Preventive Medicine 41 (2005) 108 117 www.elsevier.

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Sun protective behaviors and sunburn experiences in parents of youth ages 11 to 18

Cheryll J. Cardinez, M.S.P.H.a, Vilma E. Cokkinides, Ph.D.a,*, Martin A. Weinstock, M.D., Ph.D.c, Mary C. OConnell, B.A.b
Department of Epidemiology and Surveillance Research, American Cancer Society, National Home Office, 1599 Clifton Road NE, Atlanta, GA 30329-4251, USA b Department of Health Promotions, American Cancer Society, National Home Office, Atlanta, GA 30329, USA c Dermatoepidemiology Unit, Department of Veterans Affairs Medical Center, Department of Dermatology, Rhode Island Hospital and Brown University, Providence, RI 02912, USA Available online 26 November 2004
a

Abstract Background. Recent studies suggest that parental sun protective behaviors and communication influence their adolescents. However, there is limited information on sun protection for parents of adolescents. Methods. A telephone-based, nationally representative prevalence study of sun exposure among youth, aged 1118, and their parents living in households was conducted in 1998. Separate, independent responses were collected. Weighted prevalence estimates and 95% confidence intervals were estimated and presented for parents only (n = 1187). Results. Approximately one-third of parents planned activities to avoid the sun and used sunscreen. Among parents who used sunscreen, 70% applied it while at the beach or pool, but not as often during other outdoor activities. Almost one-third of parents were participating in water or non-water recreational activities during their most serious sunburn. Differences in sun protection and sunburn experiences were observed by age, gender, sun sensitivity, race and ethnicity, and educational attainment. Conclusions. Parents have adopted sun protection habits, but have not surpassed national sun-protection goals. Combined use of sun protection behaviors may reduce sunburn prevalence and number of incident skin cancers. These data may be useful for developing or enhancing current sun protection programs for effective sun protection that include parents and their adolescents. D 2004 Elsevier Inc. All rights reserved.
Keywords: Health surveys; Parent; Adult; Adolescent; Primary prevention; Skin cancer; Sunburn; Sunscreen agents; Ultraviolet rays

Introduction Skin cancer is the most common type of cancer in the United States [1]. In 2004, the American Cancer Society (ACS) estimates more than one million cases of nonmelanoma skin cancer and 55,100 cases of melanoma will occur [2]. The majority of skin cancer is attributable to excessive ultraviolet radiation exposure [3]. Consequently,

* Corresponding author. Department of Epidemiology and Surveillance Research, American Cancer Society, National Home Office, 1599 Clifton Road NE, Atlanta, GA 30329-4251, USA. Fax: +1 404 327 6450. E-mail address: vilma.cokkinides@cancer.org (V.E. Cokkinides). 0091-7435/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2004.10.015

reduced sun exposure and sun safe practices have been identified by physicians and skin cancer prevention advocates as important public health priorities. Late adolescence is a period of heightened, unprotected sun exposure [4]. Recent studies showed that adolescents have inadequate sun protection practices, high sunburn prevalence, and high indoor tanning bed use [512]. Parental behavior, such as indoor tanning booth/lamp use and sun protection practices, as well as parental communication about insisting that children use sunscreen are correlated with ultraviolet exposure (UV) practices [10,12]. These findings suggest that parents may play a role in adolescent UV exposure behaviors. As parental involvement becomes integrated into current sun-safe

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programs and health care delivery, behavioral scientists and physicians need prevalence estimates on parents of adolescents since they may exhibit different health behaviors and practices than childless married adults, single unmarried adults, or parents of young children. Previous studies on sun protection focused on all adults [1317] or parents of young children [1823], but analogous studies on parents of adolescents are not available. Hence, this descriptive study presents prevalence patterns of sun exposure experiences and sun protection behaviors in the parents of youth aged 1118 years old by specific sociodemographics and sun sensitivity. Our goals are to provide data that can inform, develop, or enhance sun protection programs for adolescents and their parents as highlighted in recent recommendations and to determine if parents of adolescents meet the Healthy People 2010 sun protection objective of increasing the proportion of persons who avoid the sun during peak hours, wear sun-protective clothing, use sunscreen or avoid artificial UV light [24,25].

