Planning for a brighter future: A review of sun protection and barriers to behavioral change in children and adolescentsThe Ronald O. Perelman Department of Dermatology, New York University School of MedicineNew York, New York. Chicky_Dadlani@yahoo.com
Chicky Dadlani MD, Seth J Orlow MD PhD
Dermatology Online Journal 14 (9): 1
Skin cancer is one of the most preventable groups of malignancies; however, skin cancer incidence continues to rise in the United States. The relationship between skin cancer and ultraviolet (UV) radiation is well known. Many interventions to prevent skin cancer by reducing exposure to UV radiation have been employed throughout the United States. Studies show an increase in knowledge and awareness regarding sun exposure and skin cancer. Unfortunately, sun protection interventions are slow at effecting behavioral change. In this review, we examine current barriers facing youth today in regards to sun protection practices, appropriate age groups to target for intervention, proposed methods of sun protection, the influence of role models in changing sun protective behavior, the stages of behavioral change, and characteristics and techniques of sun protection programs that can not only increase knowledge but actually elicit changes in sun protection behavior.
A systematic Medline search of publications in English was performed. Key words included "sun safety", "sun protection", "sunscreen", "suntan" and "sun protection interventions/programs" combined with "knowledge", "education", "schools", "community programs", "awareness", "beliefs", "attitudes", "barriers", and "behavioral change." These words were also combined with "child/children" and "adolescence." Other key words included "cognitive development", "stages of change", "role models for children" In many instances, once a relevant article was found, the 'Related Articles' function on Pubmed's search engine was selected. Additionally, relevant references listed in articles reviewed were selected.
New strategies are needed for sun protection programs in the United States to combat the increasing rates of melanoma and non-melanoma skin cancer (NMSC). Skin cancer is not only one of the most common types of cancer in the United States but also one of the most preventable; sun exposure is a major causative factor for skin cancer for which prevention is possible. Furthermore, excessive sun exposure during childhood is a particularly significant factor in future risk of skin cancer.
In North America, young children are reported to spend an average of 2.5-3.0 hours outdoors daily . Children are believed to receive three times the annual sun exposure of adults . New data by Godar et al. [2, 3] refutes those prior studies and reports that excluding vacations, children get similar ultraviolet radiation as indoor-working adults (3% of the available annual terrestrial UVR). Godar et al. [2, 3] report that Americans get fairly consistent UV doses during different age intervals throughout their lives. Approximately 25-50 percent of a person's lifetime sun exposure is said to occur before 18-21 years of age [2, 3, 4]. A clear relationship exists between cumulative sun exposure and the development of NMSC, and a strong relationship exists between intense intermittent sunburn and the development of melanoma . Previous research on skin cancer prevention focused heavily on the use of sunscreen in preventing NMSC. It had been estimated that the lifetime incidence of NMSC could be reduced by 78 percent with the regular use of sunscreen (sun protection factor or SPF of 15 or greater) during the first 18 years of life . Sunscreen has become the preferred method of protection, possibly because of ease of use and industry promotion. However, scientific evidence that sunscreen use will prevent skin cancer is limited [7, 8]. Thus, sun protection methods in addition to sunscreen use need to be taught and emphasized. Although general awareness about the dangers of sun exposure seem to exist, specific knowledge about sunscreen application, sun exposure during peak hours, and the correlation between ultraviolet (UV) radiation and environmental temperatures appear to be lacking . Furthermore, perhaps hastened by the depletion of the earth's protective ozone layer, skin cancer incidence continues to rise faster than that of other cancers in the United States [10, 11].
The American Academy of Dermatology reported the following statistics in 1994 from a study of teen sun exposure: 63 percent believed they look better with a tan, 59 percent believed people in general look more healthy with a tan, 43 percent report they lie out in the sun, 28 percent of females and 14 percent of males report they never use sun block, and only 3 out of 10 teens who lie out in the sun report always using sun block . Since then, Cokkinides et al.  conducted a cross-sectional telephone survey of approximately 1,100 adolescents in the United States 11-18 years of age in 1998 and in 2004. Results showed that the proportion of youth who reported regular sunscreen use increased from 31 percent to 39 percent. Little change occurred in other sun protection practices such as the number of hours spent outdoors between 10:00 AM and 4:00 PM. Sunburn trends decreased only modestly from 1998 to 2004. In 1998, 72 percent of youth reported having had one or more sunburns during the past summer compared with 69 percent in 2004. The authors concluded that there was only a small reduction in sunburn frequency and a modest increase in sun protection practices between 1998 and 2004 despite widespread sunprotection interventions and programs.
