Health Education Research, Vol. 17, No. 4, 405-414,
August 2002
© 2002 Oxford University Press
Behavior of caregivers to protect their infants from exposure to the sun in Queensland, Australia
Centre for Health Promotion and Cancer Prevention Research, Faculty of Health Sciences, University of Queensland, Herston, Queensland 4006 and 1 Department of Paediatrics and Child Health, University of Queensland, Mater Hospital, South Brisbane, Queensland 4101, Australia
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Abstract |
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Exposure to the sun by infants has been demonstrated to increase the risk of the development of melanoma and other skin cancers later in life. A cohort of 508 women who delivered healthy Caucasian babies were followed up at 1 year to determine their knowledge, attitudes and practices regarding sun protection towards themselves and their child. In addition, the 1-year-old infants were assessed by a trained nurse for the number of nevi they had on their skin. Results indicate caregivers reported a high level of sun-protection practices towards their child, with 93% of the caregivers reporting usually or always placing the child in the shade when going outside. Further, 81% of the caregivers reported usually or always placing a hat on the child, while 64% reported usually or always applying sunscreen to the child’s exposed skin. Interestingly, only 61% of the caregivers reported that they stayed in the shade to reduce sun exposure and only 42% wore a hat when out in the sun. Mother’s own personal sun-protection methods predicted the method of sun protection that she would most likely use for the child. While children appear to be reasonably protected from the sun, they are influenced by their mother’s own behaviors.
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Introduction |
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The incidence of skin cancer in Australia is a major concern for health professionals. Almost 2% of Australians are treated annually for non-melanocytic skin cancer and over 200 people die from this disease each year (Staples et al., 1998
). Between 1985 and 1995 there was a total increase of 33% in the incidence of non-melanocytic skin cancer (Giles et al., 1988; Staples et al., 1998). Standardized incidence rates for non-melanocytic skin cancer in 1985 were 823 per 100 000 person years (Giles et al., 1988) and 1109 per 100 000 in 1995 (Staples et al., 1998). This 1995 figure accounted for more than 270 000 people being treated for at least one non-melanocytic skin cancer in that year (Staples et al., 1998).
Malignant melanoma, which is the fourth most common cancer in Australia (Australian Institute of Health and Welfare and Australasian Association of Cancer Registries, 1996) and the more life-threatening form of skin cancer, kills approximately 900 Australians each year (Australian Institute of Health and Welfare, 1998). While the mortality rate from melanoma has stabilized in Australia in recent years, the incidence rate of melanoma continues to rise (Giles et al., 1996). Over the 10-year period between 1985 (Australian Institute of Health and Welfare and Australasian Association of Cancer Registries, 1992) and 1995 (Australian Institute of Health and Welfare and Australasian Association of Cancer Registries, 1998) there was approximately a 60% increase in the incidence of melanoma. Currently over 7000 cases of melanoma are diagnosed in Australia each year (Australian Institute of Health and Welfare and Australasian Association of Cancer Registries, 1998).
Not surprisingly, the economic burden of medical treatment costs associated with skin cancer in Australia is extremely high. The Australian Institute of Health and Welfare has estimated the direct costs of skin cancer to be approximately $170.05 million per year (Carter et al., 1999). Skin cancer also has huge indirect costs and results in personal suffering, including loss of wages, treatment costs, discomfort and disfigurement (Green et al., 1997).
Since the 1980s there has been increasingly strong epidemiological evidence to suggest that childhood is a critical period for establishing lifetime risk of skin cancer (Marks, 1994; Marks and Hill, 1988). Studies of both melanoma and non-melanocytic skin cancer have demonstrated that excessive sun exposure during the first 10–20 years of life is particularly important in the development of these skin cancers (Holman and Armstrong, 1984; Weinstock et al., 1989; Marks et al., 1990; Kricker et al., 1991; Khlat et al., 1992; Giles et al., 1996; Autier and Dore, 1998). Risk of developing melanoma has been found to be highest among adults who received high levels of sun exposure during childhood (Autier et al., 1998) and it has been estimated that two-thirds of melanoma are caused by excessive sun exposure in the first 15 years of life (Giles et al., 1996). Further compelling evidence of childhood being a critical period in the development of skin cancer comes from migration studies. Risk of developing melanoma and non-melanocytic skin cancer has been associated with being born in Australia or migrating to Australia before 10 years of age (Holman and Armstrong, 1984; Marks et al., 1990; Kricker et al., 1991; Khlat et al., 1992).