routinely performed three or four of the Healthy People 2010 recommended behaviors [25]. Since a single sun protection behavior is not optimal for the protection of sunburns, it is important to study a comprehensive set of sun protection practices [2427]. We asked more specific behavioral practices regarding sunscreen. Sunscreen users were asked a series of questions using a Likert scale: sun protection factor (SPF) 15+ sunscreen at the beach or pool; sunscreen on the face and the SPF used most often when in the sun for at least 15 min; sunscreen on other exposed skin areas and the SPF used most often when in the sun for at least 15 min; the frequency of reapplication; and sunscreen characteristics such as water-proof, non-greasy, or hypo-allergenic. The balwaysQ and boftenQ responses were combined to represent routine use related to specific aspects of sunscreen usage. Parental sunburn experiences The ACS sun survey assessed the number of summer sunburns, and for the most severe sunburn, the outdoor activity and the sun protection behaviors associated with it were identified; these prevalence estimates are presented in Table 3. A summer sunburn was defined as any reddening of the skin that lasted at least 12 h received from outdoor exposure, a tanning bed, or sunlamp. Three questions were used to determine the number of summer sunburns: (1) Did you get a sunburn during the past weekend?, (2) Have you had a sunburn this summer?, and (3) How many times were you sunburned this summer? The question, bWas the sunburn painful?Q was asked in relation to the sunburn during the past weekend. This question was not included in the calculation of number of summer sunburns since less than 10% of the parents responded to receiving a sunburn during the past weekend. In addition, parents were asked about the types of activities while outdoors and the types of precautions taken to protect themselves during their most serious summer sunburn. Other parental measures Parents were asked questions on age, gender, race and ethnicity, educational attainment, annual household income range, and residence location of the household (urban or rural) to assess sociodemographic characteristics. Selfreported phenotypic skin characteristics, including natural skin color, natural hair color, sunburn susceptibility based on 1 h in the summer sun without sunscreen or protective clothing, and tanning ability based on several hours in the sun for successive summer days without sunscreen or protective clothing, were used for a validated sun sensitivity scale [28]. As an example, a parent with very fair skin, with blonde or red hair, who would receive a severe sunburn with blisters after 1 h in the summer sun, and who would have a repeated sunburn after successive days in the summer sun would have a bhighQ sun sensitivity index score. Conversely,

Methods The methods of the ACS sun survey, a study of sun exposure and sun protection behaviors of youth and their parents, are described elsewhere [8]. Briefly, the ACS sun survey was a telephone-based, random digit dialed, nationally representative survey of non-institutionalized youth aged 1118 years old, living in households with a parent or primary caregiver in the contiguous United States. The survey was conducted during July to October 1998 and had an overall response rate of 58%. Questions were specific to summer 1998 and related to phenotypic skin characteristics such as skin type, attitudes toward sun exposure and sun tanning (complete attitudinal statements listed in Appendix A), patterns of summer outdoor work and recreational activities, sun protection behaviors, prevalent sources of skin cancer prevention information were asked of the youth (after parental consent) and the parent. Whereas previous analyses from the ACS sun survey concentrated on youth, [810,12] this study focuses on the 1,187 parents. Parental sun protection behaviors Seven behaviors were asked on a five-point Likert scale ranging from bneverQ to balwaysQ, including planning activities to avoid the sun, wearing sunglasses, wearing protective clothing (baseball cap, wide-brimmed hat, longsleeved shirt, or long pants), and using sunscreen. The balwaysQ and boftenQ responses were combined to represent routine use of these behaviors when outside on a very sunny, summer day for more than an hour. To coincide with Healthy People 2010 objectives, four of the seven sun protection behaviors are presented in Table 2. The remaining three prevalence estimates for all parents are mentioned in the text. We examined the distribution of parents who

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a parent with light brown skin, with black or dark brown hair, who would not sunburn or tan after 1 h in the summer sun, and who would have a moderate or deep tan after successive days in the summer sun would have a blowQ sun sensitivity index score. Analysis Descriptive categorical analyses were tabulated for all parents and by parental age (2740 years, 4145 years, and 46 years old or older), gender, sun sensitivity, race and ethnicity, and educational attainment (high school or less, some college, and college graduate). In this study, race and ethnicity were divided into White, non-Hispanic and Nonwhite, non-Hispanic or Hispanic since few parents indicated a race or ethnicity other than White, non-Hispanic. All analysis were conducted in SUDAAN to provide weighted prevalence estimates and appropriate standard errors [29]. Chi-squared tests were conducted to determine the differences of sun protection behaviors and sunburn experiences within each of the aforementioned sociodemographics.

avoid the sun or used sunscreen. The majority of parents used a SPF 15+ sunscreen when they were at the beach or pool, but only one-third used it on their face or body on other outdoor occasions. When the individual behaviors were combined, the majority practiced one or two behaviors (58 F 3.6%), whereas less than 5% of parents practiced three or four the sun protection behaviors and approximately onethird did not practice any. Sunscreen use Sunscreen use varied significantly by gender, sun sensitivity, race and ethnicity, and educational attainment. More women than men used sunscreen either at the beach, pool, or when outdoors and reapplied it; more than half of parents with high sun sensitivity compared to one-fourth of parents with low sensitivity applied sunscreen either at the beach, pool, or when outdoors on their bodies; more White, non-Hispanic parents than non-White, non-Hispanic or Hispanic parents were apt to use sunscreen and reapply it; more college graduates than high graduates used sunscreen either at the beach, pool, or when outdoors. While sunscreen use did not vary significantly by age, reapplication of sunscreen occurred more often among parents in their early 40s than among their younger or older counterparts. Planning activities to avoid the sun Planning activities to avoid the sun varied significantly by sun sensitivity and race and ethnicity. Parents with high sensitivity were more likely to plan activities to avoid the sun than parents with low sensitivity; more non-White, nonHispanic or Hispanic parents avoided sunny, summer outdoor activities than White, non-Hispanic parents. Wearing wide-brimmed hats Parents with college degrees were significantly more likely to wear wide-brimmed hats when outdoors than parents with or without high school degrees. Combined sun protective behaviors More women than men, more parents with high sensitivity than parents with low sensitivity, and more parents with college degrees than parents with or without high school degrees combined one or two sun protection behaviors. For all three or four behaviors combined, there were no appreciable differences within these subgroups. Summer sunburns Table 3 shows that more than one-half of parents had one or more summer sunburns. In decreasing order, the outdoor activities during the most severe summer sunburn occurred while parents where either swimming, boating, or doing other

