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


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. O’Connell, 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

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 11–18, 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: (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 [5–12]. 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

Sunscreen users were asked a series of questions using a Likert scale: sun protection factor (SPF) 15+ sunscreen at the beach or pool. or hypo-allergenic. a tanning bed. Whereas previous analyses from the ACS sun survey concentrated on youth. and (3) How many times were you sunburned this summer? The question. Other parental measures Parents were asked questions on age. patterns of summer outdoor work and recreational activities. Since a single sun protection behavior is not optimal for the protection of sunburns. wearing protective clothing (baseball cap. and using sunscreen. Questions were specific to summer 1998 and related to phenotypic skin characteristics such as skin type. The balwaysQ and boftenQ responses were combined to represent routine use of these behaviors when outside on a very sunny.187 parents. 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. non-greasy. sun protection behaviors. and who would have a repeated sunburn after successive days in the summer sun would have a bhighQ sun sensitivity index score. Parental sun protection behaviors Seven behaviors were asked on a five-point Likert scale ranging from bneverQ to balwaysQ. sunscreen on the face and the SPF used most often when in the sun for at least 15 min. In addition. sunscreen on other exposed skin areas and the SPF used most often when in the sun for at least 15 min. including planning activities to avoid the sun. and sunscreen characteristics such as water-proof. race and ethnicity. summer day for more than an hour. these prevalence estimates are presented in Table 3. Hence. are described elsewhere [8]. routinely performed three or four of the Healthy People 2010 recommended behaviors [25]. this descriptive study presents prevalence patterns of sun exposure experiences and sun protection behaviors in the parents of youth aged 11–18 years old by specific sociodemographics and sun sensitivity. who would receive a severe sunburn with blisters after 1 h in the summer sun. random digit dialed.12] this study focuses on the 1. four of the seven sun protection behaviors are presented in Table 2.J. a parent with very fair skin. were used for a validated sun sensitivity scale [28]. wear sun-protective clothing. The remaining three prevalence estimates for all parents are mentioned in the text. single unmarried adults. educational attainment. The balwaysQ and boftenQ responses were combined to represent routine use related to specific aspects of sunscreen usage. and tanning ability based on several hours in the sun for successive summer days without sunscreen or protective clothing. As an example. [8–10. and for the most severe sunburn. annual household income range. Our goals are to provide data that can inform. use sunscreen or avoid artificial UV light [24. We examined the distribution of parents who . nationally representative survey of non-institutionalized youth aged 11–18 years old. 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. Previous studies on sun protection focused on all adults [13–17] or parents of young children [18–23]. We asked more specific behavioral practices regarding sunscreen. and residence location of the household (urban or rural) to assess sociodemographic characteristics. the frequency of reapplication. The survey was conducted during July to October 1998 and had an overall response rate of 58%. Selfreported phenotypic skin characteristics. gender. wide-brimmed hat. attitudes toward sun exposure and sun tanning (complete attitudinal statements listed in Appendix A). / Preventive Medicine 41 (2005) 108–117 109 programs and health care delivery.25]. but analogous studies on parents of adolescents are not available. prevalent sources of skin cancer prevention information were asked of the youth (after parental consent) and the parent. Conversely. (2) Have you had a sunburn this summer?. Methods The methods of the ACS sun survey. with blonde or red hair. living in households with a parent or primary caregiver in the contiguous United States. 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. Briefly. bWas the sunburn painful?Q was asked in relation to the sunburn during the past weekend. or long pants).C. the ACS sun survey was a telephone-based. or sunlamp. or parents of young children. develop. longsleeved shirt. the outdoor activity and the sun protection behaviors associated with it were identified. To coincide with Healthy People 2010 objectives. Parental sunburn experiences The ACS sun survey assessed the number of summer sunburns. behavioral scientists and physicians need prevalence estimates on parents of adolescents since they may exhibit different health behaviors and practices than childless married adults. Cardinez et al. Three questions were used to determine the number of summer sunburns: (1) Did you get a sunburn during the past weekend?. wearing sunglasses. a study of sun exposure and sun protection behaviors of youth and their parents. natural hair color. sunburn susceptibility based on 1 h in the summer sun without sunscreen or protective clothing. it is important to study a comprehensive set of sun protection practices [24–27]. A summer sunburn was defined as any reddening of the skin that lasted at least 12 h received from outdoor exposure. including natural skin color.