Most programs promoting sun protection have involved educational interventions designed to teach people that exposure to sun increases the likelihood of skin cancer and that precautionary measures can reduce this risk . Although these programs have been partially successful in improving knowledge related to sun exposure and skin cancer, they have been failing to elicit behavioral change.
Barriers to achieving sun protection in youth can be divided into physical, psychological or attitudinal, and environmental.
Physical barriers include factors that prevent children from achieving sun protection that they may otherwise be able to undertake (Table 1). Cost is a significant barrier in itself. The cost of sunscreens [15, 16], protective hats and clothing is a realistic concern. Furthermore, the cost to design and execute intervention programs, create shade structures, and provide educational materials on sun protection requires significant financial resources. Additional barriers involve sun protective apparel and sunscreen. Hill and Rassaby reported that males feel hats are a problem in active games and pants and long-sleeve protective clothing make them too hot . Males predominantly rely on baseball caps which do not shade the ears, sides of the face, or neck. Additionally, hats are restricted in schools because they may represent gang insignias and can promote head lice transmission; thus, many children remain unprotected when outdoors during recess, physical education, and sports activities . In terms of sunscreen, children report forgetting to apply sunscreen , complain sunscreens are too messy, often apply them inadequately or infrequently , miss application to certain areas of the body , and forget to reapply after swimming, sweating, and other activities during which sunscreens are degraded or washed off .
Lack of parent compliance owing to time constraints or lack of interest coupled with lack of counseling by pediatricians on sun protection are significant factors negatively affecting sun safe behaviors. Understanding of sun protective behaviors and education about skin cancer in general at the parental level is inadequate . Weinstein et al. surveyed 254 parents at pediatric and dermatology clinics to examine their knowledge . The mean score of general skin cancer knowledge was only 61 percent with just 49 percent able to answer specific UV index questions .
Additionally, sun protection policies in schools in the US are lacking. Buller et al. performed a telephone survey to school principals and other personnel at 484 secondary schools in 27 cities from January 2002 to February 2002 . They reported that although sun protection occurred at nearly all schools (96%), a sun protection policy was found in only 10 percent of schools. Although sun safety education was prevalent, sun protection policy was a low priority for schools and written materials on sun protection were used infrequently. Glanz et al. in collaboration with the CDC developed several guidelines for school programs to prevent skin cancer . These guidelines include the following: establishing policies that reduce exposure to UV radiation, providing and maintaining physical and social environments that support sun safety and that are consistent with the development of other healthy habits, providing health education to teach students the knowledge, attitudes, and behavioral skills they need to prevent skin cancer at age appropriate level with links to opportunities for practicing sun-safe behaviors, involving family members in skin cancer prevention efforts, including skin cancer prevention knowledge and skills in pre-service and in-service education for school administrators, teachers, physical education teachers and coaches, and school nurses, complementing and supporting skin cancer prevention education and sun-safety environments and policies with school health services, and lastly periodically evaluating whether schools are implementing the guidelines on policies, environmental change, education, families, professional development, and health services.
Lack of knowledge and understanding of risks associated with sun exposure, lack of awareness of sun protection methods aside from sunscreen including hats, sunglasses, sun protective clothing, and timing of outdoor activities  contribute significantly to poor sun protection practices in children . Lastly, there has been some concern about possible vitamin D deficiency developing in infants who are exclusively breast-fed and who have limited sun exposure. It has been estimated for infants who are exclusively breast-fed that spending 30 minutes outdoors only wearing a diaper, or 2 hours a week fully clothed without a hat, is sufficient to maintain serum calcifediol levels above the lower limit of normal .
Psychological or attitudinal barriers are the most challenging to overcome and are listed in Table 2. Peer pressure is a major factor involved in the initiation of habit during adolescence . Poor self-esteem and greater need for group acceptance probably determine how prone anyone may be to resist or succumb to external pressures . Cockburn et al. conducted a survey of 2,000 students that showed 70 percent were not using adequate sun protection . Ninth and tenth graders were more likely to believe that "only jerks wear shirts in the sun" and protecting from the sun "makes you look like a wimp." Norwegian adolescents identified friend's sunbathing and friend's use of sunscreen and sun beds as predictors of sunbathing . The most frequently mentioned reason for sunbathing by these adolescents (aged 13, 15, and 17) was feeling more attractive with a tan . Branstrom et al. surveyed 2,615 adolescents and reported that adolescent boys who were most satisfied with themselves and girls who were least satisfied with themselves sunbathed the most . Increased sunbathing noted with increasing age is thought to be related to appearance. Older adolescents might be more concerned with physical appearance than younger children and older children may be more willing to take risks to achieve this goal . Individuals in Sweden reported not wanting to protect themselves from the sun. Instead, they actively seek sun exposure as they have long winters with only a few hours of sun and short mild summers with intermittent sunny days and moderated levels of UV radiation .
