth. Finally, one recent study quantified the amount of sun exposure received on adolescent children’s lower arms, cheeks, and forehead in recreational outdoor activities (i.e., baseball team, summer camps), and found that exposure was higher on arms than on cheeks and forehead.34

Children’s Exposure to Artificial UVR Exposure to artificial sources of UVR appears to begin in adolescence. In one North American sample, 34% of adolescents had used a tanning facility, 28% tanned at least once a month, and 20% had started using these facilities prior to age 15.35 Artificial tanning devices appear to be much more popular for adolescent girls than boys.29,32,35 These devices also may be used more by adolescents whose skin is more sun sensitive than by those with less sensitive skin. These adolescents may mistakenly believe that they can safely achieve a tan with these devices or that by suntanning initially with these devices, they are protected against sunburn when outdoors.32 A study in Sweden found a similar pattern of use, with more women than men using artificial sources of UVR between the ages of 15 and 24.36

Children’s Sun Precautions Sun protection for infants and young children (under age 5 years) appears to be moderate, at best, in North America and Europe. For example, parents of children age six months to six years scored only 28 out of a possible 44 on a sun protection index for children.26 Also, while surveys of day care centers found that staff reported using sunscreen on most children,27,37 observations of children on the play areas of these centers showed that very few centers used physical sun barriers: (a) While nearly all centers had shade in outdoor play areas, only 36% of the centers in one survey had more than half of that area shaded; (b) hats were observed on children in only 19% of one sample (and protective clothing and sunglasses were nearly nonexistent); (c) only 56% of centers had adequate sun protection policies, and only 17% specifically encouraged children to bring and use protective clothing in another sample.27,37 Also, some child care centers required a written physician’s instruction to apply sunscreen and/or required parents to properly dress and apply sunscreen to children before arriving at the center. These are two potential barriers to adequate protec-

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tion.37 It is important to note that state regulations did not require those centers to obtain a physician’s instructions for sunscreen application by the day care staff. Protection of preadolescent children in the United States also appears to be only moderate. Parents with children under age 13 relied most on sunscreen (32% applied it all of the time) and verbal warnings to not sunburn (46% warned children). They had children stay in the shade, wear protective clothing, and avoid the midday sun—preferable prevention strategies because they physically block UVR—less frequently.28 In another survey, though, parents reported more frequent protective behavior: 91% claimed to use at least one protective measure when children were outside for more than 30 minutes.38 Parents who take sun precautions for themselves may be more likely to take precautions for their children,28,38 calling for programs that target the entire family for improved sun safety. Sun protection and sunscreen use in particular was associated with a history of more sunburns of the child or parent,38 – 40 more skin sun sensitivity in the child,38,40 Caucasian and Hispanic parents,28 more preventive knowledge,38 more educated parents,40 younger rather than older (.12 years) children,38,40 the sex of the child,40 and parents receiving information on sun protection from sources in the community.28,40 Sun protection appears to decline among North American adolescents and college-aged children, as it does among their counterparts in Australia. In a sample of 12 to 19 year olds, 33% never used sunscreen and only 26 percent used it over half of the time that they were outdoors.29 Likewise, half of a college-aged sample rarely if ever used sunscreens and only 9% used one with a sun protection factor (SPF) of 15 or more whenever they were exposed to the sun.33 Risky behavior (use of tanning devices and lotions, outdoor time, and deliberate suntanning) was more frequent in women college students, who felt that tanning improved their appearance and were more self-conscious about their body image and personal impression.41 The likelihood of taking sun precautions was higher in one adolescent sample among children who perceived that they were more susceptible to skin cancer, felt there were more benefits to prevention, were young women, were more aware of skin cancer, had more sun sensitive skin, and demonstrated greater knowledge of skin cancer.32 Sunscreen use was higher at these ages by children who were young women, had more sun sensitive skin, who used other protective measures, believed they were more susceptible to skin cancer, who did not think they were more attractive with a tan, whose best friends used it, whose parents assisted in buying or applying it, who estimated a shorter duration of safe sun exposure time, who had more sun-related knowledge, and who did not feel that sunscreens were too expensive.29,30,32,41 Thus, the gender-based norms witnessed in Australia