Sunscreen use Sunscreen use varied significantly by gender.110 C. Cardinez et al. and friends and family. 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. gender. non-Hispanic parents than non-White. avoid the sun or used sunscreen. Approximately onethird of the parents were in their early. nonHispanic or Hispanic parents avoided sunny.J. the majority practiced one or two behaviors (58 F 3. during the past year.2%) or long pants (25 F 3. and information sources Table 1 shows that the study population was predominately female. non-Hispanic. more college graduates than high graduates used sunscreen either at the beach. more non-White. or chores. Table 2 displays the remaining behaviors that coincide with the Healthy People 2010 sun protection objective. and educational attainment (high school or less. Two thirds of parents knew someone who had skin cancer. parents tended to home repairs. attitudes. more parents with high sensitivity than parents with low sensitivity. Fewer than 10% of parents wore wide-brimmed hats or long-sleeved shirts. boating. In addition.9%). or doing other Results Sociodemographics. The majority of parents used a SPF 15+ sunscreen when they were at the beach or pool. Planning activities to avoid the sun Planning activities to avoid the sun varied significantly by sun sensitivity and race and ethnicity. All analysis were conducted in SUDAAN to provide weighted prevalence estimates and appropriate standard errors [29]. summer outdoor activities than White. sun sensitivity.7%) and approximately one-quarter wore a baseball cap (24 F 3. For all three or four behaviors combined. Analysis Descriptive categorical analyses were tabulated for all parents and by parental age (27–40 mid-40s. When the individual behaviors were combined. General sun protective behaviors Of the seven behaviors.6%). or when outdoors and reapplied it. the outdoor activities during the most severe summer sunburn occurred while parents where either swimming. and who would have a moderate or deep tan after successive days in the summer sun would have a blowQ sun sensitivity index score. / Preventive Medicine 41 (2005) 108–117 a parent with light brown skin. non-Hispanic or Hispanic since few parents indicated a race or ethnicity other than White. college graduates. Chi-squared tests were conducted to determine the differences of sun protection behaviors and sunburn experiences within each of the aforementioned sociodemographics. 41–45 years. pool. race and ethnicity were divided into White. and had household incomes of more than $50. the garden. reapplication of sunscreen occurred more often among parents in their early 40s than among their younger or older counterparts. pool. wearing sunglasses was the most popular (67 F 3. more White. and more parents with college degrees than parents with or without high school degrees combined one or two sun protection behaviors. non-Hispanic white.000. Parents received most of their sun protection information from television. or when outdoors. non-Hispanic parents. In decreasing order. Parents with high sensitivity were more likely to plan activities to avoid the sun than parents with low sensitivity. and college graduate). Combined sun protective behaviors More women than men. In this study. parents generally felt that they looked better with a tan and that the sun felt good on their skin. more than half of parents with high sun sensitivity compared to one-fourth of parents with low sensitivity applied sunscreen either at the beach. Outdoor sun exposure varied: during summer weekday and weekend hours. Summer sunburns Table 3 shows that more than one-half of parents had one or more summer sunburns. pool. and 46 years old or older). they felt that sunscreen allowed the enjoyment of outdoors without worry and stated that the lack of sun protection increased cancer risk. non-Hispanic and Nonwhite. there were no appreciable differences within these subgroups. and educational attainment. With respect to attitudes. non-Hispanic or Hispanic parents were apt to use sunscreen and reapply it. but only one-third had a physician recommendation for skin protection. and had a moderate sun sensitivity index score. but only one-third used it on their face or body on other outdoor occasions. some college. more than one-half spent some time at the beach or pool. More women than men used sunscreen either at the beach. whereas approximately one-third planned activities to . outdoor summer exposures. married. magazines. race and ethnicity. with black or dark brown hair. or when outdoors on their bodies. who would not sunburn or tan after 1 h in the summer sun. sun sensitivity. While sunscreen use did not vary significantly by age. whereas less than 5% of parents practiced three or four the sun protection behaviors and approximately onethird did not practice any. race and ethnicity.