A high number of melanocytic nevi (moles) on the body is an important potential phenotypic risk factor for the development of melanoma (Holly et al., 1987; Swerdlow and Green, 1987; Kelly et al., 1994). Epidemiological research has consistently shown that the development of melanocytic nevi is associated with excessive sun exposure during childhood (Harrison et al., 1994; Kelly et al., 1994; Chamlin and Williams, 1998). Significantly higher nevi counts have been found in children who received more than 4 h of sun exposure each day (Harrison et al., 1994). Higher nevi counts are also related to a history of sunburn, freckling and light skin, which has a propensity to burn rather than tan (Harrison et al., 1994; Kelly et al., 1994).
Reduction in levels of sun exposure in childhood is more likely to have a greater impact on the incidence of skin cancer than reducing sun exposure in adulthood (National Health and Research Council, 1996). The establishment of good sun protection habits early in life is particularly important (Hill and Dixon, 1999). Williams and Sagebiel have suggested that instruction and sun protection should begin in infancy (Williams and Sagebiel, 1989). Infants should be protected from direct sunlight and older, more mobile children should also be protected by scheduling outdoor activities to avoid the mid-day sun, wearing wide-brimmed hats, long-sleeved shirts and pants, and by applying a maximum protection, water-resistant sunscreen (Williams and Sagebiel, 1989).
It has been suggested that the majority of a person’s lifetime sun exposure has occurred during childhood (Marks et al., 1990). This suggestion is reasonable given the levels of sun exposure found in sun-related studies of children (Grob et al., 1993; Jarrett et al., 1993; Buller et al., 1995; McGee et al., 1997; Vail-Smith et al., 1997; Lovato et al., 1998; Morris et al., 1998; Robinson et al., 2000). In a study of summertime sun protection, Robinson et al. found that over a weekend, children spent an average of 7.5 h outside during the day (Robinson et al., 2000). Of these, approximately 5 h were spent during the peak times of 10 a.m. to 4 p.m. Grob et al. discovered 3-year-old children spent over 15 h per week outside in their swimming costume between 11 a.m. and 4 p.m. during summer (Grob et al., 1993).
In children, high levels of sun exposure are commonly combined with low levels of sun protection. Grob et al. found nearly 40% of young children had inadequate or no sun protection during summer (Grob et al., 1993). In a study by Jarrett et al., 70% of the children surveyed had been exposed to the sun without a shirt at least once in the previous year (Jarrett et al., 1993). A high incidence of sunburn among the children in this study was also reported, with 38% having been burnt in the previous year (Jarrett et al., 1993). Sunburn appears to be a common experience in childhood. One Australian study has estimated that 82% of Australian children will have experienced sunburn by 3 years of age (Stanton et al., 2000). Studies of summer sun exposure have found one-third (Morris et al., 1998) to nearly one-half (Lovato et al., 1998) of children experience sunburn over the summer months.
In a study of winter sun exposure and sun protection for infants and toddlers, Stanton et al. (Stanton et al., 2000) found toddlers were more likely than infants to experience sunburn. Approximately 57% of toddlers experienced one to three light sunburns (classified as being pink or red as a result of the sun) compared to 37% of infants. Twenty-five percent of toddlers experienced four or more light sunburns, whereas this amount of sunburn was not reported at all for infants. Increased mobility and a greater tendency to play outdoors have been suggested as the reason for increased sun exposure from infancy to early childhood (Moise et al., 1999). It should be noted that differences in the individual behaviors regarding sun protection might be attributed to efforts within each country to address sun cancer.
Although most parents take some action to protect their children from the sun, the high incidence of sunburn indicates inadequate sun-protective practices. One-third to one-half of parents of infants and toddlers reported they did not usually perform basic sun-protection activities (Stanton et al., 2000). Only 35% of parents in a study by Zinman et al. (Zinman et al., 1995) reported they would ensure their child was protected from the sun by the use of protective clothing, hat and sunscreen. Ninety-one percent stated they would employ at least one of these sun avoidance strategies and 69% stated they would employ two (most frequently hat and sunscreen).
Parents influence many of the activities that determine their children’s sun exposure, and are responsible for advocating and incorporating sun-protective behaviors into family routines (Buller et al., 1995; Morris et al., 1998; Hill and Dixon, 1999). The importance of parents as role models for their children is also well recognized (Buller et al., 1995; Hill and Dixon, 1999). Through role modeling, parents teach their children life and socialization skills, shape their child’s view of the world, and lay the foundation for behavior (Australian Bureau of Statistics, 1999).
