Health Education Research, Vol. 14, No. 2, 155-166,
April 1999
© 1999 Oxford University Press
Formative research for developing targeted skin cancer prevention programs for children in multiethnic Hawaii
Cancer Research Center of Hawaii, University of Hawaii at Manoa, Honolulu, HI 96813, and
1 Department of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
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Skin cancer is a significant and increasing public health problem. Improvement in sun protection practices among children holds great promise for prevention, and parents and caregivers play important roles. Health promotion programs are most likely to succeed when based on a systematic planning process including an understanding of current practices, beliefs, social norms and environments. This article describes formative research used to help develop the SunSmart skin cancer prevention program in Hawaii. Group discussions and interviews were conducted with 216 children in grades 1, 2 and 3, 15 parents, and 27 recreation staff. Children's discussion groups took place in intact classrooms. A combination of quantitative and qualitative methods was used. Multiple raters and an iterative process were used to analyze data from survey forms, observer impressions and audio tapes, and to draw the main conclusions. Sun protection practices in all groups were inconsistent, though general awareness about prevention was widespread. Children reported a reluctance to cover up with long pants and sleeves, and wide-brim hats, and did not understand what skin cancer was. Parents and recreation staff were supportive of education and policy supports, to improve both their own and the children's prevention habits. They were enthusiastic about interactive and creative activities. We conclude that targeted skin cancer prevention messages and strategies for Hawaii's children should promote gradual changes, provide environmental supports, and involve parents and recreation staff. Both the findings and procedures have implications for prevention elsewhere.
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Introduction |
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Skin cancer is a serious and increasing problem for Americans. Nearly 1 million new cases are diagnosed each year (Miller and Weinstock, 1994
) and almost 10 000 deaths per year are caused by melanoma or non-melanoma skin cancer (NMSC) (American Cancer Society, 1995). Between 1973 and 1989, the age-adjusted incidence of malignant melanoma in the US rose faster than for any other major cancer, from 5.7 to 10.7 per 100 000 (Preston and Stern, 1992). Further, in 1992, the cost of treating skin cancers in the US exceeded $500 million (National Cancer Institute, 1994).
Prevention, especially improved sun protection, holds great promise for reducing the burden of skin cancer. Most skin cancers occur on sun-exposed body areas and about 90% of all skin cancers that were diagnosed in 1994 could have been prevented by protection from the sun's rays (American Cancer Society, 1995). Increased cumulative sun exposure is a risk factor for NMSC, while the avoidance of sunburns, especially in childhood and adolescence, may reduce the incidence of malignant melanoma (Hill et al., 1992).
Children have the greatest lifetime potential to benefit from sun protection behaviors because sun exposure during childhood accounts for about 80% of total lifetime exposure (Preston and Stern, 1992). Recommended sun protection habits include: routinely using sunscreen with a Sun Protection Factor (SPF) of 15 or higher; wearing protective clothing such as wide-brim hats, long sleeves and long pants; and seeking shade during peak sun hours (National Cancer Institute, 1994). Parents and caregivers, such as teachers or recreational leaders, can and should introduce children to the importance of sun protection habits, and provide the necessary resources for adopting these habits. In addition, caregivers can serve as role models by demonstrating and practicing sun safety.
Awareness, knowledge, concern and practice of behaviors to prevent and detect melanoma are relatively low in the US (Miller et al., 1996). A number of surveys have examined the extent and correlates of sun exposure and sun protection practices in children, adolescents and adults (Arthey and Clarke, 1995). Generally, people take more precautions when they are at the beach or on vacation than when they are working or playing outdoors (Bennetts et al., 1991; Bourke and Graham-Brown, 1995; Newman et al., 1996). Parents often say that they are more concerned about sunburn than skin cancer (Bourke and Graham-Brown, 1995; Zinman et al., 1995) and report that they do not routinely protect their children from solar radiation (Bennetts et al., 1991; Bourke and Graham-Brown, 1995; Zinman et al., 1995). Parents who practice better sun protection for themselves are most likely to do the same for their children (Bennetts et al., 1991; Buller et al., 1995; Zinman et al., 1995). Other factors associated with more preventive habits include having fairer skin, higher education, more knowledge and knowing someone with skin cancer (Arthey and Clarke, 1995; Newman et al., 1996). Perceived social norms appear especially influential among adolescents and young adults (Cody and Lee, 1990; Lowe et al., 1993; Arthey and Clarke, 1995).