Media influence including fashion and advertising is a major factor affecting one's desire to obtain a tan . More problematic is that the media is known to be a major source of information for society. Weinstein et al. reported media (radio, television, and magazines) as the primary source of information for 254 parents surveyed regarding skin cancer and sun protection practices .
As long as attitudes towards tanning remain positive and perceived lack of susceptibility to skin cancer remains, the intensity with which people intentionally tan will not change.
Finally, environmental barriers include factors that increase the amount of UV exposure including the proximity to the equator, higher altitudes, low levels of cloud coverage, ozone depletion , and lack of sun-safe environments (e.g., playgrounds with inadequate shade structures) [19, 20].
Age Groups to Target
When a small number of children possess the correct information within an age group, this is an appropriate time frame to introduce a concept . Young children can be taught sun protection practices as routinely as they brush their teeth.
Successful programs must build an upward spiral of learning and behavior modification. Programs need to target all ages; however, influencing children's attitude toward sun exposure needs to begin at an early age . Preventative habits learned during a child's formative years are less resistant to change than those acquired in adulthood [15, 31]. Banks et al. found that teenagers who used sunscreen generally had parents who insisted on sunscreen use when those teenagers were children .
Although younger children (prior to grade school) know less than older children, they appear to receive greater encouragement from parents and respond to this positively [10, 24]. These children can be targeted successfully by parents and physicians. Habitual behaviors are patterns of activity that through repetition become relatively fixed, automatic, and easily carried out. They become harder to change and become more dependent on cues or stimuli in the environment with which they have been associated in the past. Thus, if sun protective behavior can be established as a habit in early life, less resistance may be encountered with sun protective behavior than if introduced in adolescence as a new behavior that opposes previously established patterns . Habitual sun protective behaviors can be reinforced in preschools and day care centers by reinforcing the use of protective clothing and sunscreen, and altering the time of day for outdoor play. Grin et al. studied sun protection practices in 25 day care centers and reported that general awareness concerning dangers of sun exposure exist, but day care workers lacked specific knowledge about the correlation between temperature outdoors and UV radiation, sunscreen application, and sun avoidance during peak hours . Most centers had less than 50 percent shade and 24 out of 25 held activities outdoors between the hours of 10:00 AM and 2:00 PM Although all centers used sunscreen, none applied it 15-30 minutes before going outside. Lastly, most centers did not apply sunscreen on children in the fall.
Studies suggest that children start to differentiate between chance and controlled outcome and may begin to recognize their own ability to affect their health by 8 years of age (3rd grade) . Primary school age children are ideal for initiation of sun protection programs geared at increasing knowledge and reinforcing behavior learned at home from parents. Children's sun protection attitudes and behavior appear generally positive in primary school (grades 3-5) [10, 32]. It is important to learn attitudes, perceptions and baseline knowledge in young children prior to designing sun protection interventions. Question and answer techniques have proven to be non-productive in young children . The draw-and-write technique has become popular among young children (ages 4-11) to study a wide range of health related topics. This technique was developed to research young children's language, feelings, and emotions. The method uses a story that does not in anyway determine the children's response but encourages them to think about the subject in question by drawing and writing in response to open-ended questions. It takes into account the different stages of children's development and can be employed in young children struggling with skills of reading . It provides a way of measuring and comparing relative attitudes and perceptions of children regarding sun and skin cancer .
Children's knowledge of sun protection will generally increase with age . Though children in mid-primary school years understand the concepts of sun protection, their attitudes and behaviors regarding sun protection become less favorable and are at odds with their knowledge. Cross-sectional data indicate that attitudes and behaviors supportive of sun protection decline in the teenage years while positive attitudes toward tanning and perceived attitudes of the peer group toward sun protection take over. This decline in early adolescence for protective behavior is referred to as the sleeper effect and may reflect a transition period during which children begin to take control of their own health-related actions . Additionally, at this time, sunburn rates increase and there is a decline in parental encouragement for sun protection . Sun protection behavior reaches a nadir and tan motivation peaks. During mid-adolescence, parental authority is challenged as young people seek independence . Teenagers become conflicted between wanting to be independent from their parents and realizing how dependent on them they really are .