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for both more deliberate suntanning and more sun precautions by girls than boys was apparent in older North American youth. Sunburns also may provoke sunscreen use on the following day.30 Children and adolescents may be better protected in outdoor recreational settings. For instance, over half of preadolescent children observed on lake beaches in New Hampshire were fully protected either by shade, sunscreen, clothing, or a combination of methods (but 17% had no protection),40 although sunscreen was once again the most common form of protection. A survey of skiers at resorts in the western United States found that nearly all children under age 20 (85 to 93 percent) were wearing sunscreen, sunscreen lip balm, and sunglasses that blocked UVR.42 European studies on parents and adolescents also have shown incomplete sun protection for children,31,43 an over-reliance on sunscreen, and less regular use of protective clothing and hats for children.31,44 Parent and child sun safety was correlated in the European samples as it was in the North American studies,31 and younger children were most protected.43 The over-reliance on sunscreen is problematic if parents do not properly apply it to children—a sample of Danish parents applied only one-quarter to one-third of the amount of sunscreen recommended by either the United States Food and Drug Administration (FDA) or Deutsches Institut fu¨r Normung (DIN) to achieve maximum protection45— or use it to extend rather than reduce sun exposure.31

Children’s Sunburn History Given the high level of sun exposure and modest sun protection measures for children in North American and European studies, it is not surprising that sunburning is a frequent occurrence in childhood. Severe sunburns before age 20 may double lifetime risk of developing melanoma.8 One North American study estimated that 53% of infants and young children had a history of sunburning, and 31% had received either moderate or severe sunburns.26 Two studies of adolescents found a higher frequency of all types of sunburning (82% had at least one burn in the previous summer; 25% and 16% on the previous Saturday and Sunday, respectively),30 and a similar frequency of severe sunburns (33% experienced a blistering sunburn in the previous two summers).29 Moreover, just over half of adolescents who used artificial tanning devices had experienced sunburns, blistering, peeling skin, or skin rashes after using them.35 Evidence of frequent sunburning also has come from a survey of 400 Florida pediatricians, 69% of whom treated up to five cases of sunburn per month in the summer.46 European statistics also revealed a pattern of overexposure: 38% of a sample of British parents reported that their preadolescent children had been sunburned at least once in the

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past (13%, three or more times);43 58% of French parents reported at least one light sunburn and 10%, at least one severe sunburn on their infants and young children; and 88% of another sample of French parents reported at least one light sunburn, and 50% at least one severe sunburn on their adolescent children.31 Care should be taken about interpreting the exact percentages too literally, as they come from varied questions with severity and time-interval often differently defined. Further, some variation would be expected as a function of latitude of the population (e.g., UVR levels) and of skin type, as well as due to behavioral factors.

Parent’s and Children’s Sun Safety Knowledge and Attitudes One of the more challenging aspects of these findings for dermatologists and cancer prevention specialists is that the high sun exposure, modest sun protection, and frequent sunburning of children occurs even though many North American and European parents are knowledgeable of the relationship between sun exposure and skin cancer.26,28,44,47 Some confusion was reported in a Scottish sample over the most suitable sunscreen to use with children, the most appropriate interval for reapplication, and the use of aftersun lotions on children.47 Knowledge cannot be assumed; clear guidelines are always necessary. Also, parents may not receive enough warnings about the dangers of sun exposure for children, particularly from physicians.28,39,46 Finally, parents’ sun-related attitudes may mitigate against prevention. North American parents still may believe that a tan makes people look better26 and that children are unlikely to develop skin cancer in their lifetime.28 Surveys of children in North America and Europe show an increasing knowledge of the harmful effects of skin cancer and sun precautions with age in preadolescent children48 –50 and moderately high knowledge among adolescent and college-aged children, including about the dangers associated with artificial tanning devices.30,33,35,41,51 Notably, sunscreen was the most wellknown protective measure among preadolescents, and the attractiveness of suntanning increased as children approached adolescence.49,50 Adolescent and collegeaged children may not understand that the rate of skin cancer is high in the United States;51 that suntanning is more harmful to adolescents than adults;35 how harmful sunburns can be;33 that sunscreens can reduce one’s risk of skin cancer;41 the meaning of SPF on sunscreens;41 the need for skin self-examinations;51 the appearance and symptoms of skin cancer;41,51 and the treatability of skin cancer.51 Unfortunately, like parents, older children in North America and Europe seemed to hold positive attitudes toward tanning.31,33 Many also may not feel highly susceptible to skin cancer.33