The evidence from these recent surveys indicates the continued and critical need for effective education for skin cancer prevention and control. It also suggests broad areas to include in skin cancer prevention programs, such as sun protection when outdoors when not at the beach, addressing parents in attempts to reach children and social norms for young adults. However, the literature provides limited guidance about how best to craft messages and strategies to successfully reach specific target audiences. Most of the published surveys have asked about only one protective behavior, sunscreen use, and many of them have surveyed small, select samples with predominantly Caucasian respondents. Few previously reported studies have reported qualitative or in-depth audience assessments to help guide the development of skin cancer prevention programs and messages (Arthey and Clarke, 1995). We were able to locate only one published report of formative research, conducted with adolescents (Gillespie et al., 1993). There are no available reports of young children's skin cancer-related beliefs and behaviors based on information collected directly from the children; no reports of how sun protection is viewed and practiced in multiethnic populations; and no data based on perspectives of multiple target audiences within the same community.
A clear understanding of the knowledge, attitudes and current practices of intended audiences, along with an understanding of the social norms and environmental context of a program, is needed to accurately identify opportunities and obstacles for a successful health promotion program (Green and Kreuter, 1991; Glanz et al., 1997). Given the gaps in available information about skin cancer among elementary-school-aged children, their parents and caregivers in a multiethnic setting, we identified a clear need for formative research conducted with our intended audiences. This effort had dual aims: (1) to collect data that would help us formulate a successful program, and (2) to help contribute to the broader base of knowledge about children's, parents' and recreation staff members' beliefs and behaviors related to sun protection.
Formative research is useful for helping to develop appealing program messages, content and format, and has been found especially valuable in designing programs for children and youth (Mathews et al., 1995; Worden et al., 1996; Harrington and Donohew, 1997). Formative research techniques include group discussions, semi-structured interviews and focus groups, all of which encourage people to express their thoughts on a specific subject. When conducted in a group setting, they enable people to consider their own views in the context of the views of others (Basch, 1988; Patton, 1990), and can provide a rich understanding of a target group's personal motivations, environments, skills, belief systems and health practices (Kirby et al., 1995).
The purpose of this paper is to describe formative research carried out during the first year of development of the SunSmart skin cancer prevention program in Hawaii. The program was designed for elementary school children in first through third grades, their parents and recreation leaders. The objectives of this formative research were: (1) to learn what children, parents and caregivers in Hawaii knew, thought and did about skin cancer and sun protection; and (2) to get ideas from the target audiences about the appeal and feasibility of various educational materials, strategies and sun safety policies.
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Methods |
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The SunSmart program
The SunSmart program is a skin cancer prevention initiative for children in Hawaii between the ages of 6 and 8 years, their parents and recreation staff. The long-term goal of SunSmart is to disseminate effective skin cancer prevention programs for children, families and recreation staff statewide. Recreation staff include lifeguards, coaches and `Summer Fun' leaders at YMCA and parks-based day camp programs.
The main objectives of SunSmart are: (1) to increase awareness, intentions, skills and practices for skin cancer prevention among parents, recreation staff and 6- to 8-year-old children in the program; and (2) to increase environmental supports and policies to promote skin cancer prevention in outdoor recreation settings for youth. The first 9 months of the project were devoted to target audience assessment, review of available materials, and development of new, tailored materials, messages and strategies. We first reviewed the results of a survey of parents of young children conducted in the state 3 years earlier, reviewed existing skin cancer prevention programs and child health promotion strategies, and obtained input from an Advisory Committee of parents, recreation leaders, educators and health professionals. The formative research reported here was conducted to supplement the above-mentioned information.
