Research article
Mailed Intervention to Promote Sun Protection of Children: A Randomized Controlled Trial

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Background

Sun exposure, especially during childhood, is the most important preventable risk factor for skin cancer, yet few effective interventions to reduce exposure exist.

Purpose

To test the effectiveness of a partially tailored mailed intervention based on the Precaution Adoption Process Model, delivered in the spring over 3 years to parents and children.

Design

RCT, with data collection through telephone interviews of parents and skin exams of children at baseline (Summer 2004) and annually (Summer 2005–2007). The control group received no intervention.

Setting/participants

Families recruited in the Denver CO area, through private pediatric clinics, a large MCO, and community settings. Children born in 1998 were approximately 6 years of age at baseline; 867 children met inclusion criteria; analysis is reported for 677 white, non-Hispanic participants at highest risk for skin cancer.

Main outcome measures

Primary outcomes were parent-reported child sun protection behaviors. Secondary outcomes included parents' risk perception, perceived effectiveness of and barriers to prevention behaviors, stage of change, reported sunburns, and observed tanning and nevus development. The longitudinal mixed-model analysis was conducted between 2008 and 2011.

Results

The intervention group reported more use of sunscreen, protective clothing, hats, shade-seeking, and midday sun avoidance; fewer sunburns; more awareness of the risk of skin cancer; higher perceived effectiveness of sun protection; higher stage of change; and lower perception of barriers to sun protection (all p<0.05). The intervention group had fewer nevi ≥2 mm in 1 year of the study, 2006 (p=0.03). No differences were found in tanning or nevi <2 mm.

Conclusions

The level of behavior change associated with this single-modality intervention is not likely sufficient to reduce skin cancer risk. However, the intervention shows promise for inclusion in longer-term, multicomponent interventions that have sufficient intensity to affect skin cancer incidence.

Trial registration

This study is registered at www.clinicaltrials.gov NCT01464957.

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

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