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Summary The context for childhood sun safety programs in North America and Europe is much less supportive of sun protection than in Australia. While many parents and children are aware of the risks of excessive sun exposure, many other areas are in need of considerable improvement before childhood sun protection will match that enjoyed by Australia’s youth. This context also presents many opportunities for child sun safety programs to be effective at enhancing the sun protection of their target groups. This apparent separation of knowledge, attitude, and behavior in several studies in Australia, North America, and Europe needs qualification. Because knowledge of what to do to protect one’s self from the sun is thought to be ubiquitous in these regions, most measures of knowledge assess esoteric aspects of sun protection knowledge (knowledge that does not necessarily relate to any specific behavioral response). Thus, the finding of little or no relationship between knowledge, attitudes, and/or behavior should be read as there is little or no relationship between having a lot of esoteric knowledge about the topic and attitudes and behavior. However, it remains the case that a person needs to have the requisite behavior-relevant knowledge, if they are to deliberately engage in sun protection behavior, e.g., knowledge of the existence and utility of sunscreen is prerequisite to using sunscreen for protection purposes. The relationship between attitudes and behavior is also complex. As we have noted, girls in Australia and possibly in North America have more positive attitudes toward sun protection and report protecting themselves better, but they also are more interested in actively seeking a suntan. This pattern of belief and behaviors is not as inconsistent as it may appear. It suggests that girls and women are more cautious when out in the sun and often act to reduce their risk of sunburn, but they may in some cases do so in a way that does not preclude, or indeed may facilitate, getting a better tan. By contrast, boys who desire a tan see it as a desirable side effect of engaging in other outdoor activities. Because sun seeking is not central to their thinking, boy’s concern about protection is less focal than may be the case among girls who seek a tan directly. Thus, some older children may try to achieve two partly incompatible goals and make some progress toward achieving both. These findings suggest the need to be quite sophisticated regarding which sun-related attitudes are measured and how they might relate to particular kinds of sun safety behaviors. It is instructive to be sensitive to the fact that individual behaviors within a complex pattern like sun safety are best predicted by attitudes toward each behavior, not general attitudes toward the domain of sun safety of which each behavior is a con-

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stituent part, and that attitudes toward different behaviors can conflict with one another. The following is a summary of goals for sun safety programs for children in North America and Europe. Y Children in North America and Europe are frequently exposed to UVR, so sun safety programs continue to be a priority. Y Boys may have more overall exposure but older girls may spend more time intentionally sunbathing. Sun safety programs must convince boys that they need to take precautions even though they do not deliberately sunbathe and must counter the suntanning norms held by girls. Y Sunbathing and sun precautions by parents may determine sun exposure and sun safety by their children, so sun safety programs must try to improve parent sun precautions, not just protection for children. Y Sunburning is very prevalent in North American and European children. Sun safety programs must seek to eliminate burning because of the link between severe burns and melanoma formation. Y Exposure to artificial sources of UVR begins in adolescence and is most prevalent among girls and possibly those with more sun sensitive skin. Sun safety programs for adolescents should include strategies aimed primarily at girls to reduce the use of artificial UVR devices. Also, programs must eliminate the beliefs that suntans obtained with these devices are safe and protect against the harmful effects of natural UVR. Y Children even at very young ages are incompletely and inadequately protected against sun exposure in North America and Europe. Sun safety programs must begin with parents at the birth of their children and utilize several community channels to ensure that parents hear warnings frequently. Y Unprotected UVR exposure increases during adolescence. Sun safety programs must directly communicate with children at older ages and use strategies that decrease the attractiveness of suntanning, highlight the benefits of sun safety, increase the awareness of and perceived susceptibility to skin cancer, and convince parents and children to take precautions even in nonrecreational outdoor activities. Improvements in knowledge may produce some gains in prevention, but knowledge does not appear to have produced adequate protection. Peers, and in some cases parents, are important agents for influencing adolescents to take precautions. Y Parents and children over-rely on sunscreen and sun safety programs should convince them to use other protective measures that actually block UVR, not to use sunscreen to prolong exposure, and to apply

