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1999 26: 317Health Educ BehavDavid B. Buller and Ron Borland

Skin Cancer Prevention for Children: A Critical Review

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Health Education & Behavior(June 1999)Buller, Borland / Skin Cancer Prevention

Skin Cancer Prevention for Children:A Critical Review

David B. Buller, PhDRon Borland, PhD

Increasing sun protection for children may reduce their risk for skin cancer, so many health authorities rec-ommend comprehensive sun safety for children. Sun protection of children in North America and Europe is gen-erally lower than desired and lower than in Australia. This article provides a critical review of evaluations on theeffects of 24 sun protection programs for children under age 14. Programs are classified based on the targetpopulation, setting, and features. Most programs improved sun safety knowledge, but changes in sun protectionattitude and behaviors were smaller. Multiunit presentations were more effective than short-duration presenta-tions. Peer education was effective but needs further evaluation. Some programs for parents have been shown toincrease sun protection for children. Strategies to improve sun safety policies need further study. A fewcommunity-wide programs have effectively improved sun protection. Future research should address innova-tive strategies and issues of design and measurement. There is no gold standard for measuring sun protectionbehavior, but self-report, prospective diaries, and observational techniques show small positive correlations.

Reducing lifetime exposure to ultraviolet radiation and eliminating severe overexpo-sure prior to age 20 may substantially reduce the risk for nonmelanoma skin cancer andmelanoma. Consequently, several health authorities, including the U.S. Centers for Dis-ease Control and Prevention (CDC), the American Academy of Dermatology (AAD), theAmerican Cancer Society, and the National Health and Medical Research Council ofAustralia, recommend comprehensive sun safety for children of all ages. Recommenda-tions include engaging in behaviors that reduce unprotected sun exposure. Skin cancerexaminations (self or clinical) are not recommended for children as very few skin malig-nancies occur in youth. More than 15 years ago, Australian anticancer organizationslaunched society-wide programs to reduce exposure for children, as well as adults. InNorth America and Europe, some health organizations, like the CDC and AAD, are initi-ating large society-wide programs, but most programs reported to date have been deliv-ered on much smaller scales, primarily by researchers interested in examining whether aparticular approach will improve the children’s sun safety. This article provides a criticalreview of sun protection programs from Australia, North America, and Europe aimed atimproving sun safety of children from birth to age 13. (For a review of programs for olderadolescents, see Buller and Borland.1)

David B. Buller is a senior scientist at the Center for Behavioral Research, AMC Cancer Research Center,Denver, Colorado. Ron Borland is a deputy director, Centre for Behavioural Research in Cancer, at the Anti-Cancer Council of Victoria, Victoria, Australia.

Address reprint requests toDavid B. Buller, Center for Behavioral Research, AMC Cancer Research Center,1600 Pierce Street, Denver, CO 80214; phone: (303) 239-3511; fax: (303) 239-3521; e-mail: [email protected]..

Health Education & Behavior, Vol. 26 (3): 317-343 (June 1999)© 1999 by SOPHE

317

CURRENT STATUS OF CHILDHOOD SUN SAFETY

Before considering the effects of sun protection programs for children, it is useful toreview the current status of children’s sun protection, because it affects both the nature ofwhat is needed, the extent of change likely, and our criteria for judging program success.In North America, young children currently have a great deal of sun exposure, with esti-mates of time spent outdoors ranging from 2.5 to 3.0 hours daily.2,3 A European samplealso showed that 35% to 45% of children at age 3 and age 13-14 spent more than 15 hoursper week outside in swimming suits.4 Australian surveys estimated the incidence of pain-ful sunburning. In representative samples of secondary school children aged 11 to 17,about two-thirds reported painful sunburn during the summer.5,6 Similarly, surveys ofchildren in North America found high frequencies of all types of sunburning: 82% of ado-lescents in previous summer and 53% of infants and young children in the past.2,7 In Euro-pean studies, 38% of British parents and 58% of French parents reported one or more lightsunburns on their preadolescent children, 13% of British parents reported more than twosunburns, and 10% of French parents reports one or more severe sunburns.4,8

It is difficult to accurately quantify the total amount of sun protection currently prac-ticed by and for children, because the estimates come from measures of different behav-iors (e.g., ratings of typical behaviors, reports of behaviors at specific times), using differ-ent metrics. What can be said is that some children are protected at least some of the timein most studies. However, protection of children in North America and Europe appears tobe less regular than protection for Australian children. For instance, a 1997 national sur-vey in the United States found that 70% of adults report using one or more sun protectionbehaviors with their children, but use of particular behaviors like sunscreen, hats, shade,and clothing varied considerably from 8% (shirts) to 53% (sunscreen).9 Other NorthAmerican surveys also show moderate overall protection (28 out of a possible 44-pointsun protection index)2 and variable use of individual strategies, with sunscreen among themost common (32%).3 European studies also have shown incomplete sun protection forchildren,4,8 with higher use of sunscreen and lesser use of protective clothing and hats forchildren.4,10

Organizations that care for and educate children also have infrequent sun protectionactivities and many have no sun safety policies. Only 36% of child care centers in a NorthAmerican survey had more than half of the play area shaded, hats were observed on chil-dren in only 19% of centers, protective clothing and sunglasses were almost neverobserved, and only 56% of centers had adequate sun protection policies.11,12In New SouthWales, Australia, child care centers had only moderate sun safety policies and no relation-ship was found between the policies and protection for children.13 Another assessment in1989 found that 64% of primary schools in this region had a written policy on sun protec-tion and 70% gave some sun-related education, but 83% still sent children outside duringmidday hours and only 25% of playground areas were shaded.14 More recently, a study oflocal governments in Victoria, Australia, in 1993 found that more than three-quarters ofkindergartens reported that they had sun protection policies.15

These surveys on childhood sun safety show that there is a wide range of sun precau-tions practiced across countries and suggest that sun protection is higher in Australia thanin North America and Europe. This has implications for assessing the “success” of vari-ous sun safety programs for children in this review. With initial protection levels low, anysignificant gains in sun protection behavior as a result of North American and Europeanprograms will be considered a “success.” By contrast, in Australia, certain sun protectionbehaviors already are high, so some changes produced by programs for children, for

318 Health Education & Behavior(June 1999)

example, reducing intentional suntanning and improving sun safety policy and environ-mental supports, are more important than others for further improving their overall pro-tection. The magnitude of program effects is important for judging success, but evalua-tions of specific programs in Australia are unlikely to show gains in prevention as large asthose seen in North America and Europe, because current protection levels are alreadyhigh there.

CRITICAL REVIEW OF CHILDHOODSUN PROTECTION PROGRAMS

Inclusion Criteria and Search Procedures

In this review, we included evaluations whose aims were to test the effects of a sun pro-tection program at improving the sun safety of children, at least some of whom wereunder age 14. Sun safety was broadly defined in terms of outcomes to include improve-ments in knowledge, attitudes, behavioral intentions, or behaviors related to reducing sunexposure to decrease the risk of primarily skin cancer. Published evaluations were identi-fied through searches of the online Medline database and examination of reference lists ofpublished articles. We also included a few unpublished reports from our own researchprograms in this area, papers presented at recent professional meetings, and the articlescontributed to this special issue. Using these inclusion criteria and selection methods, weidentified reports on evaluations of 24 sun safety programs for children under age 14 (seeTables 1 to 5).