Theoretical framework
Two theoretical frameworks—Social Cognitive Theory and the Health Belief Model (Bandura, 1986; Strecher and Rosenstock, 1997)—provided the foundation for this formative research. Social Cognitive Theory suggests that behavior is influenced by social and physical environments, along with the features of the behavior (Bandura, 1986). Thus, factors to be investigated included personal sun protection behaviors, perceptions about role models for sun protection (e.g. parents and recreation staff), perceived norms, and the availability of sunscreen and shaded areas. The Health Belief Model constructs of particular interest were perceptions about susceptibility to (risk of) skin cancer and sunburn, their perceived severity, and the benefits of and barriers to sun protection behaviors. We expected that children, recreation staff and most parents would have low levels of awareness about skin cancer, and would believe that the chances of developing skin cancer were low.
Formative research methods
Twelve group discussions, five focus groups and three semi-structured interviews were conducted over a 3 month period. Three types of audiences were included: children in first, second and third grades, parents, and recreation staff (sports coaches, `Summer Fun' leaders and lifeguards) (see Table I).
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Setting and participants
Data collection from the children and parents was conducted at elementary schools. The schools included three public schools and one private school, and were located on Oahu (Hawaii's main population center) and in Hilo on the island of Hawaii (a neighbor island). We purposefully sought diverse groups in terms of ethnicity, urban/rural areas and private/public schools to help us identify common themes that would eventually be suitable for a statewide program. Schools were recruited by contacting the principals, who worked with us to organize the school-based sessions. The principals selected which classes would participate and preferred to use intact classes where possible, as this was considered the most comfortable environment for the students (Kirby et al., 1995
). Children in participating classrooms were given a letter and consent form to take home to their parents. The sessions were held either during a regular class session or by excusing children who returned the consent forms to take part; this depended on teacher preference and the proportion of children whose parents gave permission to participate. Children's discussion groups included between eight and 28 members, for a total of 216 children. The parents were recruited through invitations that accompanied the letters taken home by their children. They were scheduled on the school premises during lunch or evening hours. Fifteen parents took part. At two schools there were too few parents for focus groups, so we conducted semi-structured interviews with these parents, using the same protocol. Recreation leaders included YMCA staff, lifeguards and sports coaches at a private school. Twenty-seven recreation staff took part in three focus groups, which ranged from eight to 11 participants.
Procedures
The group discussions and focus groups were led by pairs of trained moderators with experience in health promotion, skin cancer prevention and group dynamics. Each session was audio taped. At each session two observers, who sat outside the discussion area, completed observation protocols, and took notes on participants' ideas and comments. Classroom teachers were present during the children's sessions as required by school policies, but this did not seem to inhibit discussion among the first through third grade children.
A combination of quantitative and qualitative methods was used to structure data collection. Quantitative data supply important background information and can help to verify qualitative findings during data analysis (Miles and Huberman, 1994). To obtain quantitative data, all participants were asked to complete a brief written questionnaire before the discussion groups. Parents and recreation staff were asked about their background characteristics (demographics, photosensitivity, skin cancer history), and their sun exposure and sun protection habits. The children's survey forms used pictures of hats, shirts, sunglasses, etc., to help the children report their knowledge (what they thought they `should' do when they were out in the sun), preferences (what they `like' to do or wear) and sun protection habits (`what you wear'). Children were guided through the questions by the session leader. The forms were used to stimulate discussion during the sessions as well as to provide quantitative data.
The discussion periods of the children's sessions began with a hat-making activity, and by asking the children to tell their names and favorite games, in order to actively involve them in the discussions (McDonald and Topper, 1988). Discussion guides were then used to structure collection of qualitative data, and to elicit opinions and ideas from participants. The discussion guides included constructs from Social Cognitive Theory and the Health Belief Model (Green and Kreuter, 1991; Glanz et al., 1997), so that it would be possible to evaluate the constructs' applicability to the SunSmart program. Separate but parallel discussion guides were developed for the children, parents and caregivers. Each discussion guide began with general questions about outdoor activities (for the children) or child health (parents and recreation staff), and then inquired about sun protection habits, knowledge and beliefs about skin cancer, beliefs about sunburn, who they considered role models, and reactions to possible educational materials and strategies. Parents and recreation staff were also asked their views about introducing sun safety policies and the feasibility of program activities.
Group discussions and interviews lasted about 45 min. Participants received a `Sun Safe' gift package containing sunscreen samples, lip balm and skin cancer awareness brochures.