New strategies need to be employed during mid-adolescence as parental influence wanes and peers and other socializing agents become more important [1, 11]. Social pressures begin during the first year of junior high school (between 7th-8th grades) and continue to increase during high school . Children are becoming more self sufficient and parental involvement becomes limited to subjects that are felt to be more important than sun protection. Additionally, parents have less time at home with children to teach and supervise sun protection methods . Providing children in mid to late primary school years with greater encouragement and support in relation to sun protection including external prompts (role models, provision of shade, and media influence) may prevent these age-related effects. Adolescents need continual reinforcement of sun safe behaviors from many avenues including sun protection programs, parents, peers, and especially media role models . It is not until late adolescence that sun protection practices begin to regain their lost ground.
Methods of Sun Protection
|Figure 1. Examples of instructional material geared at children versus adults taken from brochures on sun protection for children from the American Academy of Dermatology|
A number of methods of sun protection can be taught to minimize the amount of sun exposure children receive (Fig. 1). The consensus meeting of the National Skin Cancer Prevention Program proposed methods of sun protection for adults and children older than 6 months of age (Table 3).
Exposure of children to UV radiation should be limited, especially between 10:00 AM and 4:00 PM because UV rays are more intense around midday. In the late afternoon or early morning, sun intensity is only a quarter that at noon . When outdoors, children should are encouraged to seek shade under trees, shade coverings, or large umbrellas at pools or beaches. In addition, baby carriage tops should be kept up at all times when used outdoors . If possible, children should be encouraged to wear protective clothing made of tightly woven fabrics with long sleeves, long pants, and wide-brimmed hats . Children resist sun-protective clothing for many understandable reasons including feeling hot and the conflict with fashion trends. However, typical summer shirts only provide an SPF of 6.5. Hats with a 3-4 inch brim are preferable although use of a baseball cap is better than no hat at all . Aims for sun protection should be practical and realistic in regards to what children will actually do and wear. Use of sunscreen should be an adjunct form of protection only and it should be re-applied every 2 hours after swimming or sweating. Children less than 6 months old are to be kept in shade [1, 38]. In reality, many parents will not follow this recommendation, and thus the American Academy of Pediatrics (AAP) Policy Statement suggests that if parents cannot keep their children covered and in the shade, sunscreen can be applied to limited areas of skin not covered by clothing or hats (). Sunglasses that block 99-100 percent of UVA and UVB rays are recommended to prevent cancers of the eyelid or conjunctiva resulting from cumulative sun exposure.
Caution should be advised on overcast days because 80 percent of the sun's rays still reach the earth. Because clouds filter out heat from infrared rays, children feel more comfortable and tend to stay out longer. Studies have suggested that people spend more time unprotected outdoors when the temperature is mid range than they do when the temperature is either an extreme of very hot or cool . Heat and brightness are not good indicators of UV intensity . Caution must also be exercised in the presence of highly reflective surfaces such as water, sand and snow as these surfaces can increase UV radiation exposure by as much as 90 percent .
Role models have an important position in influencing children's behavior in regard to sun protection practices. As one would expect, children's role models change as they mature. During the preschool years, a toddler's health habits most closely relate to those of parents, siblings, or adult care providers [19, 27, 39]. Parental behavior contributes to a child's sun related attitude and behavior. Parents should actively demonstrate sun safe behaviors and ensure the availability of sunscreen, hat, and sunglasses to their children . Children are more likely to sunburn if their parents were sunburned . Young children are apt to believe what their parents say is true . Furthermore, parents are often the only potential educators around when children enter "high risk" sun exposure environments (e.g., a park or beach) . Studies showed that children were less likely to sunburn if they and their parents were jointly vigilant in their sunscreen use . Although parents are most influential on young children, they are vital role models in regards to sun-safe behavior for children of all ages.
There is no specific recommendation as to the most effective time for educating parents on sun exposure habits ; however, efforts encouraging parents to serve as important role models for their children and to continue practicing sun safe behaviors have begun as early as the newborn period. Data from the New Moms Project in the maternity ward of Falmouth Hospital reported that most mothers are receptive to early sun protection education, even in the newborn nursery, despite the immediate post delivery stresses that are so common . One year later, 90 percent of the original mothers (136 out of 137 were contacted) reported that their child spent less than 3 hours per week outdoors in direct sunlight and always or almost always wore a hat. By contrast, distribution of sun umbrellas and sunbonnets from pediatricians did not increase their use by mothers .
Health care professionals such as pediatricians, dermatologists, and nurses can serve as another valuable role model and source of information to both parents and children. However, more work needs to be done in providing appropriate material to pediatrician's offices regarding safe sun practices, educating pediatricians to confidently discuss sun protection, and stressing incorporation of sun protection into the list of routinely recommended injury prevention guidelines. A clear message to not avoid outdoors and outdoor activities but to decrease unprotected time in the sun should be given to patients and parents . A study done on the attitudes and practices of Massachusetts pediatricians related to sun protection revealed that counseling on seat belt use, bicycle helmet use, and smoking prevention ranked higher than sun protection as would be expected . Pediatricians in this study reported the most frequent parental concern to be discussed is nutritional guidelines for their children. In addition, decreased rates of teaching were found among those pediatricians who rate sun protection as a lower priority for themselves, those not expressing interest in using instructional material, and those rating parental understanding of sun protection to be low.