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enough sunscreen to achieve maximum effectiveness. Y Organizations that care for and work with children (e.g., child care centers) are not providing adequate sun protection. Environmental and policy changes to improve sun safety at these organizations is another priority for sun safety programs. Y Parents and older children understand the relationship between sun exposure and skin cancer, and proper precautions against this skin damage are well known by these groups. Sun safety programs designed merely to improve knowledge are appropriate only for young children; they are unlikely to achieve substantial gains in sun safety among older children and parents. Programs for older children and parents must focus on strategies that promote prevention, that persuade parents and children to adopt sun safety, and that enable them to implement these precautions effectively whenever and whereever they are outdoors. Y Older children might be taught how to perform skin self-examinations; however, it is important to make them understand that normal moles develop in children. If we encourage skin self-examinations, we need to be doing it in the context of understanding skin, not looking for changing moles. Or else, we could have millions of harmless moles being needlessly removed from children’s skin and a lot of unnecessary worry by children and their parents.

Sun Safety Programs for Children Evaluations of the effectiveness of sun safety programs for children have been most frequent in North America. Programs for preadolescent children have garnered the most attention, but evaluations of programs for infants and preschoolers are increasing in number. Only one study has been reported that assessed the impact of a sun safety program for adolescents and only two, for college-aged children. There have been relatively few evaluations of programs or program features for children in Australia because many are incorporated within society-wide sun safety campaigns that do not lend themselves to study of features for children apart from those for adults. There have been almost no evaluations published on programs in Europe, with the exception of a program in Sweden.

Programs for Infants and Preschool Children Programs in North America Two programs to increase sun safety for infants and preschool students have been evaluated in North America in randomized trials. One program tested two sun safety interventions for parents of newborn infants.52 The low-intensity program consisted of providing parents with a list of simple guidelines for minimiz-

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ing sun exposure at the hospital following the birth of the child and a postcard sent the following summer with a message recommending that parents limit sun exposure. In the high intensity program parents received a pamphlet on sun protection, sunscreen samples, a baby sun hat and sun umbrella, as well as the list of guidelines and a postcard. Mothers enrolled in both programs reported less sun exposure (i.e., less unprotected time in sun; less time in direct sunlight, less time in shade, and less total time outdoors) for both themselves and their infants compared to a control group of mothers who did not receive these sun safety materials. There was no increase in the use of items that physically blocked the sun (e.g., hats, stroller hoods, umbrellas, clothing) by mothers receiving the interventions. There also was no difference between the two programs in mothers’ reported sun exposure. The Be Sun Safe sun safety curriculum designed to train children in three simple sun safety skills—find shade, cover up, and ask parents and adults for sun safe products (e.g., sunscreen)—successfully increased preschool students (aged 4 –5) sun safety knowledge in a study conducted in 12 preschools in Arizona.53 Sun safety comprehension was higher in the intervention classrooms both at two-week and seven-week follow-up tests, and there were no gender differences. However, the curriculum did not improve children’s ability to apply this knowledge. There are now several trials underway that will provide additional information on effective strategies for improving sun safety for infants and preschool children. The programs are being delivered through child care organizations (at the University of Illinois, Chicago, and Arizona Department of Health Services) and family physicians and pediatricians in community and managed-care environments (at Dartmouth University and the University of Colorado Health Sciences Center). Sun safety counseling by pediatricians, in particular, is a high priority.6 A recent survey reported that 70% of physicians said they educate parents about sun protection, and nearly half said that they perform skin examinations on patients with risk factors for melanoma. Most pediatricians felt that sun safety would not interfere with family lifestyle (88%) and that they should intervene to improve sun safety by their patients, when indicated (79%).54 Trials in Colorado and Arizona are assessing the effectiveness of physician counseling on sun safety for parents and children. Swedish Program for Nursery Schools As part of a large sun safety program in Stockholm, Sweden, information on awareness, etiology, and prevention of melanoma was provided to nursery school head teachers and coordinators of day care centers in lectures or by mail. A survey of nursery school administrators found that diffusion of the information on sun

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safety to school staff and parents was better if the nursery schools received the information by lecture rather than mail.55 No data were reported on the actual impact of this information on institutional or personal sun safety.