Results Sociodemographics, outdoor summer exposures, attitudes, and information sources Table 1 shows that the study population was predominately female, married, non-Hispanic white, and had a moderate sun sensitivity index score. Approximately onethird of the parents were in their early- to mid-40s, college graduates, and had household incomes of more than $50,000. Outdoor sun exposure varied: during summer weekday and weekend hours, parents tended to home repairs, the garden, or chores; during the past year, more than one-half spent some time at the beach or pool. With respect to attitudes, parents generally felt that they looked better with a tan and that the sun felt good on their skin. In addition, they felt that sunscreen allowed the enjoyment of outdoors without worry and stated that the lack of sun protection increased cancer risk. Two thirds of parents knew someone who had skin cancer, but only one-third had a physician recommendation for skin protection. Parents received most of their sun protection information from television, magazines, and friends and family. General sun protective behaviors Of the seven behaviors, wearing sunglasses was the most popular (67 F 3.7%) and approximately one-quarter wore a baseball cap (24 F 3.2%) or long pants (25 F 3.9%). Table 2 displays the remaining behaviors that coincide with the Healthy People 2010 sun protection objective. Fewer than 10% of parents wore wide-brimmed hats or long-sleeved shirts, whereas approximately one-third planned activities to

Table 1 Characteristics of U.S. parents of youth ages 1118, sun survey, 1998 Demographics Characteristic Sample size Weighted percentage (95% CI) 36 (F4.7) 30 (F3.7) 35 (F3.7) 42 (F3.4) 24 (F2.8) 35 (F3.3) Sun sensitivity Characteristic Sample size Weighted percentage (95% CI) 29 (F6.0) 52 (F4.4) 20 (F3.3) 18 (F3.2) 47 (F4.6) 19 (F2.9) 12 (F4.3) 4 (F2.5) Outdoor summer sun exposures Characteristic Sample size Weighted percentage (95% CI) 30 (F3.2) 33 (F3.0) 37 (F3.4) 37 (F5.3) 14 (F4.1) 24 (F5.0) 14 (F3.6) 43 (F5.3) 11 (F3.6) 8 (F2.8) 31 (F3.6) 32 (F3.3) 29 (F3.5) C.J. Cardinez et al. / Preventive Medicine 41 (2005) 108117

Age of parents 2740 years 4145 years 46+ years Age of referent child 1113 years 1415 years 1618 years Sex Male Female Race and ethnicity White, non-Hispanic Nonwhite, non-Hispanic or Hispanic of any race Education High school degree or less Some college College graduate

381 378 428 501 287 396

Sun sensitivity index Low Moderate High Natural skin color Very fair Fair Olive Light brown Dark brown Natural hair color Black Dark brown Medium brown Light brown Blonde Red Susceptibility to sunburna Severe sunburn with blisters Severe sunburn with peeling Mild sunburn, some tanning Turn darker, no sunburn No sunburn, no tanning Ability to tanb Repeated sunburn No suntan or only freckles A mild tan

275 664 248 213 620 221 106 25

326 861 1034 153

25 (F3.7) 75 (F3.7) 77 (F10.3) 23 (F10.3)

86 287 304 240 226 44

10 (F4.4) 24 (F3.7) 26 (F3.9) 19 (F3.2) 17 (F2.9) 4 (F1.2)

Weekday hours 0h 14 h 5+ h Main weekday activity Taking part or watching recreational activities Sitting or lying out in the sun Working outside Swimming, boating, or other water sports Gardening, home repair, chores Errands, shopping Weekend hours 0h 13 h 46 h 7+ h Main weekend activity Taking part or watching recreational activities Sitting or lying out in the sun Working outside

325 399 457 223 70 139 97 276 72 66 363 389 365

374 321 491

35 (F5.3) 29 (F3.2) 37 (F5.0)

498 114 38

52 (F4.9) 15 (F3.7) 5 (F2.4)

139 420

12 (F2.3) 32 (F3.8)

Household income Under $30K $30K to $50K More than $50K Unknown Residence Farm/rural area Small town

174 263 533 193

26 (F11.1) 22 (F4.8) 37 (F8.2) 15 (F2.6)

431 105 88

36 (F3.1) 11 (F3.3) 8 (F2.4)

Swimming, boating, or other water sports Gardening, home repair, chores Errands, shopping Number of days within past year at beach 0 days 17 days 8+ days