Sports coaches and teachers are well positioned to exert influence on a child's sun protection, especially adolescents. Pool life guards can model appropriate behavior to children of all ages by wearing sunglasses, t-shirts, and sunscreen in addition to staying in the shade when possible . Adolescents are greatly influenced by well-known popular role models (e.g., celebrities) and the behavior of their peers. For example, hat wearing might become more fashionable if popular celebrities, both male and female, were seen wearing hats .
Knowledge, attitudes, beliefs and behavioral change
Children suffer from an "illusion of immortality" . They believe they are indestructible or free from harm. Simply informing children that their behavior is unhealthy produces lasting behavior change in only a small percentage, especially when children are not inclined or ready to change their behavior .
Most models of protective health behavior emphasize effects on health per se, but Hayes and Ross argue that appearance may be as important as health in motivating health-promoting behaviors . They report that concerns with appearance predicted as much variance in nutritious eating as concerns with health. Additionally, Leary and Jones report that the degree to which people engage in excessive tanning is strongly correlated to their concerns with being physically attractive rather than to their knowledge about risks associated with UV exposure .
In a study on the effectiveness of health-based versus appearance-based messages about sun exposure involving 134 university students, Jones et al. suggest that effectiveness of appearance-based admonitions differ depending on a person's degree of motivation to be attractive . The authors report that appearance-based messages may be ineffective or, even worse, may produce a boomerang effect in persons with high appearance motivation. The appearance-based message is less successful in creating sun protective behaviors and less effective in lowering the intention to tan in people who most likely try to be tan . Although unexpected, these findings are consistent with the reactance theory  and heuristic-systematic model of behavior .
Reactance is produced when a person's freedom to make decisions appears threatened (including attempts to change one's behavior). It is created in response to the level of threat to one's freedom to make decisions. When persuasive messages create psychological reactance, people often reject the message and reassert their freedom by adopting an opposing stance or refusing to change in proportion to the strength of the threat to one's decision of freedom . The heuristic-systematic model proposes that when a threatening message is personally relevant, individuals may be more motivated to defend their preferred conclusion than to arrive at an accurate conclusion . Thus, people with high appearance motivation may be particularly threatened by messages about the effects of sun on appearance and may be more likely to reassert their freedom by resisting anti-tanning and sun protective interventions. Similarly, people who fail to obey medical advice may be attempting to restore freedoms that they believe have been taken away by the healthcare system .
Branstorm et al. studied a random population sample of 2,615 adolescent concerning habitual sun-related behaviors, attitudes toward sunbathing, and sun-exposure knowledge . The authors report that even when knowledge of UV radiation and skin cancer was good among adolescents, it did not affect sunbathing habits or the intention to change them nor did it increase the use of sun protection. Surprisingly, adolescents with more knowledge were more likely to sunbathe than adolescents with less knowledge. The authors speculated that this could possibly be explained by an increased interest in sun radiation and skin cancer among frequent sunbathers. Furthermore, adolescents who thought that sunbathing was harmful were more likely to think that they would sunbathe less often in the future, although they currently sunbathed with the same frequency as adolescents who thought sunbathing was healthy . It is likely that these adolescents experience a cognitive dissonance. Cognitive dissonance occurs when an individual experiences two conflicting thoughts at the same time or engages in behavior that conflicts with one's belief. Individuals may filter information that conflicts with what one already believes in an effort to ignore that information and reinforce one's belief.
Stages of behavioral change and cognitive development
It is important to examine the stages of behavioral change and the stages of cognitive development in order to permit more effective initiatives and programs for sun protection. To date, behavioral models have not been developed specifically for sun-protective intervention. Examining models developed for other problem behaviors may improve and be adopted into current sun protection interventions.