Classifying Program Evaluation Studies

There are several ways one could catalogue the published evaluations of sun safetyprograms for children. We considered the programs’theoretical foundations, target popu-lations, settings, and features of the sun protection programs. Only nine of the evaluationsexplicitly cited a theory that guided the development of the program, as noted in thetables. Instead, we distinguish between programs on broad categories within the otherthree variables.

We began by separating studies on whether they delivered sun safety messagesdirectly to children16-31or to their parents or adult caregivers.16-18,21,24,25,27,31-36This distinctionwas fairly easy to classify, as very few studies combined these methods. Direct instructionto children has been limited mainly to school-age children (6-12 years), but one evalua-tion examined a program for preschool children.23

Four different settings have been common within the programs that were evaluated.The most popular settings for sun safety education for children have beenschools,16-19,22,26,28-30,33,35which offer many advantages like compulsory regular attendance,health education as a recognized mission, and organizational structures that can be usedto improve program implementation and evaluation. A second setting for direct instruc-tion of children has been child care organizations,23 recreational sites,21,24,25,31and serviceprograms (e.g., 4-H)27 for children, which are other formal community organizations thatserve large numbers of children. A third setting has been the home, where programs havetried to involve parents and children together in sun protection.21,24,31,34Other settings forsun safety programs are health care environments, including pediatric and family prac-tices34 and a hospital.32

Buller, Borland / Skin Cancer Prevention 319

The features of the programs can be separated into four categories. Many programsrely on presentations and activities by teachers.16-18,20,22,26,29,30Others have involved presen-tations by other types of adult instructors, like recreation staff,21,24,31health educators,23,24

melanoma survivors,33 or 4-H leaders.27 These programs were separated further intoshort-duration (usually one presentation of 30-60 minutes) or multiunit presentations(several presentations during several days). The latter included several curricula that con-tained a series of instructional materials on several topics related to sun safety. A thirdclass of features was the delivery of sun safety education by laypeople, peer educators,19,22,27,28or community groups of adults.21 Fourth, some programs designed for parents haveused videotapes32,33 and direct mail.34,36

The small number of published evaluations on community-wide sun safety pro-grams37-44did not fit well into these classifications based on target population, setting, andprogram features, as they combined several formats of these three variables. They are dis-cussed separately at the end of the review and summarized in Table 5.

Finally, it was important to classify evaluations of sun safety programs on the qualityof the evaluation design. Higher quality designs are those that reduce the possibility ofrival hypotheses by eliminating threats to internal validity.45 Two features, randomizationof experimental units (e.g., people, schools) to study conditions and comparison ofchanges in treated units to untreated controls, eliminate many of these rival hypothesesand are noted here.

RESULTS FROM EVALUATIONSOF PROGRAMS FOR CHILDREN

Short-Duration Presentations (Table 1)

Programs using short-duration presentations have primarily been able to increase chil-dren’s knowledge related to sun safety. They have had weaker effects on attitudes and sunprotection behavior. In a randomized evaluation of short-duration programs (i.e., ran-domization of schools to single lecture from teacher, attendance at sun safety health fair,or control by fourth graders),18 children’s knowledge of sun protection improved frompretest to posttest compared with children in the control conditions both immediately fol-lowing the intervention and at a three-month follow-up at the end of the summer. The lec-ture produced slightly larger knowledge gains than attending a sun safety health fair, butthe fair reduced positive attitudes toward tanning more than the lecture. However, bothhad diminished by the end of the summer. At the end of the summer, children receivingthe intervention reported that they more frequently tried to avoid midday sun exposurethan control children, but those receiving the fair also reported laying out in the sun to tanmore frequently.

Nonrandomized evaluations of short-duration programs show that they can improvechildren’s knowledge about sun protection and, in some cases, attitudes and sun protec-tion behavior. Third graders’ knowledge of sun safety improved from pretest to posttestafter teachers read a picture book containing a sun protection rhyme, and the increase wasstill present after six weeks.29 Third through sixth graders had more understanding of sunprotection concepts, improved attitudes toward sun protection, and reported increasedprotection behavior after a single lecture or an interactive question-and-answer session.30

Fifth and sixth graders showed more knowledge of the sun’s effect on the skin, less favor-able attitudes toward tanning, and greater intentions to take precautions against sun


321

Table 1. Evaluations of Skin Cancer Prevention Programs for Children Under Age 14: Short-Duration Presentations

Intervention Evaluation MeasurementStudy Theory Sample Setting Strategies Design Instruments Findings

M. Buller None 232 children in 13 Classroom Curriculum: teacher materials, Randomized Child reports: Children’s knowledge increased 4.41 and 6.66et al. (1997)18 fourth-grade classes (Tucson, in-class activities presented pretest-posttest 10 term recognition correct responses immediately following

in three public AZ) in 1-hour session by teacher control group items (α = .51-.56) health fair and lecture, respectively, overelementary schools Health fair: interactive, health design 35 knowledge items control. Reported parental sun protection

educator–implemented Schools assigned (α = .81-83) for children increased 0.85 and 0.75 scaleactivities; students participated to one of the 11 attitude items units immediately over controls. Children’sin at least six of eight stations interventions or (α = .27-.73) attitude toward tanning decreased 0.35 andfor 45 to 90 minutes to no treatment 13 child protection 0.14 scale units immediately over controls.

control group items (α = .54-.76) Children’s knowledge remained higher atFollow-up 10 parent protection 3-month follow-up than controls. Childrenimmediately after items (α = .83-.84) reported more frequently playing outsideintervention and early or late in the day (+.40 fair, +.24at 3 months lecture) but also more frequently laying out topostintervention get a tan (+.25, +.60) than controls

Vitols and None 983 students in grades Classroom A 30- to 40-minute teaching Randomized Child reports: Children’s knowledge of sun protectionOates (1997)30 3-6 (aged 8 to 12 (Australia) session pretest-posttest 18 knowledge items behaviors at pretest was high (>87% correct

years) Didactic (lecture only) or interac- factorial design 1 child protection responses). Proportion of children givingThree state and three tive form (lecture plus question- Classes assigned intention item correct responses increased at posttest on 17private schools from and-answer session) to one or the other of 18 questions. There were no significantSydney Covered functions of the skin; intervention differences between types of intervention

fact that sunburn can lead toskin cancer; and ways toprotect self

Stickers and coloring sheetson sun protection

(continued)

322

Table 1 Continued


LaBat et al. None 1,047 fifth and sixth Classroom Classroom intervention delivered Nonrandomized Child reports: Children’s sun safety knowledge (+.51-+1.06(1996)22 graders in four rural and outdoor by teachers pretest-posttest 4 knowledge items scale units), attitudes (+.82-+.87), and

schools school areas Effects of the sun, the relation- design 8 child protection reported use of sunscreen (+.47-+.49),(Minnesota) ship between the earth’s ozone No control group items hats (+.57-+.74), and protective clothing

layer and life on earth, and Follow-up 1 week (+.29-+.35), and avoidance of suntimes of the day when the sun postintervention exposure (+.26-+.31) increased from pretestis most hazardous to health to posttest

Field experience led byuniversity faculty, a countyextension educator, a publichealth nurse, and graduatestudents. Visual materials andprops were used to illustrateconcepts and involve theaudience