Data analysis
Quantitative data from questionnaires were entered into a computer program using SPSS-PC, and tabulated to summarize information about the participants' characteristics, their sun protection practices and their opinions. Chi-square statistics and t-tests were used to test for differences between schools, grade levels and genders.
Analysis of qualitative data from the focus groups was based on observations recorded on written protocols, session audio tapes and notes made by focus group leaders. Because the children's discussion groups were very fast moving and the groups were large, we determined that verbatim transcription of the audio tapes would not be helpful. Qualitative analysis procedures included looking for patterns that reappeared among various focus groups, to identify themes that were common to several participants (Krueger, 1994) and noting illustrative comments that reflected recurring themes. The theoretical frameworks were used to help organize the results.
To achieve convergent validity in our conclusions, multiple people reviewed the observation notes and audio recordings from each session independently. To guard against interpretive bias, the first stage of analysis was completed separately by a research assistant who was present and one who was not present at the focus group sessions. The project team then discussed the key observations until consensus was reached on the main findings and conclusions.
Finally, we reviewed findings in terms of both the qualitative and quantitative data. The qualitative and quantitative data were linked initially because we used the questionnaire responses to stimulate discussion. When the quantitative data were summarized and examined for group differences, they were useful to help interpret the qualitative findings (Patton, 1990).
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Results |
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Results are presented here for children, parents and recreation staff. We first describe the participants and findings from the questionnaires (i.e. quantitative data). This is followed by highlights of findings from the group discussions and interviews (i.e. qualitative data).
Description of participants and sun protection habits
Children
As Table I
shows, participating children were fairly equally divided across first, second and third grades. Slightly over two-thirds were public school students and more than half (53.2%) were boys. Ethnic backgrounds of the children, as judged by session leaders and observers, were highly mixed, with an estimated one-third being Caucasian, one-half fair skinned Asian or mixed and about one-fifth dark-skinned Asian, Filipino, Native Hawaiian or mixed.
Table II summarizes the children's responses to questions about their knowledge, preferences and sun protection habits. Although most children knew which type of clothing was best for sun protection, many indicated they did not like to wear it (preference) and that they did not wear hats, pants and shirts that provided maximum protection (i.e. wide brim hats, long pants and long-sleeved shirts) (habit). Knowledge levels were significantly higher in the older children (P < 0.05) and there was a trend toward differences in sun protection practices by grade and school (NS) but not by gender. Both preferences and habits were most often those which provided intermediate levels of protection, i.e. a cap, medium-length shorts and T-shirts with short sleeves. About 60% reported `usually' wearing sunscreen and sunglasses, and 37.9% indicated that they used lip balm.
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Parents
Most of the parents were female (86.7%). Several ethnic groups were represented: Caucasian (26.7%), Filipino (40%), Japanese (13.3%) and Native Hawaiian or mixed (20.1%). Most were long-time residents of Hawaii, with a median of 21 years living in the state. Nearly half reported that they `rarely or never' used sunscreen outdoors, but one-third said they used it `always.' Those who used sunscreen used lotions with an SPF of 15 or higher. Most reported only rarely or sometimes following other sun protection habits such as wearing shirts with sleeves or seeking shade.
Recreation staff
Of the 27 recreation staff, 60% were coaches or physical education instructors and 40% were lifeguards or `Summer Fun' leaders. All of them worked with 6- to 8-year-old children. They were evenly divided between males (48%) and females (52%), with a median age of 32. Nearly half (48%) were Caucasian, with the others being Japanese (24%), Filipino (12%) or Native Hawaiian, mixed ethnicity or other (16%). The median time living in Hawaii was 28 years. A majority of respondents (60%) said they `usually' or `always' used sunscreen with an SPF of 15 or higher. However, most rarely wore shirts with sleeves (88%), they sought shade `sometimes' (76%) and most wore a hat `sometimes.'
Findings from group discussions and interviews
Table III summarizes observations from the discussions and interviews, along with supporting comments or conclusions drawn from the data. The summary and this narrative are organized by relevance to the theoretical constructs and comments about potentially useful educational/policy strategies.