370 496 83

39 (F4.7) 57 (F4.3) 12 (F3.3)

204 293

18 (F3.7) 22 (F3.1)

363 70 255

30 (F3.4) 7 (F2.1) 20 (F3.1)

527 411 247

49 (F4.5) 33 (F3.1) 18 (F3.4) 111

112

Suburb City Marital status Married Not married Tan appeal attitudes Characteristic

412 276 1042 144

32 (F4.2) 27 (F5.2) 70 (F12.4) 30 (F12.4)

A moderate tan A deep tan

360 131

30 (F3.4) 13 (F3.0)

Number of days within past year at pool 0 days 17 days 8+ days

465 337 377

43 (F4.7) 30 (F3.3) 27 (F4.3)

Sun protection attitudes Sample size Weighted percentage (95% CI) Weighted mean Characteristic Sample size Weighted percentage (95% CI) Weighted mean

Information sources Characteristic Sample size Weighted percentage (95% CI)

Feel healthier with tan Strongly disagree Disagree No opinion Agree Strongly agree Look better with a tan Strongly disagree Disagree No opinion Agree Strongly agree Sun feels good on skin Strongly disagree Disagree No opinion Agree Strongly agree

146 370 192 381 88

15 31 15 31 8

(F3.0) (F3.4) (F2.8) (F3.7) (F1.9)

2.86

96 228 173 516 167

11 21 15 40 14

(F2.8) (F4.2) (F2.4) (F5.1) (F2.9)

3.25

56 130 95 705 198

7 (F2.6) 12 (F2.6) 7 (F2.1) 57 (F3.6) 16 (F2.5)

3.64

Easy way to stay healthy Strongly disagree Disagree No opinion Agree Strongly agree Outdoor enjoyment without worry Strongly disagree Disagree No opinion Agree Strongly agree No protection increases cancer risk Strongly disagree Disagree No opinion Agree Strongly agree Fewer wrinkles Strongly disagree Disagree No opinion Agree Strongly agree

Television 18 37 68 523 538 2 3 5 43 46 (F1.3) (F1.3) (F1.5) (F4.0) (F3.6) 4.28 Yes No Radio Yes No Magazines Yes No Newspapers Yes No Family and friends 919 261 418 734 78 (F3.4) 22 (F3.4) 38 (F3.7) 62 (F3.7)

C.J. Cardinez et al. / Preventive Medicine 41 (2005) 108117

21 72 76 534 476

3 8 8 44 38

(F1.6) (F2.7) (F2.5) (F4.0) (F4.3)

4.06

832 347 442 725

68 (F3.8) 32 (F3.8) 36 (F4.2) 64 (F4.2)

19 24 33 391 718

2 (F0.9) 3 (F1.2) 3 (F1.1) 34 (F3.3) 59 (F3.9)

4.46

58 136 81 520 390

6 13 7 42 33

(F2.0) (F2.8) (F1.8) (F3.0) (F4.1)

3.82

Yes No Doctor recommendation Yes No Know someone with skin cancer Yes No

678 504

55 (F4.5) 45 (F4.5)

454 723

38 (F4.1) 62 (F4.1)

832 350

66 (F5.0) 34 (F5.0)

a b

Reaction to skin on a sunny day for an hour without sunscreen or protective clothing after several months of not being in the sun. Reaction to skin on a sunny day for a couple of hours for several summer days.

C.J. Cardinez et al. / Preventive Medicine 41 (2005) 108117 Table 2 Sun protective behaviors of U.S. parents of youth ages 1118, by age, gender, sun sensitivity, race and ethnicity, and education level, sun survey, 1998 Characteristic Total n = 1187 Age 2740 years old (n = 381) 4145 years old (n = 378) % (95% CI) 46 years old and older (n = 428) % (95% CI) Gender Male (n = 326) Female (n = 861)

113

% (95% CI) Individual sun protective behaviors a Plan activity to avoid the 34 (F4.8) sun Wear wide-brimmed hat 7 (F1.7) Wear long-sleeved shirt 7 (F2.2) Use sunscreen 37 (F4.8) Sunscreen-specific behaviors a (n = 958) Use SPF 15+ at beach or 70 (F5.3) pool only Use SPF 15+ on faceb 37 (F4.0) Use SPF 15+ on bodyb 33 (F3.9) Reapply when in the sun 65 (F4.3) all day Combined sun protective behaviors a Sun protection indexc 3 to 4 behaviors 4 (F1.5) 1 to 2 behaviors 57 (F3.9) None 39 (F4.2) Characteristic Sun sensitivity Low (n = 275)

Weighted Mean 2.7 1.6 1.6 2.9

% (95% CI)

% (95% CI)

% (95% CI)

37 (F8.0) 5 (F2.3) 6 (F3.5) 36 (F6.6)

30 (F6.7) 7 (F3.0) 7 (F3.9) 40 (F6.6)

35 (F6.8) 10 (F3.4) 9 (F3.8) 35 (F6.5)