Thornton and None 82 third graders Classroom An educational picture book, Nonrandomized Child reports: Children’s posttest knowledge was 22.3%Piacquadio enrolled in two (San Diego) “A Day With Ray” pretest-posttest 16 knowledge items higher immediately after the intervention and(1996)29 San Diego–area Four broad categories of sun No control group 21.8% higher at 6-week follow-up compared

elementary schools, awareness incorporated into Follow-up with pretestone public and one the text: the sun’s effects on immediately and 6private, during the skin, effective sunscreens, weeks post-first half of the skin type, and skin cancer intervention1991-1992 schoolyear

exposure 1 week following a single classroom unit presented by teachers and a onetimeoutdoor field experience led by health educators.22

Multiunit Presentations (Table 2)

Most evaluations of multiunit sun protection instructional programs for childrenimplemented in preschool classes, primary schools, service clubs, and aquatics classeshave shown that these more intensive instructional programs can produce relatively largeincreases in children’s understanding of the sun, skin damage, and sun safety skills. Also,in most cases they have produced more positive attitudes toward sun safety and somechanges in sun protection behavior. The earliest reported evaluation of a multiunitinstruction program found that children in Grades 4 to 8 had a better understanding ofinformation related to sun protection and reported more frequent sun protection behavior.Students in Grades 4 and 5 expressed more favorable attitudes related to sun protection.26

The American Cancer Society’s (ACS)Children’s Guide to Sun Protectionalso improvedchildren’s sun safety knowledge when leaders of the 4-H’s Cloverbud Program used it toteach sun safety to children aged 5 to 7 years.27

A trial in New South Wales, Australia,20 also showed that an intensive 4-week instruc-tional program, theSkin Safeprogram, improved the sun protection behavior of 9- to 11-year-olds when assessed at 5 weeks and 8 months postintervention. An alternativeonetime 30-minute presentation also improved sun protection behavior at the 5-weekfollow-up, but not at the 8-month posttest.

Two field trials of theSunny Days, Healthy Wayscurriculum found that the curriculumhad positive effects on children. In a first study on instructional materials for Grades 4-6,16

children’s knowledge improved, attitudes toward tanning became less favorable, self-reported use of sunscreen in the winter increased, and laying out to get a tan decreasedafter receiving the curriculum, as compared to students in control classes. All of theseimprovements in sun safety persisted at similar levels in an 8-week follow-up assessment.In the 8-week follow-up, students receiving the curriculum also reported greater use of lipbalm, protective clothing, and less use of sandals, than students in control classes. A sec-ond evaluation with students in Grades 4-617 found that for students receiving the curricu-lum, their recognition of terms and knowledge related to sun protection improved, atti-tudes toward tanning became less favorable, barriers to sunscreen use decreased,self-reported use of sunscreen and use of protective clothing were more frequent, reportsof purposeful tanning declined, and skin tone was lighter (less tanned) by colorimetermeasure than for students in the control classes.

An evaluation of theBe Sun Safepreschool curriculum in Arizona, teaching three sim-ple skills—find shade, cover up, ask for sunscreen—showed that the interventionimproved understanding of sun safety among children as young as ages 4 and 5. Thosewho received this instruction had larger increases in knowledge and comprehension ofinstructions at both 2-week and 7-week postintervention assessments than children notreceiving the instruction.23

Contradictory findings were reported in one recent study on a program that used four5-minute presentations by aquatic instructors during swimming lessons along with infor-mation sent home for parents.24Parents’reports of the general use of hats by children werehigher in the intervention group, but sun protection as measured by colorimeter assess-ments of tanning, prospective diaries of child sun protection completed by parents, andparents’ ratings of the child’s general use of sunscreen with a sun protection factor (SPF)≥15 were not higher in the intervention than control groups.


(text continues on p. 327)

Table 2. Evaluations of Skin Cancer Prevention Programs for Children Under Age 14: Multiunit Presentations


Mayer et al. Social Total of 48 aquatic YMCA pools Duration of intervention: Randomized Parent reports on Intervention increased parents’ reported use(1997)24 Cognitive classes from four (San Diego, 6 weeks. At each of four pretest-posttest children: of hats by children (regression coefficient =

Theory YMCAs participated. CA) aquatic lessons, 5-min control group Prospective sun .319), but there was no significant effects ofClasses included 6- SUNWISE lesson was design protection diary on intervention on children’s solar protectionto 9-year-olds. Class incorporated at the beginning Classes assigned to 2 days pre- and diary score, colorimeter measures of skinsize ranged from two of class. Lessons centered intervention or 2 days post- tone, or parents’ reports of sunscreen useto seven children around four areas: sunscreen, control condition intervention

protective clothing, shade, in pairs of adjacent Child colorimeterand peak sunlight hours. time slots within measuresParents received a manual YMCAs (interraterα = .74-.99)with home-based activities Follow-up (intraraterα = .96-.99)in-person and by mail immediately

postinterventionD. Buller et al. None 447 fourth, fifth, and Classroom “Sunny Days, Healthy Ways” Randomized Child reports: Children’s knowledge (η2 = .43), attitudes(1996)17 sixth graders, (Tucson, AZ) curriculum pretest-posttest 10 term recognition supporting sun safety (.02), reported use of

24 classes Five multidisciplinary units Solomon four- items (α = .68-.74) sunscreen (.01-.03) and protective clothingTopics covered properties of the group design 35 knowledge items (.01), sun protection factor (SPF) of sunscreensun, composition of human skin, Schools assigned (α = .83-.86) used most often (.05), and avoidance ofhistoric attitudes toward tanning, to intervention or 11 attitude items tanning (.02) were higher in intervention thanskin cancer, and strategies to control group (α = .80-.83) control groups. Intervention children also hadreduce sun exposure in an inter- Within groups, 13 child protection lighter skin tones by colorimeter measures atactive lesson/activity format classes were items (α = .61-.78) posttest (.01-.04)

Student workbook randomly assigned 8 parent protectionto pretest or no items (α = .83-.84)pretest group and Child colorimeterimmediate or 6- measuresweek posttestfollow-up conditions

324

Loescher et al. Piaget’s 12 classes of 4- Classroom “Be Sun Safe Curriculum” Randomized Child reports: Program increased children’s knowledge(1995)23 Theory of to 5-year-old (Arizona) taught by research assistants pretest-posttest Pictorial knowledge (recall of instruction) and comprehension

Cognitive children at Three units taught during a control group test (knowledge, (understanding of instruction) at 2 weeksDevelop- 12 preschools 3-day consecutive period design comprehension, (+.04, +.09 units, respectively) and 7 weeksment Each unit 45 to 50 minutes in Classes assigned to application) (+.03, +.09) postintervention over control

length intervention or children but had no effect on children’scontrol group application of concepts to new situations

Follow-up at 2weeks or 7 weekspostintervention

Ramstack None 58 fourth-grade Classroom “Sunshine and Skin Cancer” Nonrandomized Child reports: Children in all grades had more knowledgeet al. (1986)26 students (Casa curricula pretest-posttest 15 attitude items (ps < .001) and reported more sun protection

267 fifth-grade Grande, AZ) Six units on the sun, the skin, design 11 child protection behavior (ps = .014 to < .001) at posttest thanStudents the sun-friend or foe, cancer No control group items at pretest. Children in Grades 4 and 5

