Sun-Protection Behaviors Improve With Mailed Materials

Larry Hand

September 27, 2012

September 27, 2012 — A multiyear trial of mailed sun-protection kits and newsletters about sun protection to families in Colorado improved the sun-protection behaviors of those families compared with those of a control group, according to an article published in the October issue of the American Journal of Preventive Medicine.

The results indicate that longer-term interventions of this type could help to curb the rising prevalence of skin cancer largely caused by overexposure to the sun, according to Lori Crane, PhD, MPH, chair of the Department of Community and Behavioral Health at the Colorado School of Public Health, Denver, and colleagues.

The team conducted a randomized controlled trial involving 867 families in the Denver area. Data collection consisted of annual telephone interviews of parents and skin examinations of children.

For the intervention group, educational newsletters containing information about skin cancer and sun protection were mailed (4 in 2005, 5 in 2006, and 3 in 2007), in addition to resource kits including protective clothing, sunscreen, and backpacks. The first newsletter each year addressed skin cancer and its causes. The second tailored information to personalized risk perception for children based on baseline data collected in 2004, including family histories and child-specific risk factors such as eye, hair, and skin color; freckling; and tendency to get sunburn. Subsequent newsletters described protective measures, including avoiding midday sun, wearing long clothes, seeking shade, and using sunscreen.

From 4 to 7 healthcare providers trained by the study's lead dermatologist, but blind to intervention status, administered skin exams to children each summer.

A single letter was mailed to the control group each spring inviting them to participate in data collection and skin examinations.

During 2008 through 2011, the researchers conducted an analysis of the records of 677 white, non-Hispanic children. (The remaining families that had been randomly assignment were nonwhite or Hispanic and were not included in the current analysis.) The parent interview completion rate was between 90% and 97%, and the skin exam completion rate was between 77% and 82%.

For the intervention group, between 78% and 85% of parents reported receiving newsletters each year, between 70% and 82% reported reading all newsletters each year, and between 39% and 60% said they learned some or a lot of new information each year.

Parents in the intervention group reported their children using long clothing, hats, shade, and sunscreen and avoiding midday sun more frequently than those in the control group. Although general group differences were of small magnitude and inconsistent across the year, differences were more evident for the specific behaviors that were emphasized in a given year’s newsletters.

"After we emphasized long clothing in the spring of 2005, we saw a difference in clothing behavior in the summers of 2005 and 2006 not in 2007," Dr. Crane said in a university press release. "Then after emphasizing hats in 2006, we saw a difference in hat use that year. And then after highlighting shade in 2007, we saw a corresponding increase in parents' awareness and use of shade as a sun-protective behavior."

Fewer nonsevere sunburns were reported for the intervention group across all years, but severe sunburns were reduced in the intervention group in 2007 only. The intervention group also had fewer nevi (moles that may lead to cancer) that were greater than or equal to 2 mm in size in 2006 (P = 0.03), but no differences resulted in tanning or nevi smaller than 2 mm.

The intervention group also had greater perceptions of sun-protection effectiveness and lower perceptions of barriers to sun protection (both, P < .05).

Limitations of the study include self-reported data and the factor of relatively high levels of education and income of the parents, possibly reducing generalizability. Strengths include the large study population and the fact that about 80% of the intervention group recalled getting the newsletters.

"This is a low-cost, effective intervention that could be an important component in efforts to reduce sun exposure in children during the years that they acquire much of their risk for skin cancer," Dr. Crane concludes in the release.

This study was supported by a National Cancer Institute Grant. The authors have disclosed no relevant financial relationships.

Am J Prev Med. 2012;43:399-410. Abstract