Parents’ own sun-protective behavior has been shown to be predictive of their children’s sun-protective behavior (Foltz, 1993; Grob et al., 1993; Zinman et al., 1995; McGee et al., 1997; Morris et al., 1998). Reported use of sun-protection factor 15+ sunscreen by parents to protect themselves from the sun has been found to be significantly associated with the absence of sunburn in their children (Morris et al., 1998). Zinman et al. (Zinman et al., 1995) and Foltz (Foltz, 1993) found parental use of sunscreen was a key determinant of whether parents used sunscreen on their children. Parental use of sun protection was also the best predictor of sun protection for young New Zealand children (McGee et al., 1997).
Mothers, in particular, remain primarily responsible for the care and, therefore, the sun protection of their child (Australian Bureau of Statistics, 1999). In Australia during 1997, mothers with children less than 5 years old spent, on average, approximately 8.5 h each day caring for their child, compared to fathers who spent, on average, approximately 3 h each day caring for their child (Australian Bureau of Statistics, 1999).
The aim of this paper is to discuss caregivers’ (mothers’) self-reports of their own sun-protective behaviors and reported sun protection of their infants. We have also documented and reported the number of nevi on the infant’s skin as an indication of sun exposure, and its relationship with the mother’s reported sun protection towards her infant.
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Methods |
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Recruitment
All mothers giving birth at a major hospital in Brisbane, Australia over a 20-week period and who fulfilled the eligibility criterion were invited to participate in the study. Eligible mothers were those with babies who were Caucasian, born full-term, apparently healthy and weighed at least 2.27 kg. Mothers wishing to participate in the study were informed that they would be required to answer questions regarding sun-protection practices around the time of their child’s first birthday. In addition, a trained nurse would come to their house and count the number of nevi their child had on his/her skin.
Participant follow-up
When the infants turned 10 months old, mothers were sent a postcard reminding them they had agreed to participate in the study and advising them they would receive a phone call from the study’s staff to schedule an appointment for the nurse to visit. This visit occurred within 4 weeks of the child’s first birthday. A questionnaire regarding demographic details of the caregiver, knowledge, attitudes and behaviors regarding the sun protection of the child, and the caregiver’s own sun-protection practices were completed. This questionnaire was filled out prior to the nurse’s visit. During this visit, the nurse collected the questionnaire, and measured the weight and height of the child, conducted skin, hair and eye color assessments, and recorded the number of nevi on the child.
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Results |
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A total of 604 mothers were initially recruited into the study. This represented 60% of eligible women who gave birth during the recruitment period. There was no significant difference between those mothers that participated regarding the child’s gender, age of parent and marital status. At the end of 1-year follow-up, 508 (84%) mothers were contacted. Table I
represents the demographic characteristics of the mothers and infants. Almost all mothers (91%) were married or in a de facto relationship and, for about half of the mothers, this was their first child. Interestingly, in almost 100% of the cases the caregiver was the mother.
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Knowledge and attitudes of sun protection and sun damage by caregivers
Caregivers were aware that Queensland and Australia have very high rates of skin cancer, with almost 92% agreeing with this statement (Table II
). They were also very knowledgeable regarding the link between the sun and skin cancer (92% affirmative responses). Caregivers knew that, in a climate like Queensland which is located in the tropics and sub-tropics, individuals must protect themselves from the sun even in winter (93% affirmative responses). There was some ambivalence regarding the harm occasional sunburn might cause to the skin. Almost 18% of the caregivers reported that they were unsure or did not believe that sunburn caused harm to the skin.
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Nearly 90% of the caregivers did worry about skin cancer or melanoma. Notably, only 65% were worried that the sun would give them wrinkles. Of concern, was 50% of caregivers believed that their children needed direct sunlight to be healthy. This is despite the high exposure to sunlight the children receive living in the tropics. While almost all caregivers (90%) believed that they did a good job in protecting their child from the sun, as many as 20% found it difficult to protect their 1-year-old child from the sun.
Sun-safe practices
Caregivers reported high levels of sun protection towards their child (Table III). While sunscreen was the least preferred option for sun protection, with only 64% usually/always choosing this form of sun protection, nearly all caregivers usually/always placed their child in the shade (93%), and most put a hat on their child (80%) and ensured their child was wearing protective clothing (77%) when outdoors between 10 a.m. and 3 p.m..
