Key Points
Question
What are the sun protection practices and attitudes of Head Start (HS)/Early Head Start (EHS) and day care centers in Illinois for 2- to 6-year-old children?
Findings
This survey study found that staff considered sun protection a less important habit than nutrition, exercise, and brushing teeth. Avoiding outdoor activities during peak sun intensity was performed less by HS/EHS than by day care programs, and half of HS/ESHS programs used spray sunscreen to avoid unnecessarily touching children.
Meaning
Education is needed about making sun safety a high-priority health habit, the danger of spraying sunscreen into a child’s face, and using the UV index to determine when to use sun protection.
This survey study assesses the current policies, practices, and attitudes among staff of Head Start/Early Head Start and day care centers regarding sun protection in children aged 2 to 6 years.
Abstract
Importance
Sun safety attitudes developed in early childhood can reduce lifetime UV radiation exposure and the risk of skin cancer.
Objective
To assess the current policies, practices, and attitudes among caregivers regarding sun protection in children aged 2 to 6 years.
Design, Setting, and Participants
A survey of 202 administrators or managers and teachers of Illinois Head Start/Early Head Start (HS/EHS) and day care centers was conducted from July 3 through 21, 2017. Organizations were randomly selected from 4 lists of urban, suburban, town, and rural locations and stratified to ensure population-based proportional representation of the Illinois population vulnerable to UV exposure. Program administrators or managers participated in a 5- to 10-minute telephone interview that assessed importance of health and sun protection behaviors, program practices, and demographic characteristics. Data analysis was conducted August 2, 2017.
Main Outcomes and Measures
Outcomes included attitudes toward the importance of health behaviors in comparison with sun protective behaviors, reported use of sun protection (seeking shade, scheduling outdoor activities, sun protective clothing, and sunscreen practices), and sunburn prevalence.
Results
Respondents (from 102 HS/EHS programs with 52% boys overall and a mean [SD] child age of 2.5 [0.5] y and 100 day care programs with 49% boys and age of 2.3 [0.4] y) stated that the 3 most important habits were good nutrition (66 [64.7%] HS/EHS, 71 [71.0%] day care), adequate exercise (41 [40.2%] HS/EHS, 55 [55.0%] day care), and brushing teeth (35 [34.3%] HS/EHS, 38 [38.0 %] day care). Scheduling outdoor activities to avoid peak sun intensity was performed less by HS/EHS programs (46 [45.1%]) in comparison with day care programs (71 [71.0%]; P < .001). Sunscreen was provided for students in 109 programs, but 84 (77.1%) did not allow children to apply sunscreen themselves. Half of the programs (100 of 202 [50.0%]) used spray sunscreen to avoid unnecessarily touching children. Most programs did not report any children having sunburns (129 [63.9%]) and followed heat index guidelines (114 [56.4%]).
Conclusions and Relevance
Administrators and teachers did not identify sun safety as one of the most important health habits. While spray sunscreen was used frequently, avoiding spraying sunscreen directly on a child’s face, which may get it into the child’s eyes, was not done. The heat index was widely used to determine outdoor playtime. Adopting UV index policies could help prevent sunburns in early spring when the heat index is low but UV index is high. Dermatologists may assume responsibility for educating the administrators about the danger of spraying sunscreen into a child’s face and the advantage of using the UV index to determine when sun protection is needed.
Introduction
People in the United States receive approximately 25% of lifetime UV radiation (UVR) during childhood, including school activities. Young children, while less knowledgeable about risks of UVR exposure than adults, respond positively to sun protection encouragement from adults. Developing preventive health behaviors in early childhood may have benefits throughout adolescence and adulthood by reducing lifetime UVR exposure and skin cancer risk.
Despite overwhelming evidence connecting UVR to skin cancer, sun protection has not commonly been practiced in schools; therefore, it is timely to examine sun protection policies and practices among preschool children enrolled in Head Start/Early Head Start (HS/EHS) and day care programs.
Methods
From July 3 through 21, 2017, Illinois HS/EHS and day care programs were identified using the US Department of Health and Human Services Head Start online database. Licensed day care providers were found using the Illinois Department of Children and Family Services. Organizations were randomly selected from 4 lists of urban/metropolitan, suburban (within commuting distance of metropolitan area and connected by trains/major highways), town (≥2500 people, not close to an urban area), and rural (<2500 people) locations and stratified to ensure population-based proportional representation of the Illinois population vulnerable to UV exposure (Figure).