The transtheoretical model of behavior change has been studied across a wide variety of health related behavior modifications including smoking cessation, adolescent delinquent behavior, sunscreen use, safe sex, condom use, and weight control . The model involves six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and termination. Individuals in the pre-contemplation stage are not intending to change or deny the need to change. Pre-contemplators likely have a positive attitude towards sunbathing and perceive more benefits than disadvantages [29, 37]. During contemplation, individuals are seriously thinking about changing their behavior in the next 6 months. It is thought that contemplators may believe that the benefits and disadvantages of sunbathing are equal . Individuals in the stage of preparation are actively preparing to change behavior by deciding and committing to change. Action involves the six-month period following an overt modification of unhealthy behavior. Maintenance involves a period of continued change from six months after an overt behavior until the problem behavior is finally terminated. Individuals who enter the stage of termination are confident in their ability to resist relapse in all problem situations. Individuals in the last four stages probably consider the disadvantages of sunbathing to outweigh the advantages . Some of the discouraging results reported on behavior change in regards to sun protective behavior are likely the result of application-oriented strategies to participant groups not yet ready for action . Research indicates that strategies such as increasing knowledge and awareness via educational dissemination of information work best in changing individuals from pre-contemplators to contemplators or contemplators to ready-for-action, but these strategies by themselves are not effective in transitioning people to action directly. Matching interventions to the stages of change can enhance efficacy and provide specific guidance for development of intervention programs applicable not only to individuals who are ready to change but to those who are in the stage of pre-contemplation . The transtheoretical model also employs the use of distinct subsets of ten or more processes of change to help individuals transition between the stages. These processes include cognitive, affective, and behavioral strategies and techniques used by professionals to change behavior. Prior staged matched intervention programs have been successful for smoking cessation, exercise adoption, dietary fat reduction, and mammography screening .
The health belief model and theory of planned behavior state that certain cognitive factors are likely to influence health behavior changes. These factors include perceived susceptibility to a health threat, perceived severity of contracting an illness or condition, perceived benefits of change (perception that the suggested health measures are effective in reducing risk), perceived barriers (perception of physical and psychological barriers to the recommended action), cues to action or stimulus (required to tip the scales in favor of taking desired action), behavioral changes, and subjective norms [14, 48]. For example, people who believe sunbathing to be harmless are probably less inclined to decrease their sunbathing. In order to transition teenagers into an action stage of change, these cognitive factors may be addressed through behavioral change strategies such as peer leader modeling, posted feedback and goals, and knowledge and attitude based interventions [14, 48].
It is well known that adult habits are difficult to change. Thus, acquiring preventative habits in early life may affect the chances young children have of developing cancer later in life. Understanding the stages of cognitive development (Piaget's theory of cognitive development) can aid in designing age-appropriate sun safety curriculum. Piaget's theory of cognitive development is divided in four major stages: sensorimotor (from birth to age 2), pre-operational (ages 2 to 7), concrete operations (ages 7 to 11), and formal operations (ages 11 to 16). Sun protective programs targeting young children in the pre-operational stages should base their instruction on the sequence of changes from preoperational to concrete operational thinking. In the pre-operational stage, young children are developing early forms of reasoning and classification. They are able to show some ability to see from others' perspectives and show early signs of complex thought. However, their cognition tends to remain egocentric and idiosyncratic and they lack the ability for causal reasoning. At this time, children's attention is centered on a limited visual aspect of a stimulus. Repetition of curriculum activities in this age group would further enhance children's ability to incorporate sun safety concepts into their long term memory . As they progress into concrete and formal operations, they are better able to understand more abstract concepts.
These models need to be studied and incorporated when designing information campaigns and activities of sun protection directed toward groups of individuals at different behavioral and cognitive stages with different needs and levels of information in a language appropriate for them.
Techniques of Sun Protection Programs
A move from an informational or didactic approach to one that incorporates principles of behavioral science is needed for sun protection interventions . Different health promotion strategies need to be designed depending on attitude towards sun protection and stages of behavior change. For example, individuals in the stage of pre-contemplation may benefit from more information on the negative consequences of excessive sunbathing. In contrast, people in other stages who feel the disadvantages outweigh the advantages of sunbathing may be more interested in learning effective means of sun protection .
For individuals who experience a cognitive dissonance or think cancer is something that happens later in life, a cost and benefit reasoning for decision making may help reduce dissonance. For example, one might think it is worth some degree of risk taking to be attractive and look healthy today, while in the future, the cost-benefit ratio will have been altered and the harmful effects of sunbathing will be more important than appearance .
While acknowledging a potential for reactance, studies still suggest that messages which stress the negative effects of sun exposure on appearance may, under certain conditions, be more effective than warnings targeting health risks. The idea is to emphasize that individuals are paying for short term gains with long-term damage to their appearance . As media is the primary source of sun information for many individuals, this avenue for dissemination of appearance-based messages would be invaluable. Furthermore, with advances in internet technology and interactive multimedia, the avenues for message delivery are growing. Boer et al.  reported that the use of both pictures and textual arguments in sun protection public service announcements for their potential beneficial effects on judgment, cognitive processing, and persuasiveness positively influences an individual's perception of the advantages of sun protection methods and the advantages of behavior modification. Although mass media campaigns to promote sun protection are extremely important, not surprisingly, Smith et al.  found that mass media campaigns studied in Australia may contribute to short-term increases in some sun protection behaviors; however, their impact is not sustained and should be repeated and supplemented by educational, policy, and environmental strategies similar to data found in this country.