82 sixth-grade and skin cancer, prevention of Follow-up expressed more favorable sun safety attitudesStudents sun damage, and a review immediately at posttest (ps = .004 to < .001)

212 seventh-grade postinterventionStudents

77 eighth-gradestudents

M. Buller Social 139 fourth, fifth, and Classroom “Sunshine and Skin Health” Randomized Child reports: Children’s knowledge (+9.57 correct items),et al. (1994)16 Cognitive sixth graders of two (Mesa, AZ) curriculum consisted of five pretest-posttest 10 term recognition reported use of sunscreen in winter (+.15

Theory elementary schools multidisciplinary units including control design items (α = .72-.76) scale units), and avoidance of tanning (+.36)the properties of the sun, the Schools assigned to 35 knowledge items were higher and attitudes toward tanningcomposition of human skin, either intervention (α = .80-.90) (+.19-+.29) lower immediately in interventionhistorical attitudes toward or control group 11 attitude items than control groups. Knowledge gains, highertanning, skin cancer, and Follow-up (α = .42-.77) use of sunscreen in winter, and less favorablesunlight awareness strategies immediately and 13 child protection tanning attitudes continued at 8-week follow-

at 8 weeks post- items (α = .52-.73) up in intervention children, when they alsointervention 8 parent protection reported higher use of lip balm (+.39) and

items (α = .76-.81) protective clothing in the summer (+.37), andlower use of sandals in the summer (+.14)than controls

(continued)325

Table 2 Continued


Reding et al. None Unknown number of Spring Family-based intervention Cloverbud program: Child reports: In the Cloverbud program, children’s sun(1994)27,28 5- to 7-year-olds in monthly Implementation of American Randomized 10 knowledge items safety knowledge increased between 70% and

the 4-H Cloverbud meetings or Cancer Society’s (ACS) pretest-posttest 80% on 7 of 10 test items in the interventionprogram summer day “Children’s Guide to Sun control design group. In the peer education program, 70%

Two rural Wisconsin camp Protection K-3” curriculum Cloverbud groups more third-grade children answered the 10counties (Wisconsin) and the hands-on activities assigned to items correctly following the program than

528 third graders in booklet developed by the 4-H condition did controlsschools coalition Peer education:

Cloverbud program taught by Randomized4-H leaders pretest-posttest

Peer education program taught control designby 40 trained high school Follow-upstudents who were members immediately post-of the Future Farmers of intervention inAmerica (see Reding et al. both studies[1995]28)

Statewide intervention includedone control and two interven-tion counties

Girgis et al. None 648 students in Classroom Intensive intervention:Skin Safe Randomized Child reports: The sun safety program increased children’s(1993)20 Grades 5 and 6 in (Australia) program booklets for teachers pretest-posttest Prospective sun sun protection score at 5 weeks (OR = 1.18

11 public primary that promoted cooperative and control design protection diary standard intervention; 2.45 intensiveschools problem-based learning, Schools were (full protection when intervention) postintervention compared to

student participation randomly assigned 75% of body covered) children in the control group. Only childrenStandard intervention: a 30- to one intervention 19 knowledge items receiving the intensive intervention continuedminute lecture on sun safety group or a no- 19 attitude items to report higher sun protection at eight

treatment control months postintervention (OR = 0.85 standardgroup intervention; 3.06 intensive intervention)

Follow-up at 5weeks and 8 monthspostintervention

326

Peer Education Programs for Children (Table 3)

Peer education methods have been shown effective for improving children’s knowl-edge. Randomized evaluations of a peer education by high school students for third andfourth graders after two 30- to 40-minute presentations using the ACS’Children’s Guideto Sun Protectionshowed that the curriculum improved children’s knowledge. In oneevaluation, 70% of third graders receiving this peer education increased their knowledgeon a 10-item scale over controls.27 In a second evaluation of this same program, fourthgraders receiving the program correctly answered more knowledge items than controlstudents at an immediate postintervention assessment but not at the 6-month follow-upsurvey.28 A nonrandomized evaluation with a very small sample of nine first graders sug-gested that a short-duration peer education program by students in Grades 3-6 using skitsand a coloring book may be effective at improving children’s knowledge. First-graders’knowledge improved by 22.2% on a five-item test 1 week following the program.19

Evaluations of Programs Directedat Parents and Adult Caregivers (Table 4)

Randomized evaluations of sun safety programs delivered to parents show that parentsrespond favorably to appeals to improve sun protection for their children. In the medicalsettings, mothers of newborns who received sun protection recommendations at the hos-pital after delivering their babies and a reminder postcard in the following summerreported less exposure to direct sun for themselves and their children, and less unpro-tected sun exposure for themselves, compared with a no-treatment control group.32 Simi-larly, parents of children between 6 months and 10 years who received a presentation onskin cancer facts and sun protection behaviors, with or without group discussions on skincancer and sun protection, and presentation by a melanoma survivor, showed improvedknowledge of skin cancer and sun protection, attitudes in favoring child sun protection,and sun protection behaviors. The impact of the group-discussion program on attitudeswas broader than just the presentation of facts, producing changes in opinions related toparent sun protection. It also had a larger impact than the presentation alone on sun pro-tection behavior and one that lasted longer than the presentation. Attitudes toward parentprotection predicted ratings of sun protection behavior, particularly perceptions of self-efficacy at 2 weeks, severity and barriers at 12 weeks, and response efficacy at both 2 and12 weeks postintervention.33

Sun safety programs in recreation settings for parents have also been shown effica-cious. In both nonrandomized and randomized trials, Glanz et al.21,31 found that parentsreceiving take-home interactive sun safety activities from a sun safety intervention at arecreation center, with sun safety activities for their children led by recreation staff,improved their reported sun protection for their children, stage of change for protectionfor themselves and their children, and increased reported sun protection policies at therecreation programs over children at control programs. In this special issue, Parrott et al.25

show, using a nonrandomized design, that a sun safety program delivered through localsoccer clubs improved parents’self-efficacy for protecting their children and for perform-ing skin self-exams, as well as their application of sunscreen and advice to their childrento wear hats.

A program consisting of a series of printed materials on sun safety for parents deliv-ered by direct mail was found effective in a randomized evaluation in Arizona. Parentswho received mailings containing a persuasive message with high as opposed to low


Table 3. Evaluations of Skin Cancer Prevention Programs: Peer Education


Reding et al. None 401 third-grade students Classroom 40 senior high students from Nonrandomized Child reports: Third-grade children’s sun safety knowledge(1995)28 of Wisconsin public (Marshfield, Future Farmers of America pretest-posttest 10 knowledge items was higher immediately after receiving the

schools, 26 classes WI) program control design program (+3.2 correct responses) but not atTaught American Cancer Convenience sample the 6-month follow-up (+0.3) comparedSociety’s (ACS) “The of school in with children in control schoolsChildren’s Guide to Sun intervention groupProtection K-3” to third-grade Other schools withinstudents school districts

randomly selectedas control sites

Follow-upimmediately andat 6 monthspostintervention

Fork et al. None 9 first graders and 7 Classroom Third through fifth graders Nonrandomized Child reports: First-grade children’s knowledge improvedby(1992)19 third through fifth (Galveston, trained (1 hour) on skin pretest-posttest 5 knowledge items 22.2% from pretest to posttest

graders TX) cancer prevention designThird through fifth graders No control groupdeveloped their own presenta- Follow-up at 1tions and delivered them to week post-first graders intervention

