A community-based randomized trial encouraging sun protection for children

Objective. We evaluated the impact of an intervention promoting sun protect ion behavior among children 2 to 11 years of age through schools and day ca re centers, primary care practices, and recreation areas. Methods. Ten towns in New Hampshire were paired, then assigned randomly to intervention or control status. The multicomponent SunSafe intervention was provided to children and caregivers through primary care practices, day ca re centers, schools, and beach recreation areas. Training support and mater ials were provided by the SunSafe project, but project staff had no direct contact with children or parents in providing the intervention. All interve ntion components promoted the same message: avoid the sun between 11 AM and 3 PM, cover up using hats and protective clothing, use sun block with a su n protection factor greater than or equal to 15, and encourage sun protecti on among family and friends. The impact of the intervention was determined by observing children's sun protection behavior at the beach during baselin e compared with 1 year later. The primary outcomes of interest were changes in the proportion of children per town using at least some sun protection and changes in the proportion of children fully protected. Children were clustered by town, with the town thus being the unit of analysis. The primary care practice component inclu ded one practice meeting for clinicians and staff at which project staff pr esented background on skin cancer and how to promote its prevention; a sun protection office system manual based on our previous work, which provided specific direction on how to share responsibility among office staff and cl inicians in carrying out routines that promote sun protection; and educatio nal posters, pamphlets, and self-adhesive reminder notes designed to enhanc e sun protection counseling. SunSafe removable tattoos and stickers were of fered to children at well-child and illness visits during the summer months . Schools each received three project staff visits: a brief visit with the pr incipal to describe the intervention and to answer questions; an in-service program to educate teachers about skin cancer and to introduce curricular materials; and help with one parent outreach program. Larger day care cente rs each received one project staff visit. An additional six smaller day car e centers received curricular materials through the mail but no visits. Two similar sets of curricular materials were used, one for grade schools and the other for preschools and day care centers. Both emphasized the importan ce of sun protection rather than the danger of skin cancer. Materials empha sized dynamic activities modeled after the "Slip, Slop, Slap" and "SunSmart " programs and included new material developed to suit regional needs. Both manuals offered structured plans but also provided a variety of activities from which teachers could choose. Teachers agreed to devote a minimum of t wo class periods to these materials. For recreation areas, lifeguards in each of the intervention communities at tended an in-service meeting, during which background about skin cancer pre vention was presented by project staff. The project also provided displays about the ultraviolet (UV) light index and about sun protection to be poste d at each beach. Subsequently, project staff called beach staff in each com munity each morning with the predicted UV index for the day to post on the display. Educational pamphlets about the UV index and free sun-block sample s were available to beachgoers through the lifeguards. One brief follow-up visit by project staff was made to each beach area to provide reinforcement . Results. We observed 1930 children. Use of some sunscreen on at least one b ody area increased in all 5 intervention towns compared with paired control towns. In intervention towns, this mean proportion increased from 0.56 of those observed at baseline to 0.76 of those observed postintervention, with a minimal increase among control town children. Among intervention town ch ildren perceived by their caregiver not to burn easily but having fair or m edium white skin, the proportion using sunscreen increased from 0.44 to 0.6 9 with little change among similar children in control towns. Use of protec tive clothing and shade did not increase. Postintervention, the proportion of children who lacked any protect ion was 0.13 in intervention towns compa red with 0.20 who lacked protection in control towns. For full protection f rom clothing, sunscreen, and/or shade, the proportion of children increased from a mean of 0.53 to 0.74 in the intervention town group compared with a smaller increase in the control town group from 0.66 to 0.72. There was su bstantial town-by-town variation in full protection. Conclusion. Sun protection behavior of children can be improved with the Su nSafe intervention provided through schools, day care centers, primary care offices, and beach recreation areas. This intervention should be tested in other areas and expanded to preteens and adolescents. If: shown to be effi cacious elsewhere, the intervention could be disseminated more widely throu gh schools, departments of health, professional organizations of clinicians and educators, and advocacy organizations such as the American Cancer Soci ety. Some pediatricians may want to promote its application now in their of fices and communities. Materials are available from the authors.