29 (F7.2) 10 (F4.4) 11 (F4.9) 24 (F5.2)

36 (F5.2) 6 (F1.8) 6 (F2.3) 41 (F6.0)*

4.0 2.8 2.9 2.9c

66 (F8.0) 37 (F6.5) 35 (F6.3) 64 (F7.4)

74 (F6.7) 39 (F6.1) 31 (F7.8) 73 (F5.9)

69 (F8.5) 35 (F6.9) 32 (F6.7) 60 (F6.4)*

60 (F7.8) 17 (F5.3) 21 (F5.6) 55 (F10.2)

73 (F6.3)* 43 (F5.3)* 36 (F4.9)* 69 (F4.8)*

2.2 4 (F2.7) 58 (F7.4) 38 (F7.6) 3 (F2.0) 59 (F5.9) 38 (F5.9) 6 (F2.8) 53 (F5.3) 41 (F6.0) 4 (F3.1) 48 (F5.1) 48 (F6.0) Education level High school degree or less (n = 374) % (95% CI) 33 (F6.3) 4 (F2.1) 6 (F3.1) 25 (F5.3) Some college (n = 321) College graduate (n = 491) 4 (F1.7)* 60 (F5.0)* 36 (F5.2)*

Race and ethnicity Moderate (n = 664) High (n = 248) White, nonHispanic (n = 1034) % (95% CI) 30 (F5.3) 7 (F1.9) 6 (F2.0) 41 (F5.0) Nonwhite, nonHispanic or Hispanic (n = 153) % (95% CI) 46 (F8.9)* 9 (F4.4) 13 (F5.1)* 23 (F6.2)*

% (95% CI) Individual sun protective behaviors a Plan activity to avoid the 33 (F8.7) sun Wear wide-brimmed hat 8 (F3.3) Wear long-sleeved shirt 10 (F5.0) Use sunscreen 23 (F6.0) Sunscreen-specific behaviors a (n = 958) Use SPF 15+ at beach or 59 (F10.5) pool only Use SPF 15+ on faceb 27 (F8.1) 26 (F8.5) Use SPF 15+ on bodyb Reapply when in the sun 61 (F7.7) all day Combined sun protective behaviors a 34 behaviors 6 (F3.9) 12 behaviors 45 (F7.8) None 49 (F8.5)
a b

% (95% CI) 30 (F5.7) 6 (F2.1) 6 (F2.1) 37 (F5.9)

% (95% CI) 45 (F7.4)* 9 (F3.3) 9 (F3.8) 56 (F9.0)*

% (95% CI) 32 (F7.1) 5 (F2.5) 8 (F4.4) 35 (F7.1)

% (95% CI) 36 (F7.0) 12 (F2.8)* 8 (F3.5) 49 (F7.1)*

69 (F6.7) 38 (F3.9) 30 (F4.7) 66 (F5.4)

81 (F7.0)* 43 (F10.8) 46 (F7.9)* 69 (F8.7)

71 (F5.5) 38 (F3.9) 34 (F3.8) 68 (F4.4)

64 (F13.0) 32 (F10.5) 28 (F11.5) 54 (F10.4)*

55 (F10.8) 31 (F7.5) 30 (F5.2) 62 (F8.8)

69 (F8.1) 36 (F8.3) 31 (F8.4) 62 (F7.9)

80 (F4.4)* 41 (F6.8) 36 (F6.3) 70 (F5.7)

3 (F1.3) 56 (F5.4) 41 (F5.7)

6 (F2.9)* 77 (F7.6)* 18 (F7.1)*

4 (F1.7) 56 (F4.6) 40 (F5.1)

5 (F3.2) 60 (F7.5) 35 (F7.4)

2 (F1.5) 53 (F6.7) 44 (F6.5)

4 (F3.0) 54 (F6.8) 43 (F6.9)

7 (F2.9)* 63 (F4.2)* 31 (F4.9)*

Practiced boftenQ or balwaysQ. At anytime, when in the sun for at least 15 min. c On a 1 to 4 scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often). d All four individual sun protection behaviors; see Ref. [16]. * P b 0.05.

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Table 3 Sunburn characteristics of U.S. parents of youth ages 1118, by age, gender, sun sensitivity, race and ethnicity, and education level, sun survey, 1998 Characteristic Total n = 1,187 Age 2740 years old (n = 381) % (95% CI) 42 (F6.9) 43 (F6.5) 15 (F3.4) 4145 years old (n = 378) % (95% CI) 47 (F7.8) 38 (F7.5) 14 (F4.2) 46 years old and older (n = 428) % (95% CI) 58 (F6.5)* 32 (F6.2)* 9 (F3.4)* Gender Male (n = 326) % (95% CI) 40 (F8.3) 43 (F8.3) 17 (F5.1) Female (n = 861) % (95% CI) 52 (F5.3) 36 (F5.1) 12 (F2.5)