Reding et al None Two rural Wisconsin (Wisconsin, Cloverbud program taught by Peer education: Child reports: 70% more third-grade children answeredthe(1994)28 counties US) 4-H leaders Randomized 10 knowledge items 10 items correctly following the program than

528 third graders in Peer education program taught pretest-posttest did controlsschools by 40 trained high school control design

students who were members Follow-upof the Future Farmers of immediatelyAmerica (see Reding et al. postintervention[1995]28) in both studies

Statewide intervention includedone control and two interventioncounties

328

language intensity reported stronger intentions to engage in sun protection for childrenand in their own attempts to limit their time in the sun in the summer. High-intensityappeals, formatted in a deductive logical style, produced the greatest increase in sunsafety behaviors and behavioral intentions compared with other combinations. This typeof message also reduced perceived barriers to protecting themselves and their children.36

Additional analyses revealed that inductive messages (which presented a list of factswithout discussion) produced greater increases in reported protection behavior andbehavioral intentions than deductive messages for parents who had no plans to improvetheir sun protection practices prior to the program, possibly because they reacted unfa-vorably to being told to behave in a certain way. Deductively formatted messages pro-duced more reported protection behavior in parents who did plan to take more precau-tions, most likely because these types of messages reinforced their plans.34

Two randomized evaluations revealed that other adult caregivers (i.e., child care per-sonnel and school teachers and administrators) also respond favorably to sun safety edu-cation. A program in New South Wales, Australia, showed that the combination of mail-ing a package of sun safety policy guidelines and educational materials along with a stafftraining module to primary schools produced adoption of comprehensive sun protectionpolicies by more schools than sending the policy guidelines and educational materialsalone.35 The randomized evaluation of the Hawaii project described above found that rec-reation center staff at intervention sites had a net increase of 16% to 26% in knowledge,perceived norms, sun protection, and stage of change for sun protection and a reported netincrease of 26% to 59% in sun protection policies at their sites, over controls.21,31

Evaluations of Community-Wide Programs (Table 5)

Larger-scale community-wide programs also have achieved changes in sun safetybehavior of children. In the only randomized evaluation reported on a community-wideprogram,40 an intervention through primary care practices, schools, day care centers, andon beaches in New Hampshire increased the proportion of children with at least some sunprotection and with sunscreen applied on at least one exposed skin area over that inmatched control communities.

In this special issue, Miller et al.37 report that their community-wide sun safety pro-gram in a single Massachusetts seaside community was able to reduce sunburns in chil-dren under age 6 and promote more sunscreen use by all children, based on parent reportsat posttest compared with pretest (there was no comparison or control community). Atposttest, fewer parents reported sunburns on children under six, more said their childrenalways used sunscreen when outside, parents purchased more sunscreen, and more par-ents requested or received a skin exam from a physician. Shirt wearing at the beachdecreased among older children, and parents’attitudes and knowledge improved after theprogram was conducted.

In a nonrandomized evaluation of a mass media campaign for children aged 11 to 16 inNew South Wales, Australia, the campaign was shown to improve sun protection andreduce sunburning by children. However, the improvement by children aged 11 to 13 wassmaller than by those aged 14 to 16.41-43 A similar evaluation of a sun safety campaign inScotland found that parents reported more knowledge of the link between childhoodsun exposure and skin cancer formation later in life, favorable attitudes toward sun pro-tection after the campaign, and that their children wore hats and sunscreen more afterthe program.44


(text continues on p. 336)

Table 4. Evaluations of Skin Cancer Prevention Programs: Parent and Caregiver Programs


D. Buller et al. Language 804 parents in families Direct mail Three persuasive prevention Pretest-posttest, Parent reports: Prevention messages with higher language(1998)34 Expectancy with elementary to the home messages randomized 6 parent protection intensity, increased parents’ reports of

D. Buller et al. Theory school-age children (Arizona) Language intensity (high/low) 2× 2 × 2 items limiting time in the sun in summer(1997)36 (age 5 to 11 years) and logical style (deductive/ factorial design 7 child protection (+.16 scale units) and intentions to stay in the

Recruited from inductive) manipulated in Each parent items (α = .56-.93) shade in the winter (+.23). Also producedmanaged-care messages assigned to one greater intentions to protect children in thepediatric clinic and Delivered in series of four condition winter (+.22-+.30). High-intensity languagepublic elementary newsletters, three brochures, Follow-up in deductive messages produced greatestschools and three tip cards encouraging immediately increases in parent self-protection. For parents

the family to be sun safe following program with no intention of changing protectionDelivered by direct mail behavior at baseline, inductively formatted

messages increased reported sun protectionfor them and their children; for parents withintentions to change protection behavior forthemselves or their children, deductivemessages led to more self-reported sunprotection

Parrott et al. Social 8 teams from the St. Outdoor re- “Got Youth Covered” Nonrandomized Parent and supervisor Coach’s knowledge of skin examinations(1998)25 Cognitive Simons Island youth creational educational program designed pretest-posttest reports: (+.61 scale units), self-efficacy for

Theory soccer organization, environment to be implemented by design 5 knowledge items having children wear sunscreen (+.83),with team rosters (St. Simons recreational sport leaders and No control group 7 outcome expectancy and reports of performing monthly skinincluding 10 to 12 Island, GA) used to provide sun safety and items (α = .60-.73) exams (+1.11) and having skin examined by ayouths per team; skin cancer information and 9 self-efficacy items physician (+.64) improved at posttest.12 team supervisors, support for parents and children (α = .72) Parents’ self-efficacy for having children50 parents, 61 youths participants 2 early-detection wear sunglasses (+.73) and performing skin

items (α = .72) self-examinations (+.66), frequency of telling4 child protection children to wear hats (+.38), and frequency ofitems (α = .68) wearing sunscreen themselves (+.46) was

3 adult protection higher at posttest than at pretestitems (α = .72)

330

Glanz et al. Social 113 parents and their 5 recreational 4-week recreation-site and take- Nonrandomized Parent and staff At posttest, parents reported more sun(1998)31 Cognitive children 6 to 8 years sites: 4 home educational intervention pretest-posttest reports: protection of themselves (+2.5%-+12%) and

Theory of age Summer Fun Interactive booklets, brochures, design Knowledge items their children (+6.7%-+14.6%) over pretest41 recreational staff sites and 1 behavior-monitoring score No control sites Attitude items in cross-sectional samples. In longitudinalat 5 recreational sites public boards, incentives, providing Cross section and Stage of change analyses, parents also reported more sun

swimming sunscreen, and encouraging cohort samples Child protection protection for themselves and their childrenpool (Hawaii) sun-safe environments and of parents and staff items and movement along the stages of change for

policies sun protection from pretest to posttest.Parents also reported more awareness of sunprotection policies at the recreation centersand center staff expressed greater sunprotection norms at posttest

Glanz et al. Social 14 recreational sites, Recreation Educational intervention: training Randomized Parent and staff Both interventions producedincreases in(1998)21 Cognitive 756 parents and 176 sites (Oahu, for recreation leaders, on-site pretest-posttest reports: parents’ reported protection for children