Figure. CONSORT Diagram.
HS/EHS indicates Head Start/Early Head Start.
Before a program was contacted, census data by zip code were reviewed to determine whether programs served populations at risk for sunburn or skin irritation from sun exposure. On weekdays, telephone surveys lasting 5 to 10 minutes were administered by 1 research assistant (M.P.), who requested to speak with the manager or administrator. If the administrator was not available, then a teacher responded to the survey. Programs were called 3 times in 2 weeks before being removed from the call list. Screening questions regarding the demographic characteristics of the children were asked before proceeding with the survey, thus confirming that the program served at-risk children. The institutional review board of Northwestern University approved the study, and oral informed consent was obtained from all participants.
Measures
The questionnaire consisted of 2 items assessing the perceived importance of general health behaviors and their importance in comparison with sun safety behaviors. Additionally, the questionnaire had 18 items addressing the program’s policies and practices regarding sun exposure, sun protection, sunscreen, and sunburns (Table 1). Eleven items assessed the demographic characteristics of the population served by the programs, including race/ethnicity, estimated annual household income, and weeks of operation (Table 2).
Table 1. Self-reported Measures.
| Variable | No. (%) | |
|---|---|---|
| Head Start and Early Head Start (n = 102) |
Day Care (n = 100) |
|
| Comparison of health behaviors | ||
| Ranked the importance of health behavior as somewhat important or very important | ||
| General health behaviorsa | 95.9 (94.0) | 96.6 (96.6) |
| Sun-protective behaviors, excluding sunscreen useb | 78.7 (77.1) | 76.7 (76.7) |
| Sunscreen use | 96 (94.1) | 96 (96.0) |
| Ranked a health habit as 1 of the 3 most important in comparison with other health behaviors | ||
| Good nutrition | 66 (64.7) | 71 (71.0) |
| Adequate exercise | 41 (40.2) | 55 (55.0) |
| Brushing teeth | 35 (34.3) | 38 (38.0) |
| Wearing seat belts in the car | 19 (18.6) | 17 (17.0) |
| Sun protection | 5 (4.9) | 4 (4.0) |
| Sun exposure | ||
| Time outdoors between 10 am and 4 pm, min | ||
| 0-30 | 37 (36.3) | 25 (25.0) |
| 31-45 | 20 (19.6) | 12 (12.0) |
| 46-59 | 18 (17.6) | 23 (23.0) |
| ≥60 | 27 (26.5) | 40 (40.0) |
| Sun protection | ||
| Seek shade | ||
| Built environment has shade | 99 (97.1) | 99 (99.0) |
| Scheduling outdoor activities | ||
| Outdoor activities almost always or always scheduled to avoid times when sun was peak intensityc | 46 (45.1) | 71 (71.0) |
| What caregivers are most concerned about avoiding when scheduling outdoor activitiesd | ||
| Sun only | 0 | 2 (2.2) |
| Heat only | 24 (26.1) | 32 (34.8) |
| Both sun and heat | 68 (73.9) | 58 (63.0) |
| Sunscreen | ||
| Parents asked to help students apply sunscreen before program | 27 (26.5) | 39 (39.0) |
| Program had sunscreen available for students to use | 61 (59.8) | 48 (48.0) |
| Students were allowed to apply own sunscreen | 25 (24.5) | 16 (16.0) |
| Caregivers allowed time for students to apply sunscreen before going outside at program | 84 (82.4) | 92 (92.0) |
| Caregivers remind students to apply sunscreen before going outsidee | 71 (69.6) | 83 (83.0) |
| Sun-protective clothing | ||
| Students were encouraged to wear T-shirts that cover the shoulders when in the sun | 51 (50.0) | 49 (49.0) |
| Students were encouraged to wear hats or visors when in the sun | 42 (41.2) | 35 (35.0) |
| Sunburns | ||
| Times students had a red or painful sunburn for more than 12 h while at their program in the past monthc | ||
| 0 | 83 (81.4) | 46 (46.0) |
| ≥1 | 19 (18.6) | 54 (54.0) |
Mean values. General health behaviors included good nutrition, adequate exercise, wearing a seat belt, wearing a helmet when riding a bike, learning how to swim, brushing teeth daily, and having age-appropriate vaccinations.
Mean values. Sun protection behaviors included playing in the shade and wearing a sun hat and/or shirt that has at least short sleeves when outside on a warm sunny day.