Adolescents need to be interviewed to understand the basis for their risk-taking behavior and probed about why their attitudes toward sunbathing remain positive . This information can be used to better design interventions to target specific barriers noted by adolescents. Additionally, children need to be immunized against social pressures. Perhaps a similar "Life Skills Training" program can be developed for sun protection as was developed for smoking prevention . This program involved ten weekly classroom sessions to help students develop a number of basic life skills relevant to problems confronting adolescents. Topics addressed included self-image, decision making, advertising techniques (including cigarette ads), coping with anxiety, communication skills, dating skills, assertiveness training, and myths and realities of cigarette smoking. These skills are taught through role modeling and behavioral rehearsal. The training's effectiveness was greatest among younger students when social and peer pressures are greatest (7th and 8th grades) .
Another approach can be to motivate children through personally meaningful classroom activities, projects, discussions, and peer group exercises so that learning is active, participatory and personal rather than passive . One method would be to involve students in the development of new sun protection policies .
Mechanisms with open-ended, non-threatening ways of sharing perceptions such as the draw and write technique need to be employed to communicate and understand young children's views and knowledge.
Few intensive, multi-component interventions have been attempted in the United States but these have achieved greater success in changing behavior. Campaigns need to include persuasive mass media advertising, public relations, role modeling by opinion leaders for various population segments, and health education programs for all school levels, parents and child care providers . For example, prominent role models can exploit publicity about ozone depletion or fashion for hats. Essentials such as sunscreen should be effective, inexpensive, and available widely. In terms of environmental interventions, policies are needed to increase shade structures at school playgrounds and public places.
Saraiya et al.  presented the results of systematic reviews from the findings of the US Task Force on Community Preventitive Services on Reducing Expsoure to Ultraviolet light. The authors diligently summarized the effects of educational and policy approaches with regards to effectiveness, applicability, other harms or benefits, economic evaluations, and barriers to prevent skin cancer by reducing exposure to UV radiation. The authors evaluated individual-directed strategies in child care settings, primary schools, secondary schools and colleges, recreational and tourism settings, programs in outdoor occupational settings, and health care system and provider setting. Interventions included at least one of the following: provision of information directly or indirectly to the children (through instruction or brochure, pamphlets, and printed materials), modeling, demonstration, or role playing sun safe practices (games, multimedia programs, instruction in sunscreen application), activities intended to change the knowledge, attitudes, or behaviors of teachers, parents and other caregivers, and environmental or policy approaches (providing sunscreen or shade or scheduling outdoor activities to avoid peak sunlight). The authors found that interventions to decrease UV exposure and promote sun-protective behaviors in specific settings were effective when implemented in primary schools and in recreational or tourism settings. Of note, the authors reported insufficient evidence, because of the small a number of qualifying studies, to determine the effectiveness of interventions in child care centers, secondary schools and colleges, programs in outdoor occupational settings, and health care system and provider setting. It is important to keep in mind that although the authors noted insufficient evidence for the above interventions, (many studies were disqualified because of lack of including behavioral change) these interventions still may be very effective and deserve further study. In summary, the Task Force on Community Preventative Services recommends two interventions to improve sun-avoidance or covering up-behaviors: educational and policy interventions in primary schools and programs for adults in outdoor recreational or tourism settings .
A comprehensive review of sun protection programs and interventions in North America by Buller et al.  showed that most programs improved sun safety knowledge. The most effective means to improve children's knowledge of sun and sun safety included multi-unit presentations which usually improved related attitudes and intentions to engage in sun protection . Multi-unit presentations included programs that involved sun protection presentations over several days that contained a series of instructional materials on several topics related to sun safety. Although sun protection behavior was only slightly modified, this was a promising first step as little to no change was observed as a result of short duration, single unit presentations (one time presentation between 30 and 60 minutes). The authors noted that attitude and behavior change as a result of short presentations is highly variable, very small, or non-existent, implying that this technique alone is insufficient to improve children's sun protection behavior.
In addition, the delivery of sun safety information by lay people, peer educators or community groups of adults was examined. It was noted that peer education for younger children was effective in improving knowledge. No conclusions could be made on behavior change because it was not evaluated in the studies .
