Sunburn risk factors for beachgoing children
Department of Dermatology and the Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas, USA.
Sunburn prevention in children and the early establishment of sun protective behavior is predicted to result in a decreased future incidence of skin cancer. A survey of beachgoing families was conducted to evaluate the parental/guardian role in the use of sun protection for their minor children. Ethnicity and Fitzpatrick Skin Type of children and their parents were the best predictors for sunburn. White, non-Hispanic children were 7.8 times more likely to have a history of sunburn than children whose parents identified them as Hispanic when controlled for the same Fitzpatrick Skin Types.
Because sunburn results in an injury to the skin that may cause future skin cancer, primary public health measures have focused on preventing sunburn. Beachgoing during the summer is recognized as a high risk activity in an environment prone to ultraviolet light (UVL) injury because of the natural conditions and skin exposure patterns that increase sunburn risk. In order to evaluate current sun protection habits and risk factors for sunburn in children, a survey was given to beachgoing families.
Following Institutional Review Board approval, beachgoing families with children less than 19 years old anonymously completed written surveys during summer 2004 in English (Figure 1) or Spanish at Galveston beaches. Survey participants provided information about family member demographics (including ethnicity), Fitzpatrick Skin Types (FST), sun protection strategies used at the beach; parents or guardians were evaluated for basic knowledge of UVL.
Methods of sun protection other than sunscreen were assessed by giving one point for each item of protection used (hat, umbrella, glasses/sunglasses, clothing, shade) and calculating a sum for each respondent. Parent or guardian UVL knowledge was assessed via a set of nine questions. The survey response, "I don't know" was tabulated as incorrect for statistical purposes. The last survey question was developed to evaluate parental and guardian attitudes about severe childhood sunburn, in light of several recent reports of parents suffering legal consequences after their children were sunburned.
An association between an outcome (a previous history of sunburn: yes, no) and a risk factor (FST, ethnicity, sunscreen use, age, parent or guardian education, and parent or guardian basic skin protection knowledge) was assessed using the Pearson chi-square test or the Cochran-Mantel-Haenszel statistic when adjustment for a confounding factor was needed. All tests were assessed at the 0.05 level of significance. Data analyses were conducted using PROC FREQ in the SAS© system, release 8.2 . For chi-square tests, only the first two children recorded on the survey form from each family were included. It was determined that using more children from participating families would not add any more information and might increase the risk of an erroneous conclusion, since the same parent or guardian data would be used repeatedly for these families.
The total number of families completing the survey was 299, 276 in English, 23 in Spanish only. The mean age of the parent or guardian surveyed was 37.5 years (range 20-63) and was predominantly female (232/291, 79.7%). The parent or guardian provided information about sun-protection behavior for 497 children with a mean age of 9.0 (range 6 weeks to 18 years). Of the families surveyed, 6.7 percent (20/299) had at least one infant (<1 year) and 27.4 percent (82/299) included at least one teenager (13-18 years). Survey participants were ethnically diverse (Table 1) and all FST were represented (Table 2). Of the families surveyed 64.8 percent (190/293) had at least one family member who had graduated from college or who had post-graduate education.
Most families (62.4%, 186/298) indicated that they generally stayed at the beach for more than 2 hours. More than half of those surveyed applied sunscreen with a Sun Protection Factor (SPF) of 30 or greater (Table 3) prior to arrival at the beach (Table 4). Only 18.4 percent (55/298) of parents, 11.3 percent (56/497) of children, and 24.7 percent (44/178) of other adults present were not using sunscreen on the day they completed the questionnaire. Overall, 51.0 percent (152/298) of parents/guardians and 63.6 percent (316/497) of children used sunscreen with an SPF≥30.
A previous history of sunburn was noted in 245/493 (49.7%) of the children. A history of sunburn in children was significantly associated with age (p <0.0001); teenagers (13-18 years old) were more likely to have sunburn than younger children. Childhood sunburn was not significantly associated with their sunscreen use (p =0.96) or their parent/guardian sunscreen use (p =0.97).