P < .001.
n = 92 for both groups for this question.
P = .01.
Table 2. Demographic Characteristics of Programs and Children Enrolled in the Programs.
| Characteristic | No. (%) | |
|---|---|---|
| HS/EHS | Day Care | |
| Programs | n = 102 | n = 100 |
| Staff respondents | ||
| Age, y | ||
| 18-24 | 3 (2.9) | 1 (1.0) |
| 25-44 | 47 (46.1) | 41 (41.0) |
| 45-64 | 48 (47.1) | 52 (52.0) |
| ≥65 | 4 (3.9) | 6 (6.0) |
| Role | ||
| Teacher | 27 (27.5) | 17 (17.0) |
| Administrator or manager | 74 (72.5) | 83 (83.0) |
| Race/ethnicity | ||
| Non-Hispanic white | 47 (46.1) | 92 (92.0) |
| Hispanic | 26 (25.5) | 2 (2.0) |
| Black | 27 (26.5) | 5 (5.0) |
| Other | 2 (2.0) | 1 (1.0) |
| Children in program | ||
| Race/ethnicity | ||
| Non-Hispanic white | ||
| ≤20% | 62 (63.0) | 9 (9.0) |
| ≥21% | 37 (37.0) | 91 (91.0) |
| Black | ||
| ≤20% | 52 (53.0) | 70 (70.0) |
| ≥21% | 47 (47.0) | 30 (30.0) |
| Asian | ||
| ≤20% | 94 (95.0) | 95 (95.0) |
| ≥21% | 5 (5.0) | 5 (5.0) |
| Hispanic | ||
| ≤20% | 45 (46.0) | 90 (90.0) |
| ≥21% | 54 (54.0) | 10 (10.0) |
| Median annual household income, $ | ||
| <25 000 | 99 (97.1) | 16 (16.0) |
| 25 000-49 999 | 3 (2.9) | 34 (34.0) |
| 50 000-99 999 | 0 | 22 (22.0) |
| ≥100 000 | 0 | 5 (5.0) |
| Not reported | 0 | 23 (23.0) |
| Program characteristics | ||
| Geographic setting | ||
| Urban | 47 (46.1) | 54 (54.0) |
| Suburban | 20 (19.6) | 13 (13.0) |
| Town | 18 (17.6) | 15 (15.0) |
| Rural | 15 (14.7) | 20 (20.0) |
| Children per classroom, mean | ||
| 1-10 | 88 (86.3) | 24 (24.0) |
| 11-20 | 13 (12.7) | 74 (74.0) |
| 21-30 | 1 (1.0) | 1 (1.0) |
| 31-40 | 0 (0.0) | 1 (1.0) |
| Teachers per classroom, mean | ||
| 1 | 6 (5.9) | 18 (18.0) |
| 2 | 61 (59.8) | 72 (72.0) |
| 3 | 34 (33.3) | 8 (8.0) |
| 4 | 1 (1.0) | 2 (2.0) |
| Students enrolled in program, No. | ||
| 1-50 | 34 (33.2) | 30 (30.0) |
| 51-100 | 28 (27.3) | 36 (36.0) |
| 101-150 | 16 (15.4) | 16 (16.0) |
| 151-200 | 9 (8.7) | 11 (11.0) |
| ≥201 | 16 (15.4) | 7 (7.0) |
| Weeks per year program runs | ||
| <10 | 0 | 0 |
| 11-20 | 1 (1.0) | 0 |
| 21-30 | 3 (2.9) | 0 |
| 31-40 | 21 (20.6) | 7 (7.0) |
| 41-50 | 21 (20.6) | 3 (3.0) |
| 52 | 56 (54.9) | 90 (90.0) |
| Seasons of year program runs | ||
| Summer | 87 (85.3) | 94 (94.0) |
| Spring | 99 (97.1) | 100 (100) |
| Fall | 102 (100) | 100 (100) |
| Winter | 98 (96.1) | 100 (100) |
| Children | n = 467 | n = 653 |
| Age, y | ||
| ≤2 | 127 (27.2) | 156 (23.8) |
| 3 | 101 (21.6) | 100 (15.3) |
| 4 | 92 (19.7) | 98 (15.0) |
| 5 | 92 (19.7) | 94 (14.4) |
| 6-9 | 55 (11.8) | 205 (31.4) |
Abbreviation: HS/EHS, Head Start/Early Head Start.