4) 20 (F3.7) 30 (F3. or other water sports Gardening.4) 139 420 12 (F2. parents of youth ages 11–18.2) 47 (F4.3) 29 (F3.7) 75 (F3.1) 527 411 247 49 (F4.2) 33 (F3. sun survey.6) 43 (F5.3) 18 (F3.1) 22 (F4.3) 12 (F3.1) 24 (F5.7) 5 (F2.3) 14 (F4.9) 12 (F4.6) 8 (F2.0) 498 114 38 52 (F4. boating.0) 14 (F3.5) C.7) 77 (F10.3) 32 (F3.1) 363 70 255 30 (F3.4) 37 (F5.3) 4 (F2.3) 11 (F3.4) 111 . chores Errands.7) 26 (F3.0) 52 (F4.2) 37 (F5. shopping Number of days within past year at beach 0 days 1–7 days 8+ days 370 496 83 39 (F4. Cardinez et al.S. or other water sports Gardening.Table 1 Characteristics of U.6) 32 (F3.3) 86 287 304 240 226 44 10 (F4.2) 15 (F2.4) Swimming.3) 23 (F10.1) 20 (F3.J.1) 18 (F3.8) 31 (F3.3) Sun sensitivity Characteristic Sample size Weighted percentage (95% CI) 29 (F6.2) Weekday hours 0h 1–4 h 5+ h Main weekday activity Taking part or watching recreational activities Sitting or lying out in the sun Working outside Swimming.3) 8 (F2.4) 7 (F2.1) 11 (F3.7) 22 (F3. shopping Weekend hours 0h 1–3 h 4–6 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 (F5.8) 37 (F8.4) 24 (F3. home repair.5) 33 (F3.8) Household income Under $30K $30K to $50K More than $50K Unknown Residence Farm/rural area Small town 174 263 533 193 26 (F11.6) 19 (F2.7) 42 (F3.2) 17 (F2.6) 431 105 88 36 (F3.5) Outdoor summer sun exposures Characteristic Sample size Weighted percentage (95% CI) 30 (F3.4) 24 (F2. non-Hispanic Nonwhite.3) 204 293 18 (F3. some tanning Turn darker. no sunburn No sunburn.3) 29 (F3. boating. / Preventive Medicine 41 (2005) 108–117 Age of parents 27–40 years 41–45 years 46+ years Age of referent child 11–13 years 14–15 years 16–18 years Sex Male Female Race and ethnicity White. 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 (F3.0) 37 (F3.7) 57 (F4.8) 35 (F3. 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. chores Errands. 1998 Demographics Characteristic Sample size Weighted percentage (95% CI) 36 (F4.9) 15 (F3.9) 4 (F1.7) 35 (F3.9) 19 (F3. home repair.