% (95% CI) Number of summer sunburns No sunburns 49 (F4.9) 12 sunburns 38 (F4.6) 3+ sunburns 13 (F2.2) Outdoor activity during Recreational activities Sunbathing Paid outside work Swimming, boating, other water sports Gardening or home repair Characteristic

most severe summer sunburn (n = 671) 26 (F4.7) 24 (F6.7) 22 (F6.7) 17 (F3.2) 21 (F6.4) 17 (F5.6) 8 (F2.9) 7 (F4.6) 6 (F4.1) 30 (F4.6) 30 (F6.4) 33 (F9.0) 19 (F2.9) 18 (F6.0) 22 (F6.4)

33 12 11 26

(F9.2) (F6.4) (F5.8) (F7.9)

27 9 18 23

(F6.2) (F5.4) (F6.4) (F6.3)

25 21 4 33

(F6.0)* (F4.3)* (F2.8)* (F5.7)*

18 (F6.2)

23 (F6.2)

17 (F4.1)*

Sun sensitivity Low (n = 275) Moderate (n = 664) High (n = 248)

Race and ethnicity White, nonHispanic (n = 1,034) % (95% CI) 42 (F3.6) 43 (F4.3) 15 (F2.6) Nonwhite, nonHispanic or Hispanic (n = 153) % (95% CI) 73 (F8.7)* 20 (F6.5)* 7 (F3.7)*

Education level High school degree or less (n = 374) % (95% CI) 50 (F7.6) 34 (F6.0) 17 (F3.7) Some college (n = 321) % (95% CI) 48 (F6.7) 41 (F6.2) 11 (F4.0) College graduate (n = 491) % (95% CI) 50 (F6.0) 39 (F6.1) 11 (F3.7)

% (95% CI) Number of summer sunburns No sunburns 61 (F8.3) 12 sunburns 29 (F7.2) 3+ sunburns 11 (F4.7) Outdoor activity during Recreational activities Sunbathing Paid outside work Swimming, boating, other water sports Gardening or home repair * P b 0.05.

% (95% CI) 46 (F5.7) 42 (F5.7) 12 (F3.2)

% (95% CI) 42 (F7.8)* 39 (F9.6)* 19 (F5.8)*

most severe summer sunburn (n = 671) 22 (F6.3) 22 (F5.6) 39 (F11.5) 18 (F7.4) 18 (F5.2) 15 (F6.9) 14 (F8.5) 8 (F3.4) 3 (F3.1) 28 (F10.3) 33 (F5.8) 25 (F10.1) 18 (F9.7) 20 (F4.6) 18 (F7.3)

26 17 7 31

(F4.8) (F3.3) (F2.6) (F4.7)

27 19 16 26

(F13.8) (F14.2) (F12.5) (F14.2)

21 19 11 29

(F6.5) (F5.3) (F6.0) (F7.8)

30 15 7 28

(F7.6) (F6.5) (F4.2) (F7.4)

28 17 6 33

(F5.9) (F5.9) (F3.9) (F7.2)

20 (F3.1)

12 (F10.3)

20 (F4.9)

21 (F7.5)

17 (F6.7)

water sports; participating or taking part in outdoor recreational activities; completing gardening or home repair chores; sunbathing; and working a paid outdoor job. About threequarters (72 F 7.3%) used a SPF 15+ sunscreen when they received their most serious sunburn. More women were sunbathing or participating in water activities when they had their most serious sunburn whereas men were working paid outdoor jobs or completing gardening or home repair chores.

Discussion Few epidemiological studies collect independent data on children and parents. Variations in sample selection, survey methodology, questionnaire wording, and questionnaire specificity limit direct comparisons between our results and previous reports [1323]. Recognizing the drawback of direct comparisons with other studies, sunscreen prevalence for

parents of youth ages 1118 appears to be consistent with sunscreen use for all adults [13,14,16,17] and parents of younger children [2023]. However, adoption of sunscreen use among parents of adolescents does not surpass the Healthy People 2010 goal of increasing the proportion to 75% of adults aged 18 years and older who use at least one of the identified sun protection measures, namely limited sun exposure, protective clothing, and sunscreen and UV sun avoidance [25]. The Behavioral Risk Factor Surveillance System showed a lower prevalence (31.7%) of all adults aged 18 and older reported a sunburn within the past year [30]. Our study showed that 51% of parents had at least one or more sunburns during the summer. While our study reported a higher sunburn prevalence, this is likely due to recall bias since the Behavioral Risk Factor Surveillance System asks the question within the past year and our study focuses on the summer months indicating a more accurate sunburn prevalence. In addition, this study showed that approximately