Additionally, Olson et al.  performed a randomized, controlled trial conducted in ten communities to assess if a multicomponent community-wide intervention could alter the decline in sun protection that begins in early adolescence. The intervention was provided at schools, athletic and recreation facilities, primary care practices and other community venues. Results showed that after two years of intervention, adolescents in the intervention arm were better protected at the beach and pool than those in control communities. After the intervention, the average percent of body surface area protected was 66 (1%), for the intervention arm compared with 56 (8%) for the control arm. Furthermore, the percent body surface area protected only declined by 8 percent in the intervention arm compared with 23 percent in the control arm. The authors conclude that providing consistent messages across a number of venues and involving teens, as well as adults, in the effort for sun protection are needed in early adolescence in a community wide environment that supports sun protection rather than focusing on class room health education alone.
Some programs for parents have been shown to increase sun protection for their children. Parents appear to respond favorably to appeals to improve sun protection for their children. Two studies by Buller et al. [57, 58] evaluated the efficacy of postal mailings to parents of printed materials on sun safety. The authors found that parents who received mailings with printed material with high language intensity reported stronger intentions to engage in sun protection for their children and themselves. Interestingly, the authors also noticed that high intensity messages formatted in a deductive, logical style produced greater increases in sun safety behaviors and behavioral intentions in parents who planned to take more precautions as opposed to parents who had no plans to improve behavior possibly because these types of messages reinforce parent's plans and this format reduces perceived barriers to protecting themselves and their children. In parents with no plans for behavioral modification, inductive messages (a list of facts without discussion) created greater increases in reported protection behavior and behavioral intentions possibly because they reacted unfavorably to being told to behave in a certain way. Rodrique et al.  studied changes in parent awareness and sun protection behavior by presentation on skin cancer facts, sun protection behaviors with and without group discussions on skin cancer and sun protection, and a presentation by a melanoma survivor to parents who had children ages six months to eleven years. The authors found that group-discussion programs had a larger impact than the presentation alone on sun safe behaviors in changing opinions related to parent sun protection. Bolognia et al.  found that mothers of newborns who received sun protection recommendations post-delivery and a reminder post card the following summer reported less exposure to direct sun for themselves and their children and less unprotected sun exposure for themselves. Lastly, programs in recreational settings have improved parents' reported sun protection for their children and stage of change for protection for themselves and their children. Additionally, these programs have resulted in increased sun protection policies at the recreational centers. Programs include sun safe activities led by recreation staff and take home interactive sun safe activities given to parents [60, 61, 62]. Although programs designed for education of parents were generally successful for change in sun protection habits or intentions to improve behavior, the changes were still smaller than changes in knowledge . The largest changes were seen with more intensive programs that included additional printed information, products to protect children, group discussions, and presentations from melanoma survivors.
Although there is no gold standard for measuring sun protection behavior, self-report, prospective diaries, and observation techniques show small positive correlations . A repetitive large scale curriculum with a multi-channel approach targeting schools, homes, health care, recreational and health care sites is needed in North America.
Although mortality for most skin cancers is low, morbidity and collateral effects including high personal and economic costs of disfigurement and health care delivery are significant concerns . A strong link has been established between chronic unprotected sun exposure and non melanoma skin cancers and intermittent intense sun exposure and melanoma. Skin cancer is thus one of the most preventable groups of malignancies and it is our duty to guide, teach, and effect behavior change regarding the major preventable causative factor: sun exposure. Programs and interventions to date have gained some ground in improving awareness and knowledge; however, they have been slow and lagging behind in achieving behavioral change.
Although attitude does not necessarily reflect actual behavior, it is one of the first steps toward behavioral change. In addition, knowledge is an important variable and essential first step to change. Knowledge brings awareness that is an important precursor to achieving behavioral change. Thus, programs that alter knowledge may be early steps in altering attitudes and achieving behavioral change in the form of preventative actions . It is crucial for future interventions to incorporate principles of behavioral science. Furthermore, educators have reported that the method of information delivery and literature presentation affects the response and learning of the target population . Future studies are needed for direct comparisons among different methods of delivering sun protection messages.
Community and nation-wide programs in other countries such as Australia have proven to be more effective than smaller scale interventions because the message is delivered simultaneously through several channels including media, schools, homes, recreation centers, and health care facilities. People are repeatedly exposed to prevention messages, encounter messages from sources they consider credible, and the messages are consistent with one another . Thus, in addition to incorporating behavioral science, all programs and interventions in the United States need to be supplemented by nation-wide health promotion if they are to be successful and sustainable.
Once sustainable, effective sun protection programs have been created, testing promising strategies to diffuse and disseminate these programs in specific settings and target groups will be important. Early studies of this nature have been undertaken in zoological parks and community swimming pool settings with some promising results [63, 64].
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