Theory staff members HI) activities for children, and take- control group Knowledge items (+.19-+.20 scale units) and awareness of sunStages of responded to baseline home interactive educational design (α = .47) protection policies at recreation centersChange survey. Responses to activities Site “clusters” 5 self-protection (+1.17-+1.42) over control group

posttest and follow- Educational plus environmental assigned to one items Education-only intervention increased parents’up responses were and policy supports intervention: intervention group 5 child protection reports of sunscreen use with children and onslightly lower providing sunscreen in or no-treatment items themselves, stage of change in their own

dispensers, posters, portable control 12 protection policy protection, and sun safety knowledge. Educa-shade, and policy consultation Follow-up questions tion plus environment/policy supportsalong with education immediately and (α = .61-.80) increased parents’ reported stage of change

at 3 months post- Stage of change for protecting their children. Both interventionsintervention 3 sun protection norm improved recreation center staff sun safety

questions (α = .81) knowledge (+.67-+.79 scale units) andawareness of sun protection norms(+0.51-+0.69). Education only increasedsun protection and stage of change inprotection by staff; education plus environ-ment/policy supports increased sunscreen useand awareness of sun protection policies atthe center by staff. There was no significantchange in these effects at a 3-month follow-up

331 (continued)

332 Table 4 Continued


Schofield None 400 primary schools Schools Mail-only intervention: mail-out Randomized Principal reports: The number of schools with comprehensiveet al. (1997)35 and 381 high (Australia) package (letter, sample policy pretest-posttest 6 sun protection sun protection policies increased by 10.7%

schools booklet, information and support factorial design policy items when receiving mail and staff supportmaterials, and leaflets and facts Regions and regions 16 sun protection intervention and 6.0%, mail-only interventionsheets about skin cancer and within pairs practices itemssun protection) assigned to one or

Mail and staff support interven- other interventiontion: mail out package plus a group; posttests instaff development module next school year of(emphasizing policy the interventionsdevelopment) Principals sampled

Promoted adoption of compre- within regionshensive skin protection policies

Rodrigue Health 55 biological School Comprehensive program (CP): Randomized Parent reports: Both interventions increased parents’ knowl-(1996)33 Belief Caucasian mothers classroom Presentation of information pretest-posttest 26 knowledge items edge (effect size = 2.94 for CP; 2.71 IO) and

Model with at least one (Florida) regarding skin cancer facts and control group (α = .73; test-retest child sun protection (2.19 CP; 1.17 IO) at 2Self-Efficacy child between 6 myths, risk factors, and pre- design r = .74) weeks follow-up over control group. TheseTheory months and 10 years cautionary actions that can be Mothers assigned 14 parent protection gains persisted at 12-week follow-up. CP

Protection with no known taken to reduce risk, videotapes, to one of items (α = .82) produced more child sun protection than IO atMotivation developmental and family discussions. interventions or to Attitude toward parent 2 weeks (0.69) and 12-week (2.66-2.80)Theory disability, scoring Presentation by a young female no-information and child protection postintervention. CP also produced more

below the 60th adult with history of malignant control condition (α = .87) favorable sun safety attitudes over the controlpercentile on melanoma (NIC) group, at 2 weeks (1.48-1.76) and 12 weeksmeasures of skin Information only (IO): Follow-up at 2 (1.83-2.73) and more than IO at both follow-cancer knowledge presentation of information and weeks and 12 ups (1.29-1.48, 1.83-2.01, respectively)and sun exposure informational videotape weeks post-behavior describing other common types intervention

of cancer, their etiology,symptoms, and treatments

Bolognia None 275 mothers of Hospital Low-level intervention: received Randomized Parent reports: Mothers who received the intervention reportedet al. (1991)32 healthy newborns (New Haven a sheet of simple guidelines on pretest-posttest 5 child protection that they and their children spent less time in

born at Yale-New CT) minimizing sun exposure and control design items the direct sunlight (17%, 2% high-intensityHaven (CT) Hospital a postcard reminder to limit sun Mothers randomized program, 42%, 22% low-intensity, 85%, 99%between March and exposure into one of the control) and they themselves spent less timeJune 1989 High-level intervention: received intervention or in the sun without sunscreen (85% high-

the guidelines, postcard no-treatment intensity, 18% low-intensity, 35% control)reminder, educational control groups than mothers in the control condition. Thepamphlets, sunscreen samples, Follow-up at 4 intervention did not affect use of hats, strollera baby sun hat, and a sun months covers, umbrellas, or protective clothingumbrella postintervention

333

Table 5. Evaluations of Skin Cancer Prevention Programs: Community-Wide Programs


Dietrich None 10 communities Community Multicomponent community Randomized On-site observations The increase in the proportion of childrenet al. (1998)40 536 adults at baseline based intervention directed at children, pretest-posttest at beaches of use of with at least some sun protection

618 adults at follow-up (New their families, and other care control design protective clothing, after the intervention was higherRecruited on local Hampshire) givers Cities pair-matched, sunscreen, and shade in intervention (+.09) than controlbeaches Components for primary care a city in each pair (Observer communities (–.05). The change in

practices, schools, day care assigned to reliability > .85) proportion of children using sunscreen oncenters, and on beaches with intervention or at least one body area also was larger inlifeguards control conditions intervention (+.18) than control (+.01)

Pretest, summer communities1995

Intervention, spring,summer 1996

Follow-up, summer1996

Miller et al. Social Seaside community Community Multidimensional community- Nonrandomized Parent reports: At follow-up, fewer parents with children <(1998)37 Learning Parents, caregivers, based based skin cancer prevention posttest-only 3 knowledge items 6 years old reported their children sun-

Theory and children under (Falmouth, program, which combines design 8 attitude items burned (–15%), more parents reported14 years old MA) community activism through Baseline survey 4 parent protection their children wore sunscreen always

401 parents in pretest participation in a town advisory 1994 items outdoors (+22%), had bought 3+ tubes of404 in posttest board, a community-wide Follow-up survey 6 child protection sunscreen (+20%), requested or received a

publicity campaign, and 1997 items skin examination (+12.3%-+13.7%).focused behavioral and No control 3 early-detection Fewer children aged 6-13 wore shirts at theeducational interventions at community items beach (–11%). More reported thatkey sites in the community children wore sunscreen (+9%-+20%),

wear sunscreen themselves (+8%), buying3+ tubes of sunscreen (+12%), higherself-efficacy (+8%-+14%), knowledge(+7%-+20%), more skin exams (+17%,+20%)

334

Fleming et al. None 939 parents approached Community Sun protection messages Nonrandomized Parent reports: At posttest, parents were more aware that sun(1997)44 at a children’s campaign delivered through local and pretest-posttest 8 knowledge items exposure during childhood is associated

clothing shop and 8 (Glasgow, national television, radio, and design 4 attitude items with skin cancer later in life (+0.9 scaleprimary schools UK) newspaper features, lectures to No control site 2 child protection units), expressed more favorable attitudes

local shops and schools, 2 independent panel items toward sun protection (+0.1), reportedclassroom projects, and samples of parents more sun protection behavior (+0.1) thanchildren’s workbooks Follow-up right at pretest

after interventionBoldeman None 269 child health Stockholm Mailed intervention: printed Non-randomized Assessments of The lecture intervention produced a 30%et al. (1991)39 services clinics County information on sun protection posttest only distribution and use increase and the mail intervention a 18%

