Optimizing Sun Protection for Children: Having Our Day in the Sun.

Approximately 1 in 5 Americans are destined to develop skin cancer annually.1 Of particular concern is the increase in the rates of malignant melanoma, which have doubled over the past 3 decades.2 UV light exposure has been considered theprincipal knownandpreventablecarcinogen inthedevelopmentof skin cancer,3 andnumerousprogramshavebeen developed to help educate patients about the hazards of UV lightexposureandcreatepolicies for sunprotection,manyspecifically aimed at children. Over the past decade, several studies have evaluated the effectiveness of various sun protection programs. Although studydesignsvary,commonelementsstandardly includesome degree of education about using sunscreen, wearing sunprotective clothing or eyewear, seeking shade to avoid sun at peak hours, and periodically examining the skin for suspicious lesions. Someprojects initiatededucationas early asday care4orpreschool,5 andothersduringmiddleandhighschool,6 to determineoptimal timingof educational interventions. Efforts have focused predominantly on school settings,7,8 although some have targeted programs for sun protection behavior at the beach,8 at ski and snowboard schools,9 in the outpatient medical setting,10 or as part of government-based childhood public health services.11 An underlying assumptionhasbeen thatearly interventionwithchildren instills longtermbehavior changes that can translate intomeaningful outcomes. Complicating the evaluationof theseprogramsare the heterogeneity of study designs and the reliance on selfreporting of metrics (dependence on parental reports on whether and howoften sunscreen is used, howoften hats are worn, whether sun-protective clothing is worn, as just a few examples). Studies assessdifferences inknowledgebeforeand after interventions, whichmight not always translate into actual meaningful changes in sun-protective behaviors. Fewer investigationsusemoreobjectivephysicalmeasuresof sunexposure (indirectly throughmeasures ofUV light damage such asnevuscounts12ormoredirectly throughchanges inskincolor after sun exposure using techniques such as skin reflectance spectrophotometry13). The studybyHoet al14 offers an intriguingmultimodal approachtosunprotectioneducation involvingbothearlyschoolagedchildrenandtheirparentsor relatives (hereafter simply referred to as caregivers) in the outpatientwell-care setting. Key components of the interventions include the use of a childorientedread-alongbook,theprovisionofasize-appropriatesunprotective swim shirt, and a series of 4 weekly text-message reminders tocaregiversaboutsunsafety,withnominal financial compensationat thebeginningandendof thestudy. Inaddition toassessmentsof self-reportedsunsafetybehaviors,measurements of changes in skin color were taken at baseline and followed up using reflectance spectrophotometry. The choice by the investigators to educate both the caregiverandthechild throughtheuseofanactive read-aloudbook was a pragmatic one because this process engages both caregivers and their children to recruit each other in reinforcing recommended behaviors. Supplying rather than simply recommending sun-protective clothing as part of the study encouragesadherencebyeliminating theobstacleofhaving families purchase the sun-protective clothing themselves, thus removing associated economic barriers. Several hundred publications have now documented the use of shortmessage service or textmessaging in a number of othere-healthsettings to improveadherence insituations ranging frommedication adherence to smoking cessation to vaccine reminders. Our understanding of best practices for text messaging and the science around how to ideally incorporate text messaging—in terms of timing, frequency, and such— continue to evolve. A Cochrane review of patients exposed to textmessaging as ameans of facilitating self-management of long-termillnesshighlightssubgroupsofpatientswhoaremore responsive to textmessaging, namely thosewhoare younger, have smartphones, andhavea financial incentive to followthe text-messaging advice.15 Evidence indicates that this type of text messaging should be culturally tailored, and likely economically tailored as well, given the difference in smartphone data plans.16 Theremay also be a role for using social networking sites in addition to text messaging in a multimodal e-health approach.A recent systemic reviewof theuseof socialmedia for HIVcommunication17 suggested that theadditionof socialnetworking sites helped bridge communication among a diverse range of users, in various geographic and economic contexts. Anonymity benefited participants who sought to ask additional health questions, and socialmedia sites (eg, Facebook, Twitter, and blogs) brought together a diverse audience, includingpersonswithdisease,healthprofessionals,andthegeneral public. The implementation of e-health technology such as textmessaging and the emerginguseof socialmedia are increasinglybeingacceptedbypatientsandparticularlybyyoung people.10 Given the complexity of the program evaluated by Ho and colleagues,14 future studies should focus on teasing out the relative utility of the individual components of this Related article page 334 Opinion