9) 4.J.5) 3. / Preventive Medicine 41 (2005) 108–117 21 72 76 534 476 3 8 8 44 38 (F1.5) (F4.8) (F4. Reaction to skin on a sunny day for a couple of hours for several summer days. .1) (F2.4) A moderate tan A deep tan 360 131 30 (F3.9) 3 (F1.0) (F4.7) 62 (F3.3) (F1.8) (F3.7) 30 (F3.3) 4.4) 30 (F12.6) 12 (F2.7) (F1.86 96 228 173 516 167 11 21 15 40 14 (F2.2) 19 24 33 391 718 2 (F0.6) 4.25 56 130 95 705 198 7 (F2.8) (F3.5) 45 (F4.5) (F4.64 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 (F1.4) 13 (F3.0) (F3.3) 59 (F3.8) 32 (F3.3) 27 (F4.4) 22 (F3.0) (F2.3) 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 (F3.1) 34 (F3.4) 38 (F3.2) 27 (F5.4) (F2.2) 64 (F4.9) 3.0) 34 (F5.1) 57 (F3.6) (F2.6) 7 (F2.0) (F4.28 Yes No Radio Yes No Magazines Yes No Newspapers Yes No Family and friends 919 261 418 734 78 (F3.8) (F1.8) 36 (F4.4) (F5.6) 16 (F2.112 Suburb City Marital status Married Not married Tan appeal attitudes Characteristic 412 276 1042 144 32 (F4.46 58 136 81 520 390 6 13 7 42 33 (F2. Cardinez et al.2) 70 (F12.1) 832 350 66 (F5.06 832 347 442 725 68 (F3.7) (F2.2) 3 (F1.0) Number of days within past year at pool 0 days 1–7 days 8+ days 465 337 377 43 (F4.9) 2.0) 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.5) 454 723 38 (F4.7) C.0) (F3.2) (F2.1) 3.3) (F1.82 Yes No Doctor recommendation Yes No Know someone with skin cancer Yes No 678 504 55 (F4.1) 62 (F4.

0) 12 (F2.1) 5 (F3.4)* 60 (F7.9) 30 (F4.1) 6 (F3.1) % (95% CI) 36 (F7.1)* 23 (F6.7) all day Combined sun protective behaviors a 3–4 behaviors 6 (F3.7) 66 (F5.7) 38 (F3.4) 11 (F4.2) 73 (F6.8) 53 (F5.9) 40 (F6.4)* 55 (F10.9) 6 (F2.1) 5 (F2.C.1) 48 (F5.9) 6 (F2.2) 36 (F5.8 2.4) 9 (F3.5) 1 to 2 behaviors 57 (F3.5) Use SPF 15+ on bodyb Reapply when in the sun 61 (F7.1) 37 (F5.3) 6 (F3. by age.9)* 9 (F4.3) 41 (F6. d All four individual sun protection behaviors.9)* 69 (F8.3) Some college (n = 321) College graduate (n = 491) 4 (F1.8) None 49 (F8.8) 69 (F8.9) 7 (F2. sun sensitivity.7) 58 (F7.3) 9 (F3.0) 37 (F6.3) 4 (F2.9) 69 (F8.1)* 4 (F1.1) 31 (F7.3)* 43 (F5.6)* 18 (F7.5) 38 (F3.7) sun Wear wide-brimmed hat 8 (F3.4) 41 (F5.9) % (95% CI) 45 (F7.2)* % (95% CI) Individual sun protective behaviors a Plan activity to avoid the 33 (F8.9) 34 (F3.8) 43 (F6.7) 7 (F3.9) 38 (F5. c On a 1 to 4 scale (1 = never. race and ethnicity.4)* 41 (F6.0) 7 (F3.8) 46 (F7.8) 31 (F7. when in the sun for at least 15 min.S.0) 32 (F10.2) 10 (F4.6 2.3) 41 (F6.9 2.4) 2 (F1.7 1. [16]. . / Preventive Medicine 41 (2005) 108–117 Table 2 Sun protective behaviors of U.0) Use sunscreen 23 (F6.6) 35 (F6. Cardinez et al.5) a b % (95% CI) 30 (F5. 3 = sometimes.2)* 31 (F4.8) 56 (F9.5) pool only Use SPF 15+ on faceb 27 (F8.0)* % (95% CI) 32 (F7.5) 30 (F5.8) 73 (F5.5) 8 (F4. 