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Similarly, caregivers reported staying in the shade as their most preferred option for sun protection, with almost 60% reporting they always or usually stay in the shade when outdoors between 10 a.m. and 3 p.m. Hats (41%), protective clothing (47%) and sunscreen (48%) were usually or always used by less than half of the caregivers. Nevi on the skin of the 1-year-old infants were counted. The median number of nevi of the children at 1 year of age was 1. The variance of nevi ranged from a low of 0 to a high of 26.
Further analysis was conducted based on factors identified in the literature as influencing sun-protective behavior. These include the mother’s own behavior, whether or not this was her first child and whether she wanted the child to have a tan. Dependent variables were dichotomized, usually/always versus sometimes/rarely/never.
Predicting the child’s level of protection
Results of a logistic regression analysis of factors influencing mothers sun-protective practices toward the child reveal that the mother’s use of clothing on the child appears to be influenced by her desire for the child to have a suntan and her use of sunscreen (Table IV). The greater the mother’s desire for her child to have a suntan, the less likely she would use protective clothing. In addition, if the child wore a hat he/she was significantly more likely to be placed in the shade (P < 0.05) and more likely to wear sunscreen (P < 0.001). In order to examine the independent effect of the mothers’ own sun-protection practices with the respective practices for the child, the additional sun-protection practices were included as covariates in the analysis.
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Results of a logistic regression analysis of factors influencing the mother’s sun-protective practices reveals that the mother’s own selection of personal sun-protection methods predicts which method of sun protection she was most likely to use for herself. For example, use of shade by the mother predicted the use of sunscreen. Interestingly, if the child was first born, she was less likely to use sunscreen and protective clothing, but more likely to wear a hat and stay in the shade. As expected, the more she desired a tan, the less likely she was to perform sun-safe behaviors, with the exception of using sunscreen.
Limitations
There are a number of limitations to this study that must be considered when drawing conclusions from the data. The information was self-reported and no behavior of the mother or her behavior towards her child was observed. The questionnaires describing the caregivers’ sun-protective behaviors as well as protective behaviors for the child were completed prior to the nurse’s visit. This may have influenced the total amount of reported sun protection provided by the caregiver. Also, there was some loss to follow-up that occurred between delivery and the first-year follow-up of the original sample.
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Discussion |
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The fact that caregivers were knowledgeable about the sun and the damage that the sun causes to the skin is not surprising given 20 years of media campaigns promoting skin cancer prevention conducted in Australia. Caregivers reported high levels of understanding of the harmful effects of the sun on the skin. Most of these caregivers would have been exposed to media campaigns and school education as they were growing up. National adolescent data indicates a high level of knowledge among all students in secondary school (Lowe et al., 2000
). However, this high level of knowledge by the mother does not translate into high levels of sun-protection practice by themselves.
Shade, one of the natural ways of protecting infants from the sun, is the strategy most likely to be used by caregivers to protect their infants. However, shade could be also used for coolness in the hot sun. The primary purpose for the mother using shade was not addressed. Further, the use of hats, clothing and sunscreen is higher than those behaviors reported for children in other studies (Buller et al., 1995; Morris et al., 1998; Lowe et al., 2000). At this stage in the child’s development, the mother has almost complete control of the child’s protection in the sun.
Overall, caregivers at this point in time appear to be protecting their children reasonably well from the sun. A possible reason for this may be that mothers also face cultural imperatives to exercise prudence in the face of expert assessments of risk to their child (Murphy, 2000). The failure to protect a child from the adverse effects of sun exposure could, potentially, result in the mother being considered irresponsible or not a ‘good mother’ (Murphy, 2000; Tardy, 2000).
While a conceptual framework has not been currently delineated in the literature, Bandura’s Social Cognitive Theory provides a framework to begin to explain the results. Bandura’s model subscribes that mothers learn what to do through observational learning of women similar to themselves, practising this behavior of protecting their infants from the sun (Bandura, 1986). This could occur though direct observation of other mothers in playgroups, day care, in the park, etc.
While most caregivers reported that they believed they were doing a good job protecting their infant at 1 year of age, 20% of the parents reported it was difficult to protect their infant from the sun. During the next several years, the child will become more mobile, more independent, more in control with regards to the wearing of a hat and clothing, and staying in the shade. The child may become more resistant to parental efforts in protecting them from the sun and this could become an increasing issue. Previous research has found that sun-protective behavior of the caregiver towards the toddler declines with increasing age (Jarrett et al., 1993). A the child grows older and becomes more mobile, the responsibility for sun protection begins to shift during this time from solely the mother, to both the child and mother, to adolescence, when the onus for sun protection is more on the teenage child.