Boldeman 574 nursery schools (Sweden) for children control design of materials with increase in the number of nursery schools dis-et al. (1993)38 Lecture intervention: 45-minute Clinics and nursery staff and parents tributing sun awareness information to

lectures dealing with sun schools assigned parents. Staff at 97% of pediatric healthawareness etiology and pre- to receive one of clinics reported giving parents informationvention of malignant mela- interventions on sun awareness, but only 35% of parentsnoma and 12-minute videotape Another city chosen recalled receiving such information from apresentation as a control clinic

Follow-up, 6 monthspostintervention

335

Finally, in Stockholm, Sweden, information on etiology and prevention of melanomawas provided to pediatric medical officers and nurses at child health centers in 45-minutelectures or by mail. A survey of these centers found that 86% reported receiving the infor-mation, 80% of nurses desired additional sun safety information, and 97% of centersreported that information on skin cancer and sun precautions were given to parents. How-ever, only 35% of parents surveyed at two of the centers reported that they actuallyreceived such information from the center staff.38 In similar fashion, this information wasprovided to nursery school head teachers and coordinators of day care centers. A surveyof nursery school administrators found that the diffusion of the information on sun safetyto parents was twice as frequent in the nursery schools that received the information bylecture rather than by mail.38,39 Unfortunately, no data from this nonrandomized evalua-tion were reported about the impact of the information on institutional or personal sunsafety.

CONCLUSIONS FROM EVALUATIONSOF SUN PROTECTION PROGRAMS

Nearly all of the school-based sun safety programs that directly instructed childrenimproved their knowledge, but only the multiunit presentation programs consistentlyimproved their sun protection behavior. Children as young as age 4 were capable of learn-ing sun safety information23 and retained it during several weeks or months.16-18,20,29Note,though, that all but one program taught children older than 8 years. Attitude and behaviorchange as a result of short presentations is highly variable, very small, or nonexistent,indicating that this strategy alone is unlikely to improve children’s sun protection behav-ior. Most of the multiunit presentations produced greater increases in children’s knowl-edge of sun and sun safety, usually improved related attitudes, and increased either inten-tions to engage in sun protection or reports of actual sun protection behavior. Changes inbehavior and attitudes, even by these longer programs, were much smaller than improve-ments in knowledge. Achieving larger changes may require repeating instruction acrossseveral months or years, although evaluations of these programs found that changes inbehavior persisted for several weeks after instruction.

Only one evaluation of a multiunit presentation program failed to change sun protec-tion behavior.24 It included only five 5-minute presentations to children rather than threeto five 30- to 60-minute presentations in the other programs, so it might be better classi-fied as a short-duration presentation program. Also, presentations in this program weregiven by aquatic instructors, rather than classroom teachers.

Whether other children and adults in the community (other than teachers) are able toeffectively teach children about sun safety needs further examination. Three programs onpeer education19,27,28showed that older children may be capable of teaching sun safety toyounger children. However, attitude or behavior change was not assessed and one studyhad a very small sample.19 Peer education warrants additional study, as it can improvehealth service and health education for adults.46 Nevertheless, its use should be expandedbeyond schools. More work is also needed on the impact of various methods for instruct-ing children in settings other than schools, like the recreation centers and service clubsevaluated up to now.

Programs designed for educating parents were generally successful. When measured,parents’knowledge of the sun and sun safety was improved by these programs. All evalu-ated programs produced some changes in parents’sun protection behavior or intentions to


improve that behavior, but the changes were smaller than changes in knowledge. Parentsseemed more likely to report changes in children’s protection behavior than their own.34,36

These programs were successful in several settings, including health care, recreation pro-grams, and through direct mail. Parents showed larger changes after more intensive pro-grams that included additional printed information, products to protect children, groupdiscussions, and testimonials from melanoma survivors.21,32,33

Work should continue on strategies for reaching parents, for they are important rolemodels for their children, can encourage children to practice prevention in a variety ofcontexts, and often control the environment and organizational policies that promote orhinder protection for children. Additional information is required on effective strategiesfor ensuring that sun protection messages reach parents, that messages are persuasivewith parents, and that parents are given the tools and skills to teach children to practicesun protection.

Two programs were able to achieve organizational changes in sun protection policiesor to increase staff awareness of them in schools and recreation centers.21,35 It may takelonger for policy and environmental changes to occur in the United States than changes inindividual behavior, perhaps even several years, if they require involvement from manypeople within a recreation, child care, or educational organization; the perceived supportof parents and political constituencies (i.e., taxpayers); and the reallocation of financialresources. Some easily implemented policy changes, such as encouraging children toplay in the shade and recommending that parents include sunscreen in their carry bags,seem to be fairly easy to persuade decision makers to implement (also see Glanz et al. arti-cle in this issue for details).21 Policy and environmental changes should be a goal forfuture programs in the United States.

While none of the published programs were found to produce very large changes insun protection behavior, these evaluations have identified different intervention compo-nents that should be successful when employed within community-wide sun safetyefforts. Community-wide sun protection programs should prove more effective thansmaller-scale programs because they deliver messages simultaneously through severalchannels and help ensure that people are repeatedly exposed to prevention messages, thatthey encounter messages from sources they consider credible, and that messages are con-sistent with one another. Five evaluations of community-wide programs were identifiedbut only one was conducted with a randomized controlled design,40 which is not surpris-ing as it is often very expensive and difficult to evaluate entire communities and to obtaincomparable control communities. That randomized evaluation found significant effectsfrom a community-wide program using primary care physicians, schools, day careorganizations, and lifeguards at local beaches.40 While not large, the effects translate intolarge numbers of residents in the communities. The nonrandomized evaluations37-39,41-44

also showed that community-wide programs increased sun protection behavior, reducedsunburning in children, and improved parents’ perceived abilities to protect their chil-dren. Although one cannot rule out the possibility that improvements in sun protectionreflect secular society-wide trends or response bias prompted by exposure to the pro-grams, the similarity in outcomes among them is highly suggestive that community-wideprograms can be successful. However, we still need to conduct focused studies on preven-tion strategies because it was impossible to determine which program components wereresponsible for significant improvements in sun protection in those communities.

Issues in need of further evaluation include whether repeated exposure to sun protec-tion education will improve protection behavior, and if so, is there a limit to improve-ments that can be achieved. Direct comparisons among different methods of delivering


protection education would be useful, as would be studies of the best role of some newcommunications technologies (e.g., Internet, interactive multimedia). Finally, it would beinformative to determine the degree of public and decision maker support, as well as thelength of time, needed to achieve environmental and policy changes in community-wideefforts.

Limitations of This Review

There are several limitations to this review. First, it provides only a current snapshot ofthe evaluations of sun protection programs. Interest in this area, particularly in NorthAmerica and Europe, is growing and ongoing projects will answer some of the questionswe have raised very shortly. Second, the evaluations were of variable quality. It is impor-tant to conduct well-designed evaluations of all sun protection programs and when possi-ble to use randomized controlled trials. However, researchers face practical problems inimplementing community-based controlled trials and may need to offer control groupssome other types of programs to secure their participation. A third limitation is that only afew studies clearly specified the theoretical principles in their programs and very fewmeasured theoretical precursors to behavior change to detect how interventions influ-enced children’s sun safety behavior. Explicit specification of the theoretical modelsbehind the interventions and tests of mediating variables would provide a better under-standing of how the interventions work and which intervention components are most suc-cessful with whom and under what conditions.