School-based Programs for Preadolescent and Adolescent Children in North America Nearly all of the sun safety programs for preadolescents and adolescents in North America have been implemented in schools, and most have directly communicated prevention information and advice to children. Schools offer many advantages to sun safety programs, including regular access to nearly all preadolescent children and a concern for the health of children by teachers and school administrators. However, school-based programs face challenges from the shrinking resources of many schools and the competing demands on the limited time devoted to health education from advocates of other disease prevention efforts. Perhaps it is not surprising that many of the programs have been implemented in southern regions of North America (e.g., Arizona, California, Florida, Texas), where sun exposure and skin cancer rates are highest. Schoolbased programs range from short presentations on skin cancer prevention strategies to comprehensive, multiunit sun safety curricula. Several projects are in progress that are evaluating non-school-based sun safety programs for preadolescent and adolescent children. The Canadian Dermatology Association’s national Sun Awareness Program focused on childhood sun protection in 1992, with the release of an eight-page brochure, but a curriculum for children in grades 1–3 is the centerpiece of this program’s approach.56 In Hawaii, a four-week program was implemented in outdoor summer recreation sites and consisted of staff training, group activities with children aged 6 to 8, take-home booklets, children and staff incentives, free sunscreen, and sun safe environment and policy promotion. A preliminary nonexperimental field test (i.e., no control group) showed that parents’ reports of sun protection for the parent and child and of sun safety policies at the outdoor recreation site improved at posttest. Recreation staff also reported stronger norms for sun protection at posttest.57 Two additional projects have integrated sun safety education for children into aquatic education delivered by swimming instructors in San Diego and Houston, and another, in soccer leagues in Georgia. Finally, three studies in New England are providing sun safety programs for beachgoers and residents of a beach community. Outcomes of these trials are still pending. Short Duration School Programs Short duration programs typically have been delivered in either one or two sessions by the classroom teach-

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er,58,59 an older student trained in implementation,60,61 or by a member of the evaluation team (i.e., university faculty, county extension educator, public health nurse, or graduate students).32,62 In all cases, the presentations were supplemented by written materials such as activity sheets, take-home exercises, and picture books59,61 or a health fair or field day that included interactive activities on sun safety.58,62 Three studies evaluated the effectiveness of these short programs using randomized designs with control groups so comparisons could be made between children who received the program and those that did not. A program in Wisconsin providing sun safety presentations to children in third grade from high-school-aged facilitators found that the short program increased children’s knowledge of sun safety.61 Another study, conducted on children in fourth grade in Arizona, evaluated a one-hour lecture on sun safety from the classroom teacher, with in-class activities, and a health fair with eight activities on sun safety implemented by health educators.58 Both the lecture and fair increased preadolescent’s ability to recognize sun safety terms used in the lecture and health fair, and their sun safety knowledge and these gains persisted throughout the next summer. The lecture produced somewhat greater increases in knowledge, while the fair produced less positive attitudes toward tanning. The differences between the two interventions and the effect on children’s attitudes toward tanning were not present at the end of the following summer, suggesting that knowledge acquisition is more long-lived than attitude change as a result of short programs. Finally, neither intervention increased reported sun precautions immediately, but children receiving the interventions reported that they tried to play outside early in the morning or late in the afternoon more frequently during the following summer than did children in the control group who did not receive the interventions. A project in Chicago delivered a short program to ninth and tenth graders, consisting of a 45-minute lecture and a 12-minute videotape explaining the dangers of and risk factors for skin cancer and describing prevention methods. Students also completed a worksheet assessing their personal risk for skin damage and engaged in class discussions of the barriers to prevention. The program increased students’ knowledge of skin cancer and sun safety and perceived susceptibility to skin cancer. Knowledge gains were greatest in ninth graders. The program did not increase students’ perceived benefits of prevention or reported likelihood of taking precautions.32 A follow-up study on an expanded program for adolescents is currently underway at the University of Illinois. The other studies evaluating short programs employed nonexperimental designs that lacked comparisons to a no-treatment control group, so conclusions