There may be a concern among first-time mothers that the use of sunscreen may or may not be harmful to the child. This may not be unreasonable. No clear message from health professionals has either promoted or recommended against the use of sunscreen for the infant. Without a clear message, first-time mothers seem to be taking the more cautious approach to sun protection by using shade as a main sun-protective mechanism.
Of concern is the number of mothers who still report wanting their infant to have a suntan. This appears to be influencing whether they dress their infant in protective clothing. Many mothers cited health benefits as the reason for exposing their children to the sun. Grob et al. found that among their sample of mothers, mothers were reasonably well informed, but they considered the risk of sun exposure to be exaggerated by the media (Grob et al., 1993). This purposeful attempt to change the natural skin color of the infant may rest more with the social standards of what appears healthy and attractive. This perceived need to have a suntan by both children and adults is a societal issue, and has not been addressed in most sun-protection campaigns.
Research has shown that the sun protection of parents predicts the level of sun exposure of children (Foltz, 1993; Grob et al., 1993; Zinman et al., 1995; McGee et al., 1997). Effort needs to be put in place to maintain the sun-protection practices of the caregiver towards the child as well as providing interventions to increase the use of sun protection by the caregiver. Grob et al. argued the first target of sun-protection campaigns should be a parent, as they not only control exposure of their young children, but also serve as examples (Grob et al., 1993). This data supports the need to continue to focus both on the caregiver as well as the infant. Not surprisingly, mothers appear to have a direct influence on the sun-protection behaviors of the infant. The sun-protective practices of the caregiver were lower than what is expected of the primary role model for the child. Future work needs to continue to focus on the sun-protection practices of both the caregiver and infant.
Future follow-up
The results reported here represent the baseline data of a longitudinal intervention study that is designed to assist mothers to limit the sun exposure of their children during the ages of 1–3 years, and to improve sun-protective behaviors of both mothers and their young children.
This article reports on one of the first studies of its kind to follow a cohort of women and their children from birth to 1 year of age. It documents the sun-protective behaviors of primary caregivers toward their children, own sun-protective behaviors and, most importantly, the relationship between the two. Based on these results, the intervention package will need to address the behavioral, structural and social barriers which have been identified here, and that prevent mothers from keeping young children well protected from the sun. The intervention will need to address confusion regarding sunscreen on infants and the importance of the caregiver as a role model. It will also need to address issues regarding the desire for a tan in order to look healthy.
Caregivers are being matched and paired based on current levels of sun–protection practices towards their child, their own sun protection practices, whether or not the child attended day care and the socioeconomic status of the home. Within each pair caregivers and their child have been randomized to receive the intervention. Each year the caregivers and their child will be visited to recount nevi on the child’s skin, and to collect information on the sun-protection practices of the caregiver towards the child and the caregiver’s own sun-protection practices.
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Notes |
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* To whom correspondence should be addressed at Department of Community and Behavioral Health, College of Public Health, University of Iowa, 2850 Steindler Building, Iowa City, IA 52242-1008, USA
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Acknowledgments |
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Thanks are extended to Research Nurses, Cate Duggan, Tracey Macrae, Kristina O’Dwyer and Pamela Saunders for assistance with data collection, and to the staff of the Mater Mothers’ Hospital, Brisbane for their assistance with participant recruitment. Special thanks are also extended to Dr Ivan Robertson, Director of Dermatology, Royal Brisbane Hospital, and Ann Eldridge, Queensland Institute of Medical Research, for their valuable assistance in training the research nurses. Financial support for this work was provided by the University of Queensland’s Mayne Bequest Fund, Queensland Health, and primarily through the Commonwealth National Health and Medical Research Council, and is gratefully acknowledged.
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Received on January 27, 2001; accepted on November 2, 2001
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 L. S. Benjes, D. R. Brooks, Z. Zhang, L. Livstone, L. Sayers, C. Powers, D. R. Miller, T. Heeren, and A. C. Geller Changing Patterns of Sun Protection Between the First and Second Summers for Very Young Children Arch Dermatol, August 1, 2004; 140(8): 925 - 930. [Abstract] [Full Text] [PDF]
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