Very few direct comparisons among different methods of delivering sun protectionhave been conducted, so many evaluations are difficult to interpret. The few exceptionsinclude studies showing that multiunit or high-intensity presentations produce greaterchanges in sun safety knowledge, attitudes, and behavior than short-duration and low-intensity strategies;20,32,33that a short lecture might produce slightly greater changes than ahealth fair18 or information received by mail;38,39 that a sun safety education program atrecreation centers was equally effective with or without environmental and policy sup-ports;21 and that messages for parents are more effective when containing high-intensityas opposed to low-intensity language.36

The same can be said about a lack of comparisons across regions of the world. Con-texts for programs in various regions are different, so parallels between programs in dif-ferent regions must be interpreted cautiously. A frequent tendency is to look to the Austra-lian studies for guidance when designing programs for North America and Europe. It isinstructive to remember that Australia has very high rates of skin cancer and a smaller,predominantly fair-skinned population, than in many areas of North America, Europe,and other parts of the world. Thus, the effects of the Australian programs may not entirelygeneralize to other geographic areas.

METHODS FOR MEASURINGSUN PROTECTION BEHAVIOR

The final issue we consider in this review is the measures used to evaluate outcomes ofsun protection programs. The most common outcome variable measured was knowledge.Several researchers also measured attitudes and self-efficacy expectations about sun pro-tection, usually on multipoint Likert-type or bipolar adjective scales. The ultimate goal ofmost programs was to improve children’s sun protection, so the validity of measures of


sun safety behaviors is most crucial. Most of these measures can be classified as self (e.g.,children or parents reporting on their own protection behavior) or other reports of usualbehavior (e.g., parents or child care staff reporting on the protection practiced by chil-dren). Two studies employed sun protection diaries,20,24while others reported measures ofsunburn history,37 SPF of sunscreen,34,36 time outdoors in the sun,32 and skin self-examinations.25Two evaluations included mechanical measures of changes in skin tone asan indication of suntanning and sun exposure, using a colorimeter (a device that measurescolor in three dimensions),17,24 and one had trained research staff that directly observedsun protection behaviors.40

Unfortunately, there is no gold standard for assessing sun protection behavior, and allmeasures have limitations.47 Beside the usual concerns over memory, social desirabilitybias, and demand effects, self-report measures for sun protection appear to overestimatesun protection behavior.48 There is particular concern about this when these measuresinquire about typical or common behavior rather than specific behaviors during a definedperiod of time. However, parent and child reports of child behavior have high correspon-dence.47 Another key concern is whether these measures are sufficiently precise and validto assess changes in knowledge, attitudes, and/or behavior.

Other problems include that intervention itself may reduce the validity of some self-reports, by altering children’s and adults’ interpretation of key terms and prompting themto give the “right” answers about their attitudes and behaviors. For example, not all peoplemay recognize that any skin reddening, with or without pain, is a form of sunburn. Chil-dren and adults may report more frequent sunburning at posttest than at pretest in anevaluation of a program that teaches this information. The definition ofsun tanningalsocan cause problems. It is possible that people may interpret sun tanning as only the inten-tional exposure with the sole purpose of tanning the skin and not consider unprotectedexposure during other activities, yielding an underestimate of the rates of sun tanning.

Prospective diaries of child sun exposure by parents have been used in several studies.They have the advantages of monitoring behavior, including atypical behavior, over time,in several settings, and relatively unobtrusively. They also may be less costly than obser-vation by trained staff.47 However, they may pose substantial respondent burden, are notimmune to social desirability bias, may act as an intervention as well as a measure, andmay require subjective assessments of child behavior.

Observational techniques, using trained staff and colorimeter devices, may solve someproblems with the accuracy of self-reports and diaries. However, it is difficult to deter-mine the use of some sun protection behaviors from direct observation (e.g., whether sun-screen has been applied) and practically impossible to observe them in many settings(e.g., private homes). Colorimeter measures may not be capable of detecting sun tanningor sunburning, if measures are taken several weeks after their occurrence, and are lesseffective with darker-skinned individuals whose skin shows less visible color changewith sun exposure. There is some degree of interrater and intrarater error in colorimetermeasures49,50 and some uncertainty about the most accurate form of measure from thisdevice. It is reassuring, though, that positive correlations have been reported betweencolorimeter measures indicating lighter skin tone and child self-reports of sun protec-tion behavior (rs = .17-.27)17and parents’reports of intervals outside by child (rs = –.21 to–.33).49 Notably, however, none of these studies were conducted with darker-skinned per-sons. Self-reports of sun protection behavior and observations of actual behavior are alsocorrelated.20,51,52

Another measurement concern in many of the evaluations we reviewed was the lack ofestimates of reliability for measures used. Many analyzed individual items or did not


report the reliability of multi-item indices. Generally, the reliability of the questionnaireitems have ranged from marginally adequate (r= .55-.70) to acceptable (r > .70). Reliabil-ity of observational routines and the application of the colorimeter have been acceptable.40,50

When information about measures is omitted, it is difficult to determine the quality of thedata that are the basis for conclusions about programs’ efficacy.

Given the limitations of all choices of measures, the low correlations sometimes foundamong measures, and the lack of a gold standard for the validity of these methods,researchers should include multiple assessment methods in future studies. In addition,they should have them inspected for face validity, correlate them to estimate concurrentvalidity, and conduct parallel analyses to provide convergent conclusions about studyoutcomes.

CONCLUSIONS

Sun protection is essential for children if the high rates of skin cancer are to bereversed. The successes achieved by many of the sun protection programs reviewed herebode well for future sun safety programs. If community-wide sun protection efforts mate-rialize in the United States and Europe, researchers will face several challenges, such asobtaining sufficient resources to conduct controlled trials of these programs and separat-ing the effects of a particular program or strategy from those achieved by other events. Ofcourse, these challenges will be welcomed if they also mean that community-wide sunprotection is improved by these large programs.

The evidence to date shows that programs can work. If the Australian experience canbe generalized, community-wide programs are likely to provide the most effective andprobably the least costly per person reached method of achieving widespread change (seeHill and Dixon article in this issue). Their dependence on multiple interventions designedto complement each other, and mass dissemination strategies, means that it is practicallyvery difficult to tease out the contribution of particular components. However, if a rangeof strategies of known efficacy are implemented concurrently, we can be confident ofachieving considerable change. The main challenge is to understand what programs workbest in different circumstances so we can increase our armory of proven tools for whencommunities decide to address the issue at a population level.

Also, in the United States, we need to explore whether different strategies are neededin the south where sun protection is needed for most of the year, compared with what isneeded in northern latitudes where it is only a significant issue for a few months each year.With the proportion of Americans in ethnic minorities increasing rapidly, we also need toconsider the methods and impact of our programs on darker-skinned people for whomsome messages may be less relevant. This is particularly important for enlisting the coop-eration of groups and for adopting public health–oriented strategies in communities withsignificant populations with people of color and a variety of skin types.

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