2 = rarely.5) 54 (F10.9)* 69 (F4.8) 36 (F6.5) 29 (F7.5) 35 (F6.1)* 69 (F6.0) Education level High school degree or less (n = 374) % (95% CI) 33 (F6.7) 6 (F2.3) 64 (F7.0 2.9) Reapply when in the sun 65 (F4.1) 6 (F2.4)* 9 (F3.6) 3 (F2.9)* 63 (F4.1) 26 (F8.8)* 2.7) 44 (F6.9c 66 (F8.0)* 43 (F10.05. see Ref.8) 6 (F2.7)* 60 (F5.3) 31 (F8.1) 25 (F5.2) Characteristic Sun sensitivity Low (n = 275) Weighted Mean 2. At anytime.7) 56 (F4.4) 81 (F7.5) 35 (F6.0) Use SPF 15+ on bodyb 33 (F3. gender.6 1. nonHispanic (n = 1034) % (95% CI) 30 (F5.J.4) 64 (F13.7) 60 (F6.3) all day Combined sun protective behaviors a Sun protection indexc 3 to 4 behaviors 4 (F1.8) sun Wear wide-brimmed hat 7 (F1.1) 36 (F8.0) 41 (F5.8) 17 (F5.7) 39 (F6.3) Wear long-sleeved shirt 10 (F5.4) 74 (F6.8) 35 (F6.2 4 (F2.9) 24 (F5. 1998 Characteristic Total n = 1187 Age 27–40 years old (n = 381) 41–45 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. sun survey.7) 71 (F5.0) Sunscreen-specific behaviors a (n = 958) Use SPF 15+ at beach or 59 (F10.1) 48 (F6.3) 7 (F1.5) 36 (F6.0)* 36 (F5.7) 6 (F2.3) 70 (F5.2)* Race and ethnicity Moderate (n = 664) High (n = 248) White.5) 28 (F11.5) 49 (F7.0) Nonwhite.9) 80 (F4. 4 = often).8)* 8 (F3.7) Wear long-sleeved shirt 7 (F2.6) 40 (F5.2) 6 (F1.8) Sunscreen-specific behaviors a (n = 958) Use SPF 15+ at beach or 70 (F5.9) 32 (F6.0) 54 (F6.4) 13 (F5. nonHispanic or Hispanic (n = 153) % (95% CI) 46 (F8. parents of youth ages 11–18.4) 38 (F7.0) 59 (F5.6) 30 (F6.4) 35 (F7.3) 56 (F5.0)* 4.0) 5 (F2. * P b 0.8) 68 (F4.2) 60 (F7.8) 10 (F3.6) 55 (F10.3) 21 (F5.2) 62 (F8.9) 1–2 behaviors 45 (F7.5) 4 (F3.9)* Practiced boftenQ or balwaysQ.7) 3 (F1.9 % (95% CI) % (95% CI) % (95% CI) 37 (F8.9) None 39 (F4. and education level.5) 53 (F6.9)* 77 (F7.0) 4 (F3.3) pool only Use SPF 15+ on faceb 37 (F4.5) 35 (F7.2) Use sunscreen 37 (F4.3)* 36 (F4.4) 62 (F7.

Our study showed that 51% of parents had at least one or more sunburns during the summer.4) (F5.6) 39 (F11.6) 8 (F2.4) 18 (F5.3) 26 17 7 31 (F4. 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. 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.187 Age 27–40 years old (n = 381) % (95% CI) 42 (F6. nonHispanic (n = 1.14.9) 1–2 sunburns 38 (F4.7) 12 (F3. and questionnaire specificity limit direct comparisons between our results and previous reports [13–23].7)* 18 (F6. Discussion Few epidemiological studies collect independent data on children and parents.7) 22 (F6.7)* Education level High school degree or less (n = 374) % (95% CI) 50 (F7.2) % (95% CI) 42 (F7.2) 3+ sunburns 11 (F4.1) 28 (F10.0)* (F4.S.3%) used a SPF 15+ sunscreen when they received their most serious sunburn.4) 17 (F5.8) (F14.9) 7 (F4.2) 20 (F3.9) 18 (F6.5)* 7 (F3.3) 17 (F5.8) 30 15 7 28 (F7. The Behavioral Risk Factor Surveillance System showed a lower prevalence (31.3) 20 (F4.6) 18 (F7.5) 14 (F4. completing gardening or home repair