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three-quarters of parents used sunscreen during their most recent sunburn, but a Canadian study showed sunscreen use alone did not predict lower odds for sunburn [31]. While manufacturer studies have shown that sunscreen will prevent sunburn, behavioral studies have shown that application and reapplication techniques, the type of sunscreen, and the sunscreens resistance to water immersion and sand abrasion may alter the effectiveness of the sunscreen as indicated by the manufacturers [31,32]. If parents are not adequately applying sunscreen and are included as educators in sun safety measures [24], then the practices that they are conveying to their adolescents may not achieve maximum sun safety. Other protection behaviors have been proven to be effective in preventing sunburns [33]. Several leading organizations recommend the comprehensive practice of sun-safe behaviors for the prevention of sunburns [2427]. Few studies have examined combined sun protective behaviors. Our study showed less than 10% of parents of youth practiced three or four sun protective behaviors routinely when outdoors on a sunny, summer day, indicating a need for emphasis on combined behaviors as recognized by Healthy People 2010 [25], including proper sunscreen application, for effective sun safety. The ACS program, Slip! Slap! Slop! Wrap!, emphasizes the aggregate use of sun protective behaviors with particular emphasis among parents and youth age 912 [27]. This awareness campaign can be extended to adolescents and their parents with emphasis on different components for various subgroups. Our study suggests that parents classified as White, non-Hispanic may need more emphasis on planning activities to avoid the sun, whereas parents classified as non-White, non-Hispanic or Hispanic may need more emphasis on sunscreen use. These observations are relevant for targeted interventions that include parents of adolescents and emphasize multiple sun protective behaviors may be influential in decreasing summer sunburn rates among themselves and their adolescents. Parents, on average, indicated that they would usually use sunscreen with a SPF 15+ at the beach or pool if they were consistent sunscreen users. However, parents do not spend as much time at these locations as their adolescents. A considerably larger proportion of parents received serious sunburns while gardening or conducting home repairs (19%) than their adolescents (4%) [9]. In addition, consistent sunscreen users were more likely to apply sunscreen bsometimesQ when outdoors in non-beach or non-pool settings. Proper sun protective behaviors, either through interventions or physician advice, should be emphasized for any outdoor exposure, regardless of activity, including but not limited to gardening, home repair chores, non-water recreational activities, sun bathing, or paid outside work. Inadequate sun protection has been observed among farmers and outdoor workers indicating a need for sun protection messaging beyond the beach and pool settings [34,35]. Positive health behaviors among adolescents, such as not taking up cigarette smoking and engaging in consistent

physical activity, are influenced by parental behaviors [36 41]. Similarly, we have previously shown that parental and adolescent indoor tanning use and sun-safe practices are correlated [10,12]. In addition, tanning appeal attitudes, especially the attitude that a tan looks better, among parents and their youth are positively correlated (data not shown). A previous study showed that tanning appeal attitudes were associated with the frequency of sunburns among youth [9]. These observations suggest that attitudes in conjunction with behaviors may be important for sun protection programs that target both adolescents and their parents. Sun protection programs for youth have been disseminated at different locations, including schools, recreation centers, and soccer fields, and by various individuals, including health educators, recreation center staff, and coaches [22,24,42]. Despite the varied channels for youth sun protection, parents are more likely to seek this information from their physicians [43]. Our study shows that almost two-thirds of parents did not receive a doctor recommendation on proper sun protective behaviors. While recognizing the time constrains during a physicians visit and emphasis on treatment and diagnosis rather than preventive care [44], doctors remain an integral source for sun protection advice for parents. Once told of the importance of sun protective behaviors, parents are likely to diffuse this information to their friends and family, including their adolescents and children. The limitations of this study include the self-reported data, the predominantly female parent population, and the limited questions that probed on sunburn and occupational sun exposure. The reported sun protection behaviors may be socially desirable responses since more than two-thirds of parents recalled television or magazine advertising about the importance of skin cancer prevention during the summer. The telephone survey format did not allow sampling of male and female parents or caregivers equally. Parental consent and interview were obtained from the person who answered the household phone, which was generally the female head of household member in this study. In addition, the balance of the respondents time on the phone and the number of questions was critical to maximize the number of completed interviews. Hence questions on the details about the sunburn experience(s) or occupational exposure for outside work were not asked. The strengths of this study include the detailed questions on sun protection behaviors for a representative sample of the United States. Previous nationally based studies included general measures on sunscreen and one question about protective clothing [13,15,17], while our study provided sunscreen questions on an average sunny day or at the beach or pool and the use of long pants, long-sleeved shirts, baseball caps, and wide-brimmed hats. Other studies that have included the detailed sun protection questions have been limited to one geographical area [16]. Similarly, studies that have looked at parental attitudes or behaviors of young children have not been population-based study