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Children
Most children were aware of sunburn and had experienced one or more sunburns, but were not overly concerned since it usually went away within a few days. Very few of the children understood what skin cancer was, though the older children were more likely to know. A common misconception was to confuse skin cancer with other types of cancer. They expressed little acceptance of long sleeves and long pants, or wide brim hats, for sun protection when they are outdoors. The main barriers noted were discomfort in the heat and hats being difficult to wear while active.
Children in this age group agreed that they were dependent on their parents or other relatives (e.g. older siblings, grandparents) to provide and/or put sunscreen on them; the older children were more likely to apply it themselves. The children said they listened mostly to their parents' guidance on matters related to sun protection, but acknowledged that coaches, teachers, lifeguards and `Summer Fun' leaders were role models who they would listen to and imitate. Finally, with respect to activities for a sun safety program, the children said they would like them if they were fun and fit in with what they were doing.
Parents
Although some parents expressed concern about sun safety for their children, they also reported inconsistent sun protection practices because of local practices or habit, felt that sun protection was not necessary if one built up `resistance' and did not believe skin cancer was always a serious health problem. The most commonly mentioned barriers were expense, time pressure, inconvenience of applying sunscreen and children not cooperating.
Despite some misinformation and current practices that were not congruent with prevention guidelines, the parents who participated in the formative research were supportive of a sun safety program at schools or parks, and enthusiastic about strengthening policies and offering educational programs. They made some concrete suggestions about strategies and policies, including: making sun safety a routine part of activities and including sun protection in the cost of sport uniforms or school supplies.
Recreation staff
Most recreation staff had not talked to parents about sun protection due to lack of information and/or time. They admitted that they were not always exemplars, but felt they could be good role models and were willing to try to visibly practice sun safety habits. Recreation staff, particularly coaches, described some obstacles to their own and the children's sun protection habits, most notably that hats and sunglasses made it difficult to make eye contact during sports, and that hats did not stay on in the wind and when children are active. They indicated willingness to make policy and structural changes at their sites, and agreed on several feasible options (see Table III). They also suggested communication mechanisms and interactive activities to reach parents and children. The recreation staff from YMCA's indicated that encouraging the children to drink water was routinely emphasized during activities on hot days (i.e. virtually all days).
Cross-cutting theme
Throughout all the discussion groups, focus groups and interviews, participants expressed a general feeling that using sunscreen was, by itself, the most important—or even the only important—sun protection practice.
Links between qualitative and quantitative data
The children's answers in the discussion sessions were consistent with their aggregate questionnaire responses about their sun protection habits (as compiled after the discussion sessions; Table II). This pattern was also found for the parents and recreation staff (data not shown in summary form).
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Discussion |
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Our formative research helped us to understand the three target audiences for a skin cancer protection program for primary school children. Assessment of each group (children, parents and recreation staff) yielded unique insights, and the information converged to help create an overall picture of the types of messages and program strategies that might be feasible and effective.
Both the survey and focus group data indicated significant variation in sun protection knowledge, awareness and behaviors among children, parents and recreation staff. As others have reported (Arthey and Clarke, 1995), we found that most parents and staff do not practice sun-smart habits themselves. Thus, while adults and recreation staff are supportive of skin cancer prevention programs, they too can benefit from education, motivation and supportive policies.
We explored beliefs using constructs from the Health Belief Model (Strecher and Rosenstock, 1997), related to perceived risk, severity, barriers and benefits. We learned that children in this age group do not understand what skin cancer is nor perceive it as a threat and that they confuse it with other types of cancer. They believe themselves vulnerable to sunburn, but do not consider it a serious problem. Thus, messages about sunburn prevention may motivate children initially; but any messages addressing `skin cancer' and not just sun protection should be aimed at adults (parents and staff) rather than at children in the early primary grades (Hughes, 1994).
Each audience group identified barriers to consistent sun protection. The children's remarks about the obstacles to wearing long sleeves, long pants and wide-brimmed hats outdoors in Hawaii were particularly compelling, and suggested that messages recommending these cover-ups would probably be seen as too extreme to be acceptable in Hawaii at this time. Messages will probably be better received if they encourage more gradual change, e.g. the use of short sleeves, longer shorts and some type of cap or hat as protective clothing.
