Research articleMailed Intervention to Promote Sun Protection of Children: A Randomized Controlled Trial
Introduction
Skin cancer incidence is increasing dramatically and is caused largely by sun exposure.1, 2, 3 Exposure in childhood is particularly important for risk.4, 5 Prevention efforts have focused on minimizing ultraviolet (UV) exposure through a combination of avoiding the midday sun, wearing clothing and hats, seeking shade, and using sunscreen. Although studies show widespread sunscreen use, the use of other sun protection strategies has lagged.6 Interventions are particularly needed to promote the use of hats and clothing, which a recent study showed may be more effective than sunscreen in reducing skin cancer risk.7
Interventions in single settings have been effective for improving the UV protection of children, including school-based programs8, 9, 10, 11, 12, 13, 14, 15, 16; programs at swimming pools and zoos17, 18, 19; programs in pediatric care settings20, 21, 22; and multimedia computer programs.23, 24 The most successful interventions for changing sun protection behaviors of parents and children have been community-wide, multicomponent approaches.25, 26 However, research is needed to inform evidence-based decision making about effective components for comprehensive interventions, particularly for children approaching adolescence, when their responsibility for preventive behaviors increases. Effective interventions are needed that promote behavior change to both parents and children and encourage family communication about sun protection.
The present study evaluated the effectiveness of a partially tailored newsletter intervention, supplemented by sun protection resources, mailed to parents and children as the children aged from 6 to 9 years. The intervention was based on the Precaution Adoption Process Model (PAPM), a stage theory of health behavior change.27 The model is depicted in Figure 1 as applied in the current study for adoption of protective clothing. Movement through seven stages is hypothesized to be influenced by cognitive mediators, including knowledge of risk, personalization of risk, perception of risk severity, perception of effectiveness of preventive strategies, and perception of barriers to prevention strategies.27 It was hypothesized that the intervention would result in changes in PAPM cognitive mediators, PAPM stage of change, sun protection behaviors, sunburns, tanning, and development of nevi.
Section snippets
Study Design
The current study was a longitudinal RCT. Parent–child dyads were enrolled in 2003–2004, completed baseline measures in Summer 2004, and were randomized by computer to two groups, intervention or no-intervention control, in equal proportions in Spring 2005. Outcome assessments were conducted using annual telephone interviews of parents (cognitive outcomes, sun protection behaviors, and sun exposure experiences) and annual skin exams of children (total body nevus counts and tanning). The study
Participation Rates
Figure 2 presents the CONSORT chart. Of 919 families that indicated interest, 867 (94%) were enrolled and completed some portion of the baseline data collection; of these, the data for 677 white, non-Hispanic children were included in the present analysis. Participation in data collection was comparable between study groups throughout the follow-up period (2005–2007). Completion of interviews was 90%–97%, and completion of skin exams was 77%–82%. There were no consistent differences across
Discussion
This theory-based mailed intervention produced change in sun protection behaviors and the hypothesized cognitive mediators of these behaviors. Differences were found in all behaviors measured. Differences were small in magnitude, and within years, greater differences were found in behaviors emphasized by the intervention that year. The greater progression through the PAPM stages by the intervention group compared to the control group suggests the potential for future change. Studies of smoking
References (50)
- et al.
Meta-analysis of risk factors for cutaneous melanoma: IISun exposure
Eur J Cancer
(2005) - et al.
The epidemiology of UV induced skin cancer
J Photochem Photobiol B
(2001) - et al.
Block the sun, not the fun: evaluation of a skin cancer prevention program for child care centers
Am J Prev Med
(1999) - et al.
An intervention for parents to promote preschool children's sun protection: effects of Sun Protection is Fun!
Prev Med
(2005) - et al.
Reducing ultraviolet radiation exposure in children
Prev Med
(1997) - et al.
Promoting sun safety among zoo visitors
Prev Med
(2001) - et al.
A randomized intervention study of sun protection promotion in well-child care
Prev Med
(2006) - et al.
Interactive computer technology for skin cancer prevention targeting children
Am J Prev Med
(2000) - et al.
Development and reliability of a brief skin cancer risk assessment tool
Cancer Detect Prev
(2003) - et al.
Effect of hair color and sun sensitivity on nevus counts in white children in Colorado
J Am Acad Dermatol
(2010)