Mean UV Index (UVI) values for northern and southern Illinois were obtained for June through July from the Environmental Protection Agency website.
Statistical Analysis
Descriptive statistics were used to summarize the results of survey items (Table 1). Sun protection behaviors and demographic characteristics of HS/EHS programs and day care centers were compared using the χ2 test. P values were 1 sided, and the level of significance was <.05.
Results
The telephone interview was completed by 202 programs (Figure). The greatest differences between HS/EHS and day care programs was that the proportions of Hispanic and black children and households with an annual income less than $25 000 were greater in the HS/EHS programs (Table 2).
All health behaviors were considered important for young children (Table 1). The 3 healthy lifestyle habits considered most important for children were (1) good nutrition, (2) adequate exercise, and (3) brushing teeth (Table 1). Learning to swim, wearing a helmet when riding a bike, sun protection, and having age-appropriate vaccinations were ranked among the 3 most important by less than 15% of administrators and teachers.
Scheduling outdoor activities to avoid peak sun intensity was performed less frequently by HS/EHS programs (46 of 102 [45.1%]) in comparison with day care centers (71 of 100 [71.0%]) (P < .001, χ2 test). When staff members were asked whether they scheduled outdoor activities to avoid peak sun intensity, 114 (56.4%) commented that they followed heat advisory guidelines to determine their ability to conduct outdoor activities (eTable in the Supplement). Even though programs followed temperature as a guideline, more than half stated that both sun and heat avoidance were concerns when scheduling outdoor activities (Table 1).
Sunscreen was often provided for students’ use; however, most programs did not allow students to apply sunscreen due to their young age. Instead, approximately half of the programs (100 of 202 [50.0%]) used spray sunscreen to avoid unnecessarily touching children but did not avoid spraying it in the face (eTable in the Supplement). Wearing sun-protective clothing, including long-sleeved shirts, pants, and sunglasses, was not encouraged.
Day care centers (54 [54.0%]) were more likely to state that 1 or more children had sunburns in the past month than HS/EHS programs (19 [18.6%]; P < .001, χ2 test). During the survey period, the UVI had the following mean (SD) scores for June and July in northern Illinois: 6 (1), 7 (2); and southern Illinois: 7 (1), 7 (1). Both were considerably greater than the minimum UVI of 3 associated with sunburns.
Discussion
This study found that early-childhood programs rarely identified sun safety as one of the most important healthy habits, highlighting the opportunity for education and advocacy by dermatologists. The novel comparison of the importance of sun protection with that of other health behaviors defined the need to improve attitudes about the relevance of sun protection. A secondary finding was that more than half of HS/EHS programs used spray sunscreen to avoid unnecessarily touching children. Most children were outdoors for 16 to 60 minutes, sufficient to experience sunburn in Fitzpatrick skin types I and II. While the heat index was a powerful determinant of scheduling outdoor activities, most programs were unaware of the UVI.
A nationally representative survey of children aged 11 to 18 years found that 72% reported 1 burn in the past summer. Despite day care centers trying to schedule activities to avoid peak hours and allowing time for sunscreen application, 54.0% of children experienced at least 1 sunburn. While there was a difference in the race and ethnicity of children enrolled in day care and HS/EHS, HS/EHS staff more often used spray sunscreen on the children than day care centers, which suggested that day care staff need to increase application of sunscreen.
A limitation of this study is generalization to climates with less seasonal variation in UVI and heat index than Illinois. Sunscreen is an over-the-counter medication regulated by the US Food and Drug Administration; therefore, it was included in the overreaching Illinois medication ban that requires a physician’s prescription for the school nurse to apply it. This ban does not apply to Illinois preschools. The ability to use medication in schools varies among states and local organizations, possibly limiting generalization. Given the survey method of this study, another limitation is the potential for self-reporting bias.
Conclusions
This study demonstrated that staff of HS/EHS and day care centers used spray sunscreen to protect children. Having the children wear hats while spray sunscreen was applied would avoid spraying sunscreen directly onto the child’s face, which may get into the child’s eyes and sting. Because heat index policies were widely used to determine scheduling outdoor playtime, adopting policies about sun protection when the UVI is 3 or greater could help prevent sunburns in early spring when the heat index is low and the UVI is sufficient for people to sustain sunburn.
eTable. Respondent Sun Protection Themes
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable. Respondent Sun Protection Themes