Most of the comments about benefits of sun protection were about sunscreen. Thus, the idea that sunscreen alone is not sufficient protection from ultraviolet radiation is another important message to convey. It is therefore important to consciously emphasize the various types of practices that comprise sun protection, including protective clothing and shade seeking.
We further examined key constructs from Social Cognitive Theory (Bandura, 1986), related to the social environment, role models, norms and availability of environmental supports. The central role of parents in influencing children's sun protection practices, reported in the literature (Bennetts et al., 1991; Buller et al., 1995; Zinman et al., 1995), was clearly affirmed. The opportunity for, and willingness of, recreation staff to serve as role models for sun safety also emerged. Social norms in Hawaii suggest a need to promote change that is acceptable within a tropical climate where children are used to dressing lightly, and where the population includes a mix of fair- and darker-skinned persons. Also, we found that sun safety messages could be included with reminders for children to drink water often when outdoors, as part of general health and safety messages in the environment.
In response to our inquiries about the type of educational materials and strategies that might effectively reach all three audiences, the participants stressed the importance of providing creative and engaging sun protection messages. Ideally, interactive on-site activities and education materials that children can take home to their parents would engage all parties in the health promotion process. Therefore, as a result of the focus groups we planned to create group activities to actively involve the children in hands-on experiences and take-home activities for children to complete with their parents.
This is the first report of formative research on skin cancer prevention for children that used data from both child and adult audiences, the first to report data on sun protection beliefs collected directly from children in the lower primary grades, and the first to explore influences on skin cancer prevention in a multiethnic population. A strength of this formative research is the large number of child and recreation staff participants from diverse settings, and the use of complementary quantitative and qualitative data. The use of multiple researchers to collect and analyze the qualitative data also reduced the potential for investigator bias in interpreting the findings. We note particularly that any conclusions based on data from parents are limited by the small number of non-randomly selected participants. Future studies of this type will require other, more aggressive, strategies to recruit parents to take part.
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Implications for program development |
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Improving skin cancer prevention for children has the potential to significantly reduce the increasing burden of skin cancer. Information from this formative research increased our understanding of children's and adults' beliefs, practices and norms regarding sun protection, beyond what could be learned from previously published literature. This audience assessment was an important step toward guiding the development of educational and environmental/policy strategies that are most likely to be effective. Results of this phase were used, along with reviews of available data and materials, to inform the development of educational materials and activities for the SunSmart project. A full-scale pilot study of SunSmart was then conducted in five recreation sites (Glanz et al., 1998
) before the program materials and procedures were finalized for evaluation in a randomized controlled trial. Our specific findings are most likely to be generalizable to locales with warm, sunny climates elsewhere in the US. Hawaii's multiethnic population looks like the increasingly mixed populations in many other states, in states like California, Florida, Texas and Arizona. In addition, the procedures, questionnaires and discussion guides (available on request from the first author) can serve as models for formative research to help design health promotion programs about skin cancer prevention in other regions.
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Acknowledgments |
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The authors gratefully acknowledge the contributions of the following individuals: Michael Cheang, Laurie Chang, Gwen Ramelb, Mae Isonaga, Haiou Yang, Eiko Cusick, Manju Chatani, Nobuhiro Kadoi, Fumiko Takahashi, Ellen Roberts, Roger Bellinger, Paul Berry, Sharon Hanzawa, Kathryn Braun, Laurel Muneoka and Valerie Ah Cook. We are also most grateful to the children, teachers, parents and recreation leaders who participated. The work reported here was completed through a cooperative agreement with the Health Promotion and Education Branch, Department of Health (DOH), State of Hawaii, and the Chronic Disease Prevention Control Program of the Centers for Disease Control and Prevention (CDC), within the US Public Health Service
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Received on January 2, 1998; accepted on April 8, 1998
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 C. Black, K. Grise, J. Heitmeyer, and C. A. Readdick Sun Protection: Knowledge, Attitude, and Perceived Behavior of Parents and Observed Dress of Preschool Children Family and Consumer Sciences Research Journal, September 1, 2001; 30(1): 93 - 109. [Abstract] [PDF]
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