The majority of parents and guardians, 79 percent (236/298), answered at least 7 of 9 questions about UVL correctly. Nearly half of the parents or guardians, 46.9 percent (138/294), thought that adult caregivers should be held responsible if their child suffered a blistering sunburn. Subjects were significantly more likely to respond "yes" to the final question if their children had never been sunburned (p <0.0001).
Of the children reported to be using sun protection other than sunscreen, 55.2 percent (171/310) were only using one additional item. In comparison, 35.6 percent (96/270) of the parents and guardians who used additional methods were only using one item. Adults most frequently used sunglasses (45.3%, 186/411), and children most frequently used umbrellas (64.8%, 201/310). Of those who used additional sun protection, 10.0 percent (27/270) of parents/guardians and 5.8 percent (18/310) of children utilized 4 or 5 methods of sun protection in addition to sunscreen.
There were similar numbers of children in this survey who had previously experienced sunburn (245) and those who had not (248). Chi-square tests were performed to determine which factors were most highly associated with sunburn. The results showed that an increased risk for sunburn in children was significantly associated with their FST (p <0.0001), ethnicity (p <0.0001), parental/guardian FST (p <0.0001) and parental/guardian ethnicity (p <0.0001). Although greater parental/guardian UVL baseline knowledge (p =0.0002), parental education level (p =0.008), and income (p =0.0001) were found to be significantly associated with a history of childhood sunburn, after adjusting for ethnicity and FST, adult baseline UVL knowledge, education, and income were not significant factors.
A difference between White (non-Hispanic), and Hispanic adult documentation of sunburn history in children was noted after controlling for children's FST (Table 5). Among Hispanic and White (non-Hispanic) children with FST I or II, White adults were significantly more likely to recall sunburn in children than Hispanics with and odds ratio (OR) of 12.6. This trend was also present for FST III or IV (OR=6.3) and for FST V or VI (OR=13.1). Overall (adjusted for FST) White non-Hispanic adults were 7.8 times more likely to recall a history of sunburn in children than were Hispanics (p <0.0001).
Child and parental ethnicity and FST were the best predictors of childhood sunburn. Another important factor, the number of hours of UVL exposure, was not measured due to the nature of this survey, but it has previously been noted that subtropical summertime sunlight exposures greater than four hours at the beach were more likely to result in sunburn than shorter exposures, regardless of sunscreen use or FST . This observation may be due to suboptimal sunscreen use, reapplication or other factors .
This study was consistent with another that showed parents primarily rely on the use of sunscreen to protect their children from UVL, rather than such measures as avoiding the sun, using shade, or protective clothing .
In that study, girls had better sun protection of their head and torso, but boys were slightly better at protecting their legs from sun exposure. Almost one half of the respondents in another study thought that sunscreen use permitted children longer periods of sun exposure . Other reported parental attitudes were the belief that a tan improved appearance and that sun exposure was healthy . In addition, parental use of sun protection for their children was more frequent for those reporting more favorable attitudes about sun protection. Adjunctive methods of childhood sun protection in conjunction with sunscreen and education about UVL should be stressed by health care providers, especially when counseling adult caregivers.
There have been several recent publications about severely sunburned children whose parents were charged with a crime [6, 7]. The last survey question about the ethical/legal implications of childhood sunburn evoked much interest from study participants. Most had a strong opinion on the subject. Parents of children who had never been sunburned were significantly more likely to answer this question affirmatively. This issue deserves further study and analysis because childhood sunburn is such a common type of skin injury.
White, non-Hispanic children were 7.8 times more likely to have a history of sunburn than Hispanics, regardless of FST. Future sunburn research questionnaires in this area may require more nuanced assessment of sunscreen application behavior and sunburn recall, rather than simple "yes or no" responses, in order to determine if variations in sunscreen use, sunburn frequency and sunburn severity act as survey confounders.
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