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about their effectiveness are tenuous. In a study in California, third graders’ knowledge of sun safety improved from pretest to posttest after teachers read a picture book containing a rhyme promoting sun awareness (i.e., sun’s effects on the skin, effectiveness of sunscreens for protection, differences between skin types, and information on skin cancer).59 Similarly, children in fifth and sixth grades in Minnesota showed more knowledge of the sun’s effect on the skin, less favorable attitudes toward tanning, and greater intentions to take precautions against sun exposure following a classroom intervention delivered by other students and an outdoor field experience delivered by health educators. The changes in attitudes toward tanning and intentions to practice prevention were higher in girls than boys.62 In a Texas school, children in third through seventh grade performed skits for first graders on sun safety and helped them complete a coloring book with information on sun safety. Both the third through seventh graders and the first graders learned information about sun safety from pretest to posttest.60 Multiunit School Curricula Recently, multiunit sun safety curricula have been developed for preadolescent children at several ages. One of the first multiunit sun safety curriculum for preadolescent children contained units on the benefits of sun for life on earth, functions of the human skin, positive and negative aspects of the sun, skin cancer, and methods of preventing skin damage.63 An evaluation of this curriculum in fourth and fifth grade classes showed that it improved children’s knowledge and attitudes related to sun safety. In another project, the American Cancer Society’s skin cancer prevention curriculum was used to teach sun safety to children aged five to seven years in the Cloverbud program of the Wisconsin 4-H. Leaders of the 4-H chapters conducted the program that also contained a survey of the family’s sun safety, science projects, art activities, and a board game. Children in two Cloverbud groups who received the curriculum showed an increase in their sun-related knowledge from pretest to posttest relative to two groups who served as controls.64 A comprehensive multiunit curriculum for preadolescent children, Sunny Days, Healthy Ways, has been developed and evaluated in a research program in Arizona.48,65,66 The curriculum contains six multidisciplinary age-appropriate components at each grade level for kindergarten through fifth grade, with content intended to satisfy state and local curricular mandates in a variety of subjects like math, science, language arts, fine art, music, and culture. Each component contains three to five units and is delivered by the classroom teacher. Components for the youngest grades stress comprehension and application of simple sun safety skills. Components for older grades contain increas-

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ingly sophisticated information about environmental and biological science related to the sun and sun damage, along with additional training and practice on sun safety skills. Skin cancer is not introduced until fourth grade because children have little concept of chronic disease until that age. The curriculum comprises primarily interactive exercises and demonstrations; components for the oldest grades contain some lecturebased lessons. In three field tests, students receiving the curriculum demonstrated substantial gains in sun-related knowledge, more positive attitudes toward prevention (i.e., fewer barriers to sunscreen use), less favorable attitudes toward suntanning, more reported sun protection behavior, and in one study, less actual sun exposure as measured by skin color changes associated with suntanning.48,65,66 The improved sun-related knowledge persisted over several weeks and months, as did some of the attitudes supporting prevention and reported sun precautions.48,65 Children in the youngest grades primarily showed increases in knowledge, with no change in actual sun exposure.66 Also, sixth graders in one study held less favorable attitudes toward prevention after receiving the curriculum, implying that additional strategies may be required to motivate adolescents to practice sun safety.65 The effect of curriculum repetition is being tested in a current field trial on the Sunny Days, Healthy Ways curriculum. Additionally, an interactive multimedia program to supplement the curriculum components for fourth and fifth grades is under development. A project to create and evaluate components of the Sunny Days, Healthy Ways curriculum for grades six to eight will begin in 1998 at the AMC Cancer Research Center in Denver and the University of Alabama, Birmingham. One project has shown that a curriculum can be effective at improving knowledge among students in grades seven and eight.63 Two other sun safety curricula for preadolescent children are currently being evaluated at Dartmouth University and the M.D. Anderson Cancer Center in Texas. The latter curriculum also has a component for middle and high school students. The results of field trials on these two curricula will be available in the future.