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C.J. Cardinez et al. / Preventive Medicine 41 (2005) 108117 Institute; 2002. Available at: http://www.nci.nih.gov/cancerinfo/ wyntk/skin [Accessed on 10/16/02]. Jemal A, Tiwari RC, Murray T, et al. Cancer statistics, 2004. CA Cancer J Clin 2004;54:8 29. National Institutes of Health. Summary of the consensus development conference on sunlight, ultraviolet radiation, and the skin. J Am Acad Dermatol 1991;24:608 12. Buller DB, Borland R. Public education projects in skin cancer prevention: child care, school, and college-based. Clin Dermatol 1998;16:447 59. Robinson JK, Rademaker AW, Sylvester JA, Cook B. Summer sun exposure: knowledge, attitudes, and behaviors of Midwest adolescents. Prev Med 1997;26:364 72. Branstrom R, Brandberg Y, Holm L, Sjoberg L, Ullen H. Beliefs, knowledge and attitudes as predictors of sunbathing habits and use of sun protection among Swedish adolescents. Eur J Cancer Prev 2001;10:337 45. Richards R, McGee R, Knight RG. Sun protection practices, knowledge and attitudes to tans among New Zealand adolescents, 19911997. N Z Med J 2001;114:229 31. Cokkinides VE, Davis KJ, Weinstock MA, et al. Sun exposure and sun protection behaviors and attitudes among US youth, 11 to 18 years of age. Prev Med 2001;33:141 51. Davis KJ, Cokkinides VE, Weinstock MA, OConnell MC, Wingo PA. Summer sunburn and sun exposure among US youths ages 11 to 18: national prevalence and associated factors. Pediatrics 2002; 110:27 35. Cokkinides VE, Weinstock MA, OConnell MC, Thun MJ. Use of indoor tanning sunlamps by US youth, ages 11 to 18 years, and by their parent or guardian caregivers: prevalence and correlates. Pediatrics 2002;109:1124 30. Livingston PM, White V, Hayman J, Dobbinson S. Sun exposure and sun protection behaviours among Australian adolescents: trends over time. Prev Med 2003;37:577 84. Cokkinides VE, Weinstock MA, Cardinez CJ, OConnell MC. Sun-safe practices in US youth and their parents: role of caregiver on youth sunscreen use. Am J Prev Med 2004;26: 147 151. Hall HI, May DS, Lew RA, Koh HK, Nadel M. Sun protection behaviors of the US White population. Prev Med 1997;26:401 7. Koh HK, Bak SM, Geller AC, et al. Sunbathing habits and sunscreen use among White adults: results of a national survey. Am J Public Health 1997;87:1214 7. Hall HI, Rogers JD. Sun protection behaviors among African Americans. Ethn Dis 1999;9:126 31. Weinstock MA, Rossi JS, Redding CA, Maddock JE, Cottrill SD. Sun protection behaviors and stages of change for the primary prevention of skin cancers among beach goers in the southeastern New England. Ann Behav Med 2000;22:286 93. Santimyre BR, Feldman SR, Fleischer AB. Lifestyle high-risk behaviors and demographics may predict the level of participation in sun-protection behaviors and skin cancer primary prevention in the United States. Cancer 2001;92:1315 24. Bolognia JL, Berwick M, Fine JA, Simpson P, Jasmin M. Sun protection in newborns. A comparison of educational methods. Am J Dis Child 1991;145:1125 9. Johnson K, Davy L, Boyett T, Weathers L, Roetzheim RG. Sun protection practices for children: knowledge, attitudes, and parent behaviors. Arch Pediatr Adolesc Med 2001;115:891 6. Robinson JK, Rigel DS, Amonette RA. Summertime sun protection used by adults for their children. J Am Acad Dermatol 2000;42: 746 53. Robinson JK, Rademaker AW. Sun protection by families at the beach. Arch Pediatr Adolesc Med 1998;152:466 70. Glanz K, Lew RA, Song V, Cook VA. Factors associated with skin cancer prevention practices in a multiethnic population. Health Educ Behav 1999;26:344 59.

[19,45,46]. Lastly, the methodology for this study included an independent assessment of youth and parental data, unlike past studies where parents served as proxies for their young childrens responses [2023,47,48]. This study observed that parents are more consistent sunscreen users at the beach or pool, but need improvement using other sun protective behaviors individually and in conjunction with sunscreen. Parents of adolescents in certain subgroups, especially parents with high sun sensitivity and parents with college degrees, have heeded earlier skin protection messages as demonstrated by this study, but continued improvement for themselves, other subgroups, and their adolescents is necessary to reduce the number of incident skin cancers. Many internal and external forces affect adolescent development, including parental influence. Parents may serve as conduits for information delivery as more programs are created or enhanced to include health behavior messaging beyond the individual. Several methods for increased sun protection among parents and their adolescents observed in this study include using sun protective clothing in conjunction with sunscreen more often, reapplying sunscreen throughout the day after its initial application, using sun protection during any outdoor exposure beyond the beach or the pool, and providing more sun protection advice during physician visits. By including parents of adolescents in current or future sun protection programs, skin cancer advocates and physicians may address their priorities of reduced sun exposure and sun safe practices.

[2] [3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

Appendix A. Tan appeal and sun protection attitudinal statements A.1. Tan appeal 1. 2. 3. The sun feels good on my skin. I feel healthy when I have a nice tan. I look better when I have a tan.

[13] [14]

[15] [16]

A.2. Sun protection 1. 2. 3. 4. Protecting my skin from the sun is an easy way to stay healthy. Using sunscreen lotion allows me to enjoy the outdoors with less worry. Spending time in the sun without any protection can increase my chances of developing cancer. My skin wont wrinkle as fast if I spend less time in the sun.

[17]

[18]

[19]

[20]

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