chores.8) 25 (F10.16. protective clothing.3)* (F2.2) (F7.1) 12 (F10.6) 3+ sunburns 13 (F2. boating. nonHispanic or Hispanic (n = 153) % (95% CI) 73 (F8. race and ethnicity. other water sports Gardening or home repair Characteristic most severe summer sunburn (n = 671) 26 (F4.7) 17 (F3. parents of youth ages 11–18.2) 46 years old and older (n = 428) % (95% CI) 58 (F6. questionnaire wording.8)* 39 (F9.05.6) (F4. Recognizing the drawback of direct comparisons with other studies.5) 18 (F7.2) 17 (F4.7) 42 (F5.9) 43 (F6.6) (F6.7) % (95% CI) Number of summer sunburns No sunburns 61 (F8.3) (F6.7) 20 (F4. 1998 Characteristic Total n = 1.0) 39 (F6.4) 28 17 6 33 (F5. In addition.9) (F3. sunscreen prevalence for parents of youth ages 11–18 appears to be consistent with sunscreen use for all adults [13.2) 11 (F4. / Preventive Medicine 41 (2005) 108–117 Table 3 Sunburn characteristics of U. this study showed that approximately . boating.5) 8 (F3. and working a paid outdoor job.3) 33 (F5. sun survey.4) 33 (F9.3) 25 21 4 33 (F6.7) water sports.034) % (95% CI) 42 (F3.2) (F5.7) 27 19 16 26 (F13.2) 23 (F6.9) 27 9 18 23 (F6.7%) of all adults aged 18 and older reported a sunburn within the past year [30]. gender.2) 21 19 11 29 (F6.2) (F6.7)* 20 (F6.1) Female (n = 861) % (95% CI) 52 (F5.8)* (F5.5) (F4. survey methodology. While our study reported a higher sunburn prevalence. About threequarters (72 F 7.3) 1–2 sunburns 29 (F7.5) 15 (F3.3) (F2.1) 11 (F3.2)* 9 (F3.1) 18 (F9.0) College graduate (n = 491) % (95% CI) 50 (F6.4)* Gender Male (n = 326) % (95% CI) 40 (F8. other water sports Gardening or home repair * P b 0. sunbathing. However.8) (F7. Cardinez et al.6) 30 (F6. participating or taking part in outdoor recreational activities. and sunscreen and UV sun avoidance [25].3) 36 (F5.3) 15 (F2.0) 17 (F3. namely limited sun exposure.6) 6 (F4.114 C.8)* most severe summer sunburn (n = 671) 22 (F6.J.6)* 19 (F5.9) (F5.2) 15 (F6.1) 30 (F4.5) % (95% CI) Number of summer sunburns No sunburns 49 (F4.6) 43 (F4.7) Some college (n = 321) % (95% CI) 48 (F6.1) 12 (F2.5) (F14.9) (F7.4) 3 (F3.1)* Sun sensitivity Low (n = 275) Moderate (n = 664) High (n = 248) Race and ethnicity White. and education level.3) 43 (F8. 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.7) 41 (F6.6) 34 (F6.2) 21 (F6.8) 38 (F7.4) (F6.0) (F7.0) 19 (F2.8) (F3.0) 22 (F6.6) Nonwhite.5) (F5.9) 21 (F7.5)* 32 (F6. sun sensitivity.7) Outdoor activity during Recreational activities Sunbathing Paid outside work Swimming.4) 33 12 11 26 (F9.4) 41–45 years old (n = 378) % (95% CI) 47 (F7.5) 17 (F6. by age.7) 24 (F6.9) 14 (F8.2) (F12.3) 22 (F5.4) (F6. % (95% CI) 46 (F5.2) Outdoor activity during Recreational activities Sunbathing Paid outside work Swimming. Variations in sample selection.17] and parents of younger children [20–23].