Programs for Preadolescent and Adolescent Children in Australia In New South Wales, Girgis and associates67 conducted a controlled trial in schools that assessed the differential effectiveness of two school-based interventions at increasing the knowledge, attitudes, and solar protection behaviors of 9- to 11-year-olds. An intensive program, called the Skin Safe program, was implemented over a four-week period as part of the school curriculum. The standard program was of short-duration and consisted of a 30-minute lecture by a health educator. Compared

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to a control group that received no intervention and the standard intervention group, students in the intensive intervention group were more likely to have used a high level of solar protection at both four-week and eight-month follow-up posttests. Thus, a multiunit intervention integrated into the school curriculum was more effective than a short-duration intervention in actually changing students’ solar protection behavior, as was the case in the North American studies. Also in New South Wales, Sanson-Fisher68 –70 showed that a mass-media-based campaign targeted at 11- to 16-year-old teenagers has been successful in encouraging increased sun protection and in reducing sunburn levels. Girls increased their reported protection more than boys, but from a lower baseline level of protection. Similarly, 14- to 16-year-olds improved more than 11- to 13-year-olds, again from a lower baseline level. In both cases, the most recent data suggest no age or sex differences in level of protection following the campaign.

Programs for Parents of Preadolescent Children in North America Two recent projects have evaluated sun protection programs delivered to parents of preadolescent children.71–74 An informative presentation on skin cancer facts and sun protection behaviors or experiential groups discussions on skin cancer and sun protection and presentation by a melanoma survivor were delivered to parents with children between six months and 10 years in Florida. Both interventions improved parents’ knowledge of skin cancer and sun protection, attitudes in favor of sun protection, and reported sun protection behaviors. The effects of the experiential program showed more persistence (at the 12-week followup) than those of the informative presentation, which diminished but did not disappear after 12 weeks. The effectiveness of a sun safety program for parents with children aged 5 to 11 years is currently being evaluated in three studies in Arizona.71–73 In the program, parents received four newsletters, three brochures, and three tip cards containing information on sun safety skills, tips for teaching children to be sun safe, and persuasive appeals to practice more sun safety. Their children also received newsletters containing exercises and activities based on the Sunny Days, Healthy Ways skin cancer prevention curriculum described above. All materials were mailed to parents, who were recruited either from public elementary schools or pediatric practices. In the first study, the format of the persuasive messages in the parent materials was evaluated. Messages that employed high as opposed to low language intensity produced more reported sun protection by parents for their children. High intensity appeals that were formatted in a deductive logical style (problem to solution or evidence with

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explicit conclusions) yielded the most improvements in parents’ own sun safety. Similar effects were evident in parents’ attitudes and self-efficacy expectations related to sun precautions.71 Further analyses showed that inductively formatted messages (i.e., provided only a listing of facts about skin cancer and sun precautions) improved the sun safety of parents who had no plans to increase their precautions prior to the program, presumably because these parents did not like being pushed to make a particular decision. By contrast, deductively formatted messages improved the sun safety of those who did plan to take more precautions, most likely because such messages reinforced their plans to take action.73 In a second study, messages from school principals and office-based counseling by pediatricians were evaluated and did not improve the effectiveness of the direct-mail program. The first two studies also showed that the program stimulated communication between parents and children on sun safety.75 A third study is presently underway to evaluate the entire sun safety program for parents in a randomized trial. This project is also testing the effects of repeating the program over two summers as opposed to a single summer.

Swedish Program in Child Health Centers and Schools The sun safety project in Stockholm reviewed earlier also provided information on etiology and prevention of melanoma to pediatric medical officers and nurses at child health centers in 45-minute lectures or by mail. A survey of these centers found that 86% reported receiving the information, 80% of nurses desired additional sun safety information, and 97% said that information on skin cancer and sun precautions was given to parents. However, only 35% of parents surveyed at two of the centers reported that they actually received such information from the center staff.55 The program planners in this program also added sections on sun awareness to the three biology and health education textbooks most frequently used in schools in the Stockholm region. Planners also produced a 43-page textbook and 12-minute video on sun awareness for parents and professionals working with kids.55 To date, no data on the efficacy or effectiveness of this school-based program has been published.