If parents are not adequately applying sunscreen and are included as educators in sun safety measures [24]. The ACS program. or paid outside work. parents do not spend as much time at these locations as their adolescents. including health educators.12]. This awareness campaign can be extended to adolescents and their parents with emphasis on different components for various subgroups. Our study shows that almost two-thirds of parents did not receive a doctor recommendation on proper sun protective behaviors. whereas parents classified as non-White. The limitations of this study include the self-reported data. regardless of activity. Cardinez et al. Our study suggests that parents classified as White. then the practices that they are conveying to their adolescents may not achieve maximum sun safety. the predominantly female parent population. are influenced by parental behaviors [36– 41]. home repair chores. the balance of the respondent’s time on the phone and the number of questions was critical to maximize the number of completed interviews. Other protection behaviors have been proven to be effective in preventing sunburns [33]. and the limited questions that probed on sunburn and occupational sun exposure. Slip! Slap! Slop! Wrap!. parents are more likely to seek this information from their physicians [43]. and soccer fields. Similarly. doctors remain an integral source for sun protection advice for parents. and by various individuals. including proper sunscreen application. the type of sunscreen. should be emphasized for any outdoor exposure. indicated that they would usually use sunscreen with a SPF 15+ at the beach or pool if they were consistent sunscreen users. among parents and their youth are positively correlated (data not shown). Other studies that have included the detailed sun protection questions have been limited to one geographical area [16]. including but not limited to gardening.15. Once told of the importance of sun protective behaviors. Few studies have examined combined sun protective behaviors. In addition. behavioral studies have shown that application and reapplication techniques. non-Hispanic or Hispanic may need more emphasis on sunscreen use. studies that have looked at parental attitudes or behaviors of young children have not been population-based study . Despite the varied channels for youth sun protection.J. and coaches [22. 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. we have previously shown that parental and adolescent indoor tanning use and sun-safe practices are correlated [10. either through interventions or physician advice. sun bathing. These observations suggest that attitudes in conjunction with behaviors may be important for sun protection programs that target both adolescents and their parents.17]. long-sleeved shirts. recreation centers.32]. including their adolescents and children. which was generally the female head of household member in this study. consistent sunscreen users were more likely to apply sunscreen bsometimesQ when outdoors in non-beach or non-pool settings. Previous nationally based studies included general measures on sunscreen and one question about protective clothing [13. recreation center staff. while our study provided sunscreen questions on an average sunny day or at the beach or pool and the use of long pants. The strengths of this study include the detailed questions on sun protection behaviors for a representative sample of the United States. parents are likely to diffuse this information to their friends and family.C.24. While manufacturer studies have shown that sunscreen will prevent sunburn. Several leading organizations recommend the comprehensive practice of sun-safe behaviors for the prevention of sunburns [24–27]. such as not taking up cigarette smoking and engaging in consistent physical activity. Proper sun protective behaviors. emphasizes the aggregate use of sun protective behaviors with particular emphasis among parents and youth age 9–12 [27]. A considerably larger proportion of parents received serious sunburns while gardening or conducting home repairs (19%) than their adolescents (4%) [9]. Hence questions on the details about the sunburn experience(s) or occupational exposure for outside work were not asked. but a Canadian study showed sunscreen use alone did not predict lower odds for sunburn [31]. and wide-brimmed hats. In addition. non-water recreational activities. While recognizing the time constrains during a physician’s visit and emphasis on treatment and diagnosis rather than preventive care [44]. In addition. Similarly. and the sunscreen’s resistance to water immersion and sand abrasion may alter the effectiveness of the sunscreen as indicated by the manufacturers [31. tanning appeal attitudes. for effective sun safety. Positive health behaviors among adolescents. A previous study showed that tanning appeal attitudes were associated with the frequency of sunburns among youth [9]. Our study showed less than 10% of parents of youth practiced three or four sun protective behaviors routinely when outdoors on a sunny. 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. / Preventive Medicine 41 (2005) 108–117 115 three-quarters of parents used sunscreen during their most recent sunburn. non-Hispanic may need more emphasis on planning activities to avoid the sun.42]. 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. Sun protection programs for youth have been disseminated at different locations. The telephone survey format did not allow sampling of male and female parents or caregivers equally. including schools. on average. indicating a need for emphasis on combined behaviors as recognized by Healthy People 2010 [25]. Parents. baseball caps.35]. However. especially the attitude that a tan looks better. Parental consent and interview were obtained from the person who answered the household phone. summer day.

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