Programs for High School and College-Aged Children in North America and Australia There have been only three published reports on projects evaluating sun safety messages with high school and college-aged students. None of these projects were evaluated in a large, sophisticated skin cancer prevention program or integrated into schools or organizations that provide educational, social, or health services to this group. Instead, these studies focused on reactions to single messages or a very short program by

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samples of undergraduate students enrolled in fouryear colleges. One experiment had undergraduate students read one of three different warnings to apply sunscreen when exposed to the sun: One was accompanied by information on the health effects of unprotected sun exposure (health-based warning), another by information on the effects on the physical appearance of the skin (appearance-based warning), and a third by no additional information (unsupported warning). The undergraduate students felt that the health-based and appearance-based warnings were more convincing than the unsupported warning; but those reading the appearance-based and unsupported warnings were more concerned about the effects of the sun than those reading the health-based admonition.76 In another study, college students and high school students received a 25- to 30-minute presentation on basic facts about skin cancer and preventive measures, followed by a brief question and answer session. Sunrelated knowledge improved at both ages, but it declined somewhat at a two-week follow-up.51 Finally, in an experiment conducted on a sample of Australian university students, an emotionally charged eight-minute videotape containing interviews with people diagnosed with melanoma and an informational videotape on the causes, consequences, and incidence of skin cancer with advice on sun protective behavior both increased intentions to take precautions.77 However, only the effects of the emotionally charged videotape persisted 10 weeks after presentation. Neither videotapes improved the frequency of skin self-examinations by these students. Following are successful strategies for sun safety education of children.

Strategies for Communicating with Children Y Children as young as four years of age can be taught simple sun safety skills. Y Programs for very young children should focus on parents and children, together, because even preschoolers may not have enough autonomy and skill to apply sun safety skills. Y Short presentations or programs can effectively teach children information about the sun, its effects on the skin, and ways of protecting the skin against sun damage. Y Short presentations or programs may cultivate opinions that support prevention, but these attitudes may be short-lived. Y Short presentations or programs can improve children’s intentions to practice prevention but are unlikely to convince children to adopt long-term sun safety practices. Y Comprehensive, multiunit sun safety curricula can substantially improve children’s sun safety knowledge, may produce sustained changes in attitudes,

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and may stimulate actual improvements in sun protection. Y The adoption of sun safety curricula by schools will be facilitated if these programs can be easily integrated with state and local curricular requirements. Y Sun safety education may be more effective at increasing sun precautions by girls, who currently take more precautions than boys. Whether they can actually reduce deliberate suntanning by girls, however, is unknown. Y Emotionally charged content on sun safety may produce more enduring decisions to adopt prevention practices by older children.

Strategies for Communicating with Parents, Medical Professionals, and Adult Caregivers Y Parents are an important and responsive audience for sun safety programs aimed at improving sun precautions for their children. Y It is always easier to practice sun protection in an environment that supports it, e.g., one with plenty of shade, minimum demands to be out in the sun, and prompts to remind children and parents to protect themselves. Y Public pressure for structural change emerges as parents realize the difficulty of achieving sun protection in a non-supportive environment. Y Sun safety programs for parents and sun safety curricula for children can provoke discussions between parents and children on sun protection skills. Y Generally speaking, parents respond best to messages with intense language and that contain explicit conclusions and recommendations about their risk for skin cancer and precautions they can take to reduce this risk. Y Parents who have not made a decision to increase their sun safety should be approached with less directive recommendations; they should be encouraged to consider the evidence on sun exposure and skin cancer and reach a conclusion to take more precautions on their own. Y Parents who plan to improve their sun safety should have this decision reinforced and should be reminded to take action. Y Programs to educate medical professionals that care for children and day care and school staff can improve their dissemination of skin cancer prevention messages to their patients and clients.

Conclusions Sun safety continues to be a priority for children, particularly in North America and Europe, where skin cancer prevention campaigns lag far behind the sustained society-wide programs in Australia. The research conducted on programs in North America for

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youth also demonstrate that children are capable of learning and deploying prevention strategies and that parents and other adults caring for children are responsive to sun safety recommendations. At the same time, there are considerable gaps in our understanding of how to effectively communicate with and motivate children, particularly during adolescence and later at college age. In addition, most programs have been applied within day care, preschool, or school settings; programs that reach children through other community channels such as health and medical organizations, recreational leagues, and social organizations are just now being investigated. Also, the role of adults, other than teachers, needs further consideration in community-wide efforts to reduce children’s sun exposure, especially health professionals who are highly credible on medical topics at least for adults.28 The widespread knowledge of the harmful effects of sun exposure in North American and European adults bodes well for the future success of sun safety programs, as do the successes of Australian campaigns with children and adults and in